As amended (in the Standing Committee), considered.
Ew Clause 12
`(1) At any time when the successor company is wholly owned by the Crown the Treasury may guarantee, in such manner and on such conditions as they think fit, the redemption or repayment of any stock issued or temporary loan raised by the successor company and the payment of interest on any such stock or loan.
(2) Immediately after any guarantee is give under this section the Treasury shall lay a statement of the guarantee before each House of Parliament, and where any sum is issued for fulfilling such a guarantee or a guarantee such as is mentioned in subsection (6) below the Treasury shall, as soon as possible after the end of each financial year, beginning with that in which the sum is issued and ending with that in which all liability in respect of the principal of the sum and in respect of interest thereon is finally discharged, lay before each House of Parliament a statement relating to that sum.
(3) Any sums required by the Treasury for fulfilling any guarantee given or treated as given under this section shall be charged on and issued out of the Consolidated Fund.
(4) If any sums are issued in fulfilment of any guarantee give or treated as given under this section, the successor company shall make to the Treasury, at such times and in such manner as the Treasury may from time to time direct, payments of such amounts as the Treasury may direct in or towards repayment of the sums so issued and payments of interest on what is outstanding for the time being in respect of sums so issued, at such rates as the Treasury may direct.
(5) Any sums received by the Treasury under this section shall be paid into the Consolidated Fund.
(6) Any guarantee given by the Treasury under section 7 of the National Health Service Act 1966 with respect to a liability of the Corporation which becomes a liability of the successor company by virtue of section 1 above shall be treated as if it were a guarantee given under this section.
(7) Any guarantee given or treated as given under this section shall be extinguished when the successor company ceases to be wholly owned by the Crown.
(8) The successor company shall be regarded for the purposes of this Act as wholly owned by the Crown at any time when each of the issued shares in the company and the whole of any stock issued by it is held by, or by a nominee of, the Secretary of State.'.— [Mrs. Currie.]
Brought up, and read the First time.
I beg to move, That the clause be read a Second time.
With this it will be convenient to take the following:Government new clause 13—Statutory accounts of the successor company. Government new clause 14—Corporation Tax. Governments amendments Nos. 20 to 22 and 24 to 27. Amendment No. 41, in clause 3, page 2, line 27, leave out 'section' and insert 'sections'. Government amendment No. 28. Amendment No. 44, in page 2, line 45, at end insert— '2B. The Corporation shall have the duty to furnish the Secretary of State with an Annual Report on the performance of its functions, and the Secretary of State shall have the duty to publish the report and to lay copies of the report before both Houses of Parliament.'. Amendment No. 43, in page 2, line 45, at end insert— `2C. The Corporation shall have the duty to satisfy itself, after consulting such bodies as appears to it to represent the interests of the public within the National Health Service, that the loans made pursuant to subsections 2A (c) and 2A (d) are available without discrimination in all areas of the country and to all medical practitioners in contract with a Family Practitioner Committee'. Government amendment No. 29.
On a point of order, Mr. Speaker. Government amendments Nos. 16, 17, and 18, which are further down the batting order, concern a definition of "private patient" and certain aspects of rights of admission to hospital. I undertook in Committee to come back on Report with a Government amendment which met the aims of Opposition amendment No. 117, which was debated in Committee. I am now advised that the amendments that we put down do not achieve what amendment No. 117 sought to achieve, nor do they meet our aims.With the leave of the House, therefore, I shall not move amendments Nos. 16, 17 and 18. I undertake, however, to put down amendments in another place which will achieve those aims and reflect the sentiments of our discussion in Committee. I apologise to the House for that.
I am sure that the House will be indebted to the hon. Lady for what she has said.
The principal effect of our clauses today is to enable the Government to reconstitute the General Practice Finance Corporation as a statutory company under the Companies Act 1985. Right hon. and hon. Members will know that private sector finance is now readily available for lending against all sorts of properties, including doctors' premises. Even with the existence of the GPFC, many doctors are turning to the private sector to meet their needs for financing practice accommodation.With such funds readily available and rigorous competition among lenders, it makes sense to concentrate public resources on those things which only the public sector can do. We therefore intend that a major and reputable financial institution should be given the opportunity to acquire the GPFC and continue to administer it in the interests of doctors and patients and possibly other professionals, such as dentists. As well as commanding the confidence of private sector investors, we wish to retain the interest and involvement of family doctors in the business. To this end, we are undertaking discussions with their representatives and with the corporation as to how best to achieve this. We are also seeking powers to influence the content of the memorandum and articles of association so as to safeguard the main objectives of the present corporation through the successor body, and Government amendments Nos. 21 and 22 modify and clarify those powers. In clause 3(3), as members of the Committee will know, we are increasing the corporation's borrowing powers to ensure that it remains actively in business pending the conclusion of the new arrangements that we propose. The new clauses put down today are required to clarify the tax position, particularly during the transitional period between the old corporation and the successor company. Without new clause 14, there would be a substantial tax liability, which, of course, has never been our intention. New clause 13 will avoid an unnecessary audit. New clause 12 is needed to ensure Treasury powers to guarantee new borrowing—and existing borrowing—by the successor company as long as the body remains in public hands. The Government amendments are also intended to render the changes consistent with other privatisations so that we can draw on successful experience in negotiations to come. It is on that basis that I move the new clause.
We are concerned that there has not been any consultation about the new clause which is now being brought in on Report. In particular, there has not been any consultation about the way in which the clause and the amendments would work with the General Practice Finance Corporation, from which I should have thought that the Government would want to seek advice in respect of such complicated and technical clauses.The annual report of the GPFC has still not been published although it was submitted some time ago—[Interruption.] Perhaps the Minister is saying that it has been published. Indeed, we are glad of that at long last. We are opposed to flogging off the GPFC. The new clause and the Government amendments do not alter the fundamental problem of clauses 1 to 3. There is a need to improve primary care. Although GP services are a vital part of primary care, there are still some places where people have to travel too far to get to a GP's surgery. We need a strategic organisation that is publicly owned, such as the GPFC, to ensure that finance is available for setting up surgeries in areas where private capital might not otherwise be available to finance them. We want the GPFC to be publicly owned, accountable and used as part of the Government's armoury to improve GPs' premises and to make them more accessible to disabled people. At present, many GPs' premises are not so accessible. We want the GPFC to invest public money in improving the services that are available at GPs' premises and to enable GPs to have new equipment, such as computers and new diagnostic equipment. That should be the role of a publicly owned and accountable body, which would be used by the Government strategically to improve primary care services. In many cases, GPs' premises are currently not fit for the task that they are required to perform, let alone for the task that we should like to see them develop in the future, with increasing emphasis on the prevention of ill health and the promotion of good health. The Government are planning to flog off the GPFC, with all its interests in GPs' premises, to the private sector. It could be bought up by a drug company or by an American commercial health care company. The Minister mentioned "reputable finance institutions", but there are no guarantees in either the clauses or the new clauses that there will be a reputable financial institution. We have no guarantee that financial interests in GPs' premises will not be bought up by drug companies or by American or other foreign-owned commercial health care companies. The Government are opting out of a strategic role in a vital part of our primary health care services. The Government have not offered any criticism of the way in which the GPFC has worked in the past. There is only one justification for abolishing it. The Minister talked about reducing public spending. The GPFC does not involve public spending. It breaks even or makes a profit. It does count against the public sector borrowing requirement, but only to the tune of one thousandth of 1 per cent. Therefore, we are against the new clause that would abolish the General Practice Finance Corporation. We are concerned that the Government have tabled the new clauses without any consultation. The new clauses do not deal with the main problems of clauses 1 to 3. Therefore, we cannot support them.
On the point about consultation, I am sure that if the hon. Member for Peckham (Ms. Harman) were to read the amendments which, as she rightly says, are quite technical, she would realise that some have been drawn up directly in response to comments made in Committee by herself and her hon. Friends. We are concerned to ensure that the Treasury guarantee should continue during the period of transition. That was one point that was raised. I am sure that if we consulted almost everybody about whether there should be a new tax liability, which we had not realised might exist, their response would be that we should go ahead in bringing forward the amendments, which we have done.I am sorry that the hon. Lady has not seen the GPFC annual report. It was published on 29 March 1988, which is now more than a fortnight ago. I shall ensure that a spare copy is at the back of the Chair for her so that she can read it in her own good time. It is really quite interesting. Much of what the hon. Lady has said—[Interruption.] There is a copy in the Library. The hon. Lady will know from the long discussions that we had in Committee that we agree about the conditions of some GPs' premises. Indeed, we are trying to extend the provisions to dentists' premises, as there is room for improvement. We share her concern about premises not being accessible to disabled people. We also share her concern that some GPs do not always help equip their premises as they should. In the remarks that she has just made, and possibly in Committee, the hon. Lady has shown a degree of confusion in her mind between the role of the GPFC and that of family practitioner committees. It is the job of the family practitioner committee to do all of the things that she has said. It has the powers to do so and we expect it to use those powers. Indeed, it could go so far as to withhold payments for rent and rates from premises that are not suitable. The GPFC does not have the role that the hon. Lady has identified. I think that she wanted a strategic planning organisation, that is the family practitioner committee. The new clause satisfied some of the points that were made to us in Committee. Therefore, we are endeavouring to ensure that the handover to the private sector is as smooth as possible.
Question put and agreed to.
Clause read a Second time, and added to the Bill.
New Clause 13
Statutory Accounts Of The Successor Company
'(1) For the purposes of any statutory accounts of the successor company—
(2) For the purposes of any statutory accounts of the successor company the amount to be included in respect of any item shall be determined as if anything done by the Corporation (whether by way of acquiring, revaluing or disposing of any asset or incurring, revaluing or discharging any liability, or by carrying any amount to any provision or reserve, or otherwise) had been done by the successor company.
Accordingly (but without prejudice to the generality of the preceding provision) the amount to be included from time to time in any reserves of the successor company as representing its accumulated realised profits shall be determined as if any profits realised and retained by the corporation had been realised and retained by the successor company.
(3) References in this section to the statutory accounts of the successor company are references to any accounts prepared by the successor company for the purposes of any provision of the Companies Act 1985; and in this section "complete financial year" means a financial year ending with 31st March.'.— [Mrs. Currie.]
Brought up, read the First and Second time, and added to the Bill.
New Clause 14
'(1) Subject to subsection (2) below, if on the day specified under section 1(1) above the successor company is a company limited by shares which is wholly owned by the Crown, it shall be treated for all purposes of corporation tax as if it were the same person as the Corporation.
(2) The successor company shall not by virtue of subsection (1) above be regarded as a body falling within section 272(5) of the Income and Corporation Taxes Act 1970 (bodies established for carrying on industries or undertakings under national ownership or control).'.— [Mrs. Currie.]
Brought up, read the First and Second time, and added to the Bill.
New Clause 15
'The following section shall be inserted after section 20A of the Opticians Act 1958—
" Duties to be performed on sight-testing
20B.—(1) The Secretary of State may by regulations provide that, subject to any exceptions specified in the regulations, when a registered medical practitioner or registered ophthalmic optician tests the sight of another person, it shall be his duty—
(2) Except in circumstances specified in regulations under subsection (3)(b) of this section, it shall also be his duty to give the person whose sight he has tested, immediately following the test, either a signed, written prescription for an optical appliance or a signed, written statement that he does not need to wear or use an optical appliance.
(3) The Secretary of State may by regulations specifiy—
(4) A person shall not be required as a condition of having his sight tested—
(5) A fee shall be payable in a case where a duty arises under this section only if that duty has been fulfilled.
(6) Any term of an agreement for a testing of sight which is inconsistent with this section shall be unenforceable, and any sum paid in respect of a fee otherwise than in pursuance of this section shall be recoverable.
(7) In this section "fee" means any payment in connection—
(8) Any power to make regulations conferred by this section includes power to make different provision for different classes of case and shall be exercisable by statutory instrument, which shall be subject to annulment in pursuance of a resolution of either House of Parliament.
(9) In the application of this section to Northern Ireland—
Brought up, and read the First time.
I beg to move, That the clause be read a Second time.
With this it will be convenient to consider Government amendments Nos. 35 to 37.
New clause 15 replaces and, as we believe, improves upon, the existing clause 11. It is essentially a consumer protection provision, which commands support quite independently of the proposals in clause 10, which we shall come to at a later stage, concerning eligibility for NHS sight tests.For the most part, the new clause repeats the requirement of the original clause—principally that, following any sight test, the practitioner must give the patient a written prescription or a written statement that there is no need for glasses; that it must not be a condition of carrying out the test that any spectacles required must be bought from any particular person; and that in any case where a fee is to be charged it must not be levied in advance of the test being performed and will not be enforceable if the duties laid on the practitioner have not been properly carried out. There are two differences from the present clause 11. First, new clause 15 incorporates an additional requirement for the patient to be told in writing whether he is being referred to a doctor. The second difference, which is the reason we have a new. clause, rather than merely an amendment, is that we have decided that it is right to take the power, which curiously does not exist at present, to specify clearly in regulations what duties a practitioner must perform as part of a sight test. As the House is aware, the sight test is generally understood and expected to include a test to establish whether spectacles are required, and an eye examination in which signs of injury, disease or abnormality can be detected, leading perhaps to a need for onward referral. However, that does not rest on any specific statutory requirement. A current service committee case—concerning an NHS test, of course—has raised doubts about whether a practitioner is under any obligation to carry out an eye examination, as distinct from simply determining whether spectacles are needed. Therefore, subsection 1(a) is intended to provide the regulation-making powers to enable us to put the matter beyond doubt. It is our intention that, under whatever arrangements people receive a sight test, there should be certainty about what they are getting and that it should include a proper eye examination. Of course we shall consult the professions when we come to draw up the relevant regulations. However, I can assure them that our general aim will not be to create so rigid a set of rules as to constrain the proper exercise of their professional judgment, but simply to maintain the existing arrangements, which have generally worked satisfactorily for patients and practitioners under the NHS. I believe that the proposals to legislate in this way will be welcomed by the optical professions. They will put beyond doubt the requirements on them in relation to the sight test. Moreover, they will confirm the practitioners' primary care role in carrying out the eye examination on patients who present themselves and referring for further medical investigation or treatment cases where an abnormality is detected. The associated Government amendments No. 35 to 37 do no more than eliminate the existing clause 11 to allow for the replacement and make a couple of consequential drafting changes. I hope that on that basis the House will agree that the new clause is desirable and beneficial, and will agree to its incorporation into the Bill.
Perhaps I may mention at this stage that obviously we are not dealing here with the highly contentious abolition of the free sight test under the National Health Service, which we shall reach later.The professional organisations have asked me to raise with the Minister some technical points. If he does not feel that they have been covered by what he has said, perhaps he will add something about them. The British Medical Association ophthalmic group committee thinks that the present arrangements are satisfactory because they require opticians to refer patients to their general practitioners if there are any signs of injury, disease or any other abnormality in the eye, or if a satisfactory standard of vision is not attained, even with corrective lenses. The committee says:
There is also concern in the Association of Optometrists. Echoing the BMA view, it says:"These regulations have been and remain adequate to protect the public. The wording of paragraph 20B(1)(a) may be contrary to its intent and undermine that protection."
"there is a clear legal duty, which is not disputed by the Government, to refer any patient in whose eyes a practitioner sees signs of injury or disease. That duty is apparent as a consequence of Rules made by the General Optical Council under the provisions of the Opticians Act 1958.
Perhaps the Minister could address himself in more detail to why he thinks that the current regulations do not satisfactorily protect the consumer so that there may be wider understanding about the matter.We would, therefore, very much like to know why the Secretary of State feels it is necessary to have the provisions in (1)(b)(i) and (ii)."
I wish to commend my right hon. Friend on the changes that he has proposed. It is important that the person who is carrying out the test shall be reminded not only of his obligation in conditions which may in future be much more competitive but that it is his job to test not just for glasses, but for the eye health of the patient.Secondly, it is important that the patient should also be reminded that when he or she goes to have his or her eyes tested, the test is not merely to determine whether the person needs a pair of spectacles or stronger lenses but that, as a result of the test, the optician should give the patient a statement on any eye condition that is present. The patient must be aware of his or her rights.
There is an interesting principle involved in what is inherent in subsection (1)(a), namely, beginning to define the necessary obligations and form of practice for a doctor or other professional. It is a principle which is becoming more and more dominant in specifying how a patient is examined and what is involved in an ophthalmological or ophthalmoscopic examination. That is a principle on which I have as yet undetermined views, unusually for me.Subsection (3)(a) deals with the prescription. Subsection (3)(b) refers to the
Can the Minister say in what circumstances he envisages that it would not arise that a patient who had had an eye examination, a sight test or whatever we wish to call it, would not necessarily be given a prescription?"circumstances in which that duty does not arise."
I want to draw the Minister's attention to an issue which we shall not be able to debate today. When I saw the new clause, it seemed to be an improvement on the previous clause, but I thought that it might be improved further. One improvement would be to provide that a patient or, where appropriate, a parent or other representative understands the contents of the written statement, because some people might not understand what they were being offered.Unfortunately, a gremlin appears to have attacked the administrative works and an amendment in these terms has been printed as though it applied to the original clause 11 and not to the new clause. This will be raised in another place but I trust that the Government will take note of the point.
I observe, in passing, the inaccuracy of the initial remarks of the hon. Member for Peckham (Ms. Harman) about the abolition of the free NHS sight test. Under any proposal that we have put forward there will continue to be a substantial number of free sight tests. Indeed, about one third of the population will continue to be entitled to free NHS sight tests under the proposals that the Government have put forward. That falls a long way short of abolition. I do not wish to make an issue of the point, but I did not think that the hon. Lady should be allowed to get away with slipping the reference in as an aside at the beginning of her remarks.As to the points which were brought to the hon. Lady's attention by the BMA ophthalmic group committee and the Association of Optometrists, the point at issue is not whether there is a duty to refer patients to their GP—the point on which her comments seemed to concentrate—but whether there is a duty to conduct an eye examination of the kind that might lead to referral to a GP. I am more than prepared to consider any further representations that the hon. Lady or those bodies make if they have genuine concerns about the import of the proposals that we have brought forward. I can only repeat that the reason for the proposal, whatever views might be held about the nature of the existing law by those bodies, is that a service committee case concerning the carrying out of a sight test under the existing provisions has raised real doubts about whether there is a duty to carry out an eye examination. We do not want that doubt to continue. Therefore, we are seeking powers to eliminate the doubt by means of regulations. I can only acknowledge and welcome what my hon. Friend the Member for Portsmouth, North (Mr. Griffiths) has said. Our purpose is to reinforce these important aspects of the sight test. Of course, the interests of the customer are at one with the interests of the practitioner and what the general body of practitioners will welcome. I do not care to engage in the debate on grand principle offered to me by the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith), not because I am fearful of principle or debates about principle. On the contrary, they are sometimes easier. However, this has been brought forward by the Government in the best possible pragmatic spirit to achieve what everybody agrees is desirable. It is on that pragmatic principle, if I may put it that way, that I stand. The answer to the hon. Gentleman's point about the purpose of subsection (3)(b) is that a prescription as such is inappropriate when a patient is referred to a general practitioner or when a sight test is carried out not to establish a need for spectacles but, say, as part of a general health check to establish whether the person needs spectacles for occupational requirements, for example. The subsection is intended to cover a limited number of circumstances. At any rate, I can certainly assure the hon. Gentleman that there is no sinister intent. The hon. Member for Southport (Mr. Fearn) raised some issues which, in studying some papers at an earlier stage today, or yesterday, I noted he had sought to raise in an amendment, seeking to establish that a practitioner should have a duty to make the meaning of a piece of paper clear to the person to whom he hands it. There is limited scope for misunderstanding a piece of paper that contains a prescription for spectacles, a statement that spectacles are not required, or a statement that somebody is or is not to be referred to a general practitioner. I do not find it easy to understand how such a piece of paper can be misunderstood or how there can be some further need to impose on a practitioner a duty to explain such a piece of paper to the ordinary citizen. But if I can be persuaded that there is a genuine problem, of course I shall look at it. On the face of it, there can be few simpler pieces of paper that the citizen is likely to be handed, save only, of course, that he may not understand all the technicalities of a prescription and the way in which it is expressed. I hope that I have dealt sufficiently with the points that have been raised and that the House will proceed to adopt the new clause.
Question put and agreed to.
Clause read a Second time, and added to the Bill.
New Clause 1
Cervical Cytology Screening
'Each district health authority shall operate a comprehensive computerised call and recall system for cervical cytology screening of all women within the district over 20 years every three years.'.— [Ms. Harman.]
Brought up, and read the First time.
I beg to move, That the clause be read a Second time.Every year, over 2,000 women in this country die of cervical cancer. At least half would be saved if we had a proper, comprehensive computerised call and recall system in operation. Women are still dying of cervical cancer, and, because of the Government's failure to act, they will continue to die. The reason is quite simple. Instead of asking themselves only how much money they can save, the Government ask themselves only how much money they can save. As long ago as 1981, the Government were told by their own expert committee for gynaecological cytology that they should take action. They were told that cervical cancer gives an early warning signal and that that signal can be detected by taking a smear, which is a completely painless procedure, and examining it in a laboratory. If a pre-cancerous cell is discovered, the condition can be treated. There was nothing tendentious or controversial about the report. Indeed, it appeared at the end of many years of international debate and experience. Despite their rhetoric about preventing ill health, the Government have failed to act on the report's recommendations. The report proposed that each district health authority should set up a computerised scheme and invite women to have smear tests, and that the tests should be repeated at regular intervals. The report firmly stated that it was not good enough simply to urge women voluntarily to come forward for a test. That approach had been tried and had failed, and women were still dying of cervical cancer. The Government did not act on that advice. It was not that they disagreed with the advice; they just did not follow it up. I am certain that they would never have even begun to act had they not been pushed month by month and year by year, and we still have not got there. What has been achieved stands not at all to the credit of the Government, but to the credit of those outside the Government who have relentlessly campaigned on the issue. I pay tribute to my hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson) who, as shadow Health Minister, led the campaign in Parliament. If a woman asks me whether she should have a smear test or wait until she is called for a test by her local health authority, the best advice that I can give her is, "I do not think that you should wait to be called, because you might be not be called for a further five years and you could be dead before then." If the Minister is honest, she will admit that that is still the best advice. Indeed, I recently saw her on television urging women to put themselves forward for smear tests. Why does she still have to give that advice seven years after she was told that the Government must set up a call and recall system on a district basis? Sadly, the answer is because the scheme is only just starting. 7.45 pm After the Government's announcement last year that they intended to require district health authorities to set up a call and recall scheme, I became concerned that, for the sake of political advantage, the Minister might announce to the nation that the cervical cancer problem had been solved and that no one need worry about it any more. To check whether the problem had been solved, staff in my office and I telephoned every district health authority which, according to the Government, was due to set up a computerised call and recall scheme between March 1987 and the end of March this year. There were 83 of them. The survey was based on speaking to each district health authority about what was happening in its area. The survey showed that by the end of 1993, 36 per cent. of the districts will not have called all women between the ages of 20 and 65 years for their first smear test. That means that, 12 years after the Government's expert committee's report was published, there will still be women who have never had or even been called for a smear test. The very least that the Government can do is to accept the new clause and agree that, up to and possibly beyond 1993, their failure to act will result in the unnecessary death of women from cervical cancer. The Government's failure to act is directly attributable to their obsessional opposition to public spending and to the Health Service. There can be no other explanation for their failure to act on such clear medical advice. In 1981, when the Government were told that there was conclusive evidence that cervical cancer could be detected and prevented, they should have jumped at the chance to save lives, but, perversely, they are the enemy of medical advance and the opponent of new life-saving treatment. They see them only as extra demands on the Health Service. As well as being morally bankrupt, that approach is a false economy. The British Society of Clinical Cytology estimates that it costs £30 million a year to nurse and treat the 2,000 women who die from cervical cancer, to say nothing of the financial support that is needed for the children whom they leave behind. All is not well even where computerised call and recall systems are in operation. The Government have failed to ensure proper laboratory services to back up the schemes that are being set up. National Health Service laboratories are finding it hard to recruit staff because the pay does not compete with private sector pay. I shall refer to two districts, although the picture is the same throughout the country. A report to the Oxfordshire health authority on laboratory work loads states:
It goes on to state:"During this financial year there were no suitable applicants for the ‖ vacant post. The inability to fill the vacancy is due to lack of applicants with suitable training. Trained people are rare on the job market and if they exist they find it difficult to move to Oxford because of house prices."
In the Bloomsbury district health authority last year, five out of 11 laboratory posts were vacant. It is worrying that the Government are so unconcerned that they do not even know the full level of laboratory vacancies throughout the country. I hope that they will not once again leave it to us to do a survey of all laboratories to show the full national picture of vacancies. The Government must take action. The problem is that the Government are trying to provide the service on the cheap, and laboratory staff are voting with their feet. This means that the more women are called for a smear, the longer they will have to wait for the results to be sent back to their doctors. In a parliamentary answer to me, the Government acknowledged that already 53 districts—more than one fifth of the country as a whole—are taking one month or longer to send the results of smear tests back to women's doctors. This means that at least one fifth of the districts are already failing to achieve the targets set down in the Government's own guidelines for the turnround time on smear tests. I urge the Minister to find out how many vacant posts there are in the laboratories and to ensure that the pay is increased so that this responsible job becomes attractive and the Health Service can compete with the private sector. Let me ask the Minister two specific questions relating to the inaccurate diagnosis as negative of smear tests at the women's hospital in Liverpool between 1983 and 1985. That occurred because of what was later officially described in a report as"Two other vacancies have been filled by trained MLSOs who do not have cytology experience. These two people are being trained by experienced MLSOs hence cutting down on the productivity of the latter."
First, will the Minister tell us whether compensation has been assessed and paid to those women who went on to develop invasive and untreatable cervical cancer as a result? Secondly, I should like the Government to report to us on the progress of the national quality control checks on smears—a procedure that was revised after the Liverpool episode. Will the Minister require health authorities to recall women at three-year intervals? In the past, the Government have not been very good at taking expert medical advice, even when it has been unanimous. They have failed in that respect on this issue. Here is another opportunity for them to take the advice of medical experts. Medical opinion, including the opinion of the British Medical Association, is now unanimous that women must be tested every three years, and not just every five years. A report of the inter-collegiate working part on cervical cytology screening, conducted by the Royal College of Obstetricians and Gynaecologists, the Royal College of Pathologists, the Royal College of General Practitioners and the Faculty of Community Medicine backs up the argument that the interval between tests should be three years. In Oxford it was assessed that to leave the test for five years would be"a massive error of professional judgment".
I should hate the Government to respond to the problems in the laboratories and the district health authorities by simply saying, "We will leave the interval at five years." The Government should take the issue seriously. They should make sure that they sort out the problems in the laboratories, and they should require district health authorities to screen women every three years. The Government must also ensure that district health authorities, family practitioner committees and general practitioners have enough resources to run the schemes successfully. We do not want to find that in two years' time district health authorities are having to make difficult decisions about whether to keep their cervical cancer screening programmes or to make cuts in some other life-saving services. Will the Minister set up a national advertising programme to encourage women to go for tests, because we are concerned about the take-up rate? Even for the schemes that have been going for some time it is difficult to know what the take-up rate is because there have been problems with the computer software which the Government have not ironed out. There is not a great deal of hard evidence about the take-up rate, but we suspect that it is lower than it should be. We know that the take-up rate for cervical cancer tests would be greatly improved by a television advertising campaign. A letter calling a woman for a smear test would have more effect if, before it dropped on her mat, she had seen advertisements on the television explaining the importance of responding to the call and going for a test. The Department of Trade and Industry has recently spent £5·6 million on its television advertising campaign on the so-called enterprise initiative. It seems to me that if the DTI can spend that sort of money on advertising a bogus initiative, it is well worth the Department of Health and Social Security spending money on an advertising campaign that would actually save women's lives."bad medicine, especially when disease prevention is a priority. It would result in twice the number of invasive cancers of the cervix in this District."
I think that I am right in saying that all family practitioner committees had computers installed for call and recall as long ago as February and that all of them now have the complete age/sex registers on computer.I have a particular interest in this matter because before entering this House I was chairman of a health authority which had its computerised call and recall system in place last June. It seems to me that the hon. Member for Peckham (Ms. Harman) has painted an unnecessarily gloomy picture. We are one of the few countries that now has a fully computerised and comprehensive call and recall system, and only an impractical person would imagine that such a system, which has involved many, many hours of personnel input, could possibly work instantly, correctly and perfectly—as we all hope it will—within a few short weeks. I know from practical experience that in my own health authority it took some time for the gremlins described by the hon. Member for Peckham to be smoothed out of the computer. Earlier, my right hon. Friend the Minister for Health said that we were talking about pragmatism and principles. The principle has been recognised and is in place, but pragmatically we have to wait to be sure that it is working effectively everywhere. Obviously, all hon. Members have every sympathy with the aim of the new clause in reducing screening time to three years. However, I know from practical experience that if we pile task upon task on GPs, family practitioner committees and health authorities, we severely risk losing the advantage that we have gained in having installed the system already. If we overload the system now, before the initial difficulties are smoothed out, we shall not be able to respond to the needs of women in this very important area of preventive health care. I quite agree that one of our first aims must be to raise the consciousness of women about the importance of cervical cancer and I am sure that all of us, as Members of Parliament, are busy doing just that. However, I am not sure about the effectiveness of a television campaign. Most people are perfectly capable of responding to an invitation that falls on their doormat; I am sure that my constituents are. The important point is that the principle has been recognised and the machinery is in place. As I said before, we are one of the few countries that has recognised the importance of having such a system and is carrying out the work and I strongly urge that we should not overload the system so that we lose the advantage that the Government have put in place for all women.
It cannot be said too often that cervical cancer killed 2,000 women last year. This killer disease can and should be eradicated, but how many health authorities are experiencing the problems that we have in North Staffordshire?On 21 January, I wrote to the Minister about a women who had had a smear done on 15 September last year but who had received the results on 6 January this year; she had waited 16 weeks. Unfortunately, that lady had an abnormality that required immediate treatment, but she had had to wait 16 weeks. On 10 February, I had a letter from the Minister saying that the waiting time in north Staffordshire was between 10 and 12 weeks. On 16 February, I had a letter from the community physician for north Staffordshire saying that the waiting time was eight weeks. On 19 February, I had a letter from the district health authority chairman saying that the waiting time was now eight weeks in North Staffordshire. There had been problems with maternity leave and sickness but the tests were now being sent to other pathology laboratories and the waiting time was down to eight weeks. On 24 February, I had a letter from a lady who had had her test on 15 October and whose results were returned on 18 February. That was 18 weeks waiting time. She said that she had never felt so depressed about anything in her life, and that week after week she had worried herself silly. On 8 March, the Minister replied to me and claimed in her letter that the waiting time was eight weeks in north Staffordshire. On 25 March, I received my smear test result, almost 11 weeks after I had had the test. Meanwhile, I have had a letter from the chairman of the family practitioner committee which said that the committee was considering abandoning all tests in north Staffordshire for four weeks because it could not cope. For some time, north Staffordshire has had a call and recall system. Like the hon. Member for Norfolk, South-West (Mrs. Shephard) I served on a district health authority when this system was installed. It is a good system but what comfort is it to the women of north Staffordshire when the family practitioner committee says that it cannot use its expensive life-saving system because it cannot cope? What comfort has the Minister to offer the people of north Staffordshire?
I am sure that we have all listened with concern and perhaps shock to the speech of the hon. Member for Newcastle-under-Lyme (Mrs. Golding). I am sure that my hon. Friend the Minister will take note of what has been said. The House resolving to reduce the period of recall under a computerised system would not alter by one jot the situation that the hon. Lady had described. The position would not be improved by the new clause.We need a far more personal approach to testing and re-testing. I wished to intervene in the speech by the hon. Member for Peckham (Ms. Harman) to say that, no matter how efficient a computerised recall system may be, there will always be those who, because of moving from one place to another or because of living in houses in multi-occupation, do not receive the regular postcard recalls. It is important to seek to place the responsibility firmly on women to ensure that it is their task to seek the important advice that they can get from testing.
How can that be done?
I am about to make some suggestions about that, and I can do so without the hon. Gentleman's help.No hon. Member has mentioned an approach to women who are at the receptive age young women at school or at college. That is the time at which young girls should have drawn to their attention the fact that these tests are not carried out just once or that at some time in the future they ought to seek them, but that it is a process in which they have a personal responsibility for their own health and well-being in the years to come. A campaign directed at sixth forms and colleges would be perhaps the most effective way of setting in train the responsible attitude that we wish to see. Because of age and lifestyle, some women are acknowledged to be particularly at risk, and they should be reminded of their responsibility. If they move from one part of the country to another and then move on again, they should not wait for the system to catch up but should seek treatment. The weakness of the new clause is exemplified by the attitude of some Opposition Members who interrupted me when I suggested that we should ask women to help themselves. The idea that we can rely on a computerised system is quite wrong. The primary responsibility for health care rests with the individual, and we should start to inculcate that feeling in schools and colleges.
I support the new clause moved by my hon. Friend the Member for Peckham (Ms. Harman), with whom I share a local district health authority. I commend to the House the practice of that health authority, Lewisham and North Southwark. It takes the view that the greatest public interest and the specific health interest of women can be served only by having a call and recall system with a three-year interval for women between the ages of 20 and 65. That is the scheme that the authority has put in train. It is one of the health authority districts that was able to meet the Minister's deadline, and it sent out its first call list by 31 March. It was able to do that only because of the extreme dedication of the staff who are pioneering the scheme and who carried out all the work prior to the Government bringing in the legislation.Having decided to carry out the scheme, the authority found, as all health authorities will find, that there are constraints on finance and personnel. Let us first examine the financial constraints. The simple smear test will not in itself save the lives of women. It must be backed by expert colposcopy if we are to take advantage of the best medical practice. In Lewisham and North Southwark, there was until recently a five-month delay for colposcopy. I hope that Conservative Members will note that that means that women who are told that the smear is abnormal will wait in absolute terror until they are called for the vital further work that will confirm whether the abnormality is trivial or signals terminal illness. The provision of colposcopy services has not been adequately dealt with to enable it to match the simple smear test and the call and recall provisions. For Lewisham and North Southwark district health authority to deal with that problem and to reduce the five-month delay to one month, which is its target, and to deal adequately with the only 40 per cent. response that it expects from the call-in system, it has had to find £27,000 in capital and an extra £13,000 in revenue. The Government have not provided that money. It has had to be found by taking money from one part of the budget to fund another part. In order to fund the system, other parts of the Health Service in Lewisham and North Southwark have had to be cut. No woman and, I hope, no man who wants to see this life-saving system in operation wants to see it instituted at the expense of other parts of the much needed Health Service. Will the Minister confirm that at the moment category one carcinoma in situ is not being subjected to colposcopy examination? I understand that that is the case in Lewisham and North Southwark, although the authority believes that the ideal and best clinical practice demands that such conditions are properly investigated. It would be extremely serious if the scheme for encouraging women to come forward for testing were to be inadequate so that pre-cancerous stages were not subjected to the best possible clinical investigation. Finally, I turn to the question of technicians. As my hon. Friend the Member for Peckham said, there is a shortage of medical laboratory scientific officers. My district health authority is aware of this and is enthusiastic about recruiting trained people. The authority has told me that when it advertises it receives no applications from that category of health worker. It is partly to do with the fact that wages are so low but it is also because there are far too few people with adequate training. The health authority is in a position to offer skilled people to provide training. It would like to have training on a regional basis, but, of course, again there is no provision and there would be no funding unless it stole money from some other part of the budget. I ask the Minister to tell us whether any advice is being given to general practitioners about spatulas. As has been said, there is far too high a rate of false negatives. We should like to know whether that could be improved, as some of the literature suggests, by encouraging GPs to cease using the Ayre spatula and to use the Aylesbury or some other spatula. Clearly it is in all our interests that, once women are in the computerised system, they should not be misled, especially when there are ways in which we could improve the accuracy of the diagnosis.
I must apologise to hon. Members for coming to the debate late. I was chairing a Committee upstairs and I came as soon as I could. I am grateful for the opportunity to speak on this subject.I am aghast that there can be any question of Government Members opposing the new clause. Screening for cervical cancer is the epitome of a preventive medical technique. In the whole sphere of cancers, it is the only occasion on which we can find a pre-cancerous lesion and treat it successfully in every case. Therefore, it is mandatory for us to use the techniques that are available to maximise a woman's chance of benefiting from such a technique. I know of no medical opinion anywhere in the world that would recommend anything other than a three-yearly period for screening. If the Minister can offer any other informed evidence on the subject, I would be only too glad to receive it. The economic and medical case is unanswerable. It saves lives and, in the long run, it saves money because the treatment of women who develop cancer is an expensive business. As I have said, it is a preventive medical technique and that means that we must encourage women, if possible, to take advantage of it. We can do that by three methods. The standard procedure in health education is to inform women, to increase their knowledge and hopefully to modify their attitudes. Through doing that we can hope to change their behaviour. It is always easy to inform people about a technique, but it is much more difficult to change their attitude and much more difficult still to change their behaviour. We are talking about two groups of women. We are talking about a group who will benefit from screening of any sort; those who will respond to the request to come for screening. That group includes the majority of women about whom we are talking. Sadly, there is another group who do not respond to any form of call by letter for many reasons. In my area in Fife, one of my former colleagues has conducted extensive research on the subject of women's attitudes to screening and the things that modify their take-up of it. For example, the availability of screening, when they can go, facilities for looking after children and whether they can attend when they are at work all play a key role. Perhaps most important is the issue whether they can have a woman doctor to carry out the technique. That is very important for many women, particularly older women. Not only do we need an efficient system for those who will take advantage of it; we need to conduct research into modifying general behaviour. We must not rely on the individual's behaviour alone. Appeals to individual behaviour do not work and that is why I oppose them. I notice that the Minister agrees with that. Even if every woman on the average GP list were to respond to the call—let us say there are 800, and that is an overestimate—screening every three years instead of every five would mean a difference of less than two cases per GP per week. That is taking no account of the fact that half of the women may be attending a community health clinic anyway. That is not an overwhelming burden of work for a GP, and it is wrong to suggest that it is. It is something with which they could easily cope. I commend the new clause to the House and I hope that it will be passed.
I want to respond to the comments by the hon. Member for Portsmouth, North (Mr. Griffiths). I do not disagree with him, but I want to develop what he said. He said that the way forward is for people to look after their health and that it is all about taking a cold shower in the morning, going for a run, and so on. Those methods are favoured by the Minister. He said that each individual has responsibility for his or her health, and we accept that. However, on top of that is another important layer and that is what is involved in the new clause.There should be a suitable call and recall system to ensure that as many women as possible have the test. That is what it is all about. We are not talking about removing responsibility. There will always be people who will accept responsibility for themselves, but, as I have said, there is another layer. I want to re-emphasise what was said by my hon. Friend the Member for Kirkcaldy (Dr. Moonie). As he said, the systems involved in the technique are curative. Other systems of screening for cancer, such as chest X-rays, barium meals, and so on, can detect a cancer which may be excised, thereby preventing complications. However, that is less than curative. This type of screening detects a pre-cancerous condition, which, if dealt with, can be cured and cancer does not develop. That is the important difference and that is the importance of the new clause. That is why we are asking all hon. Members to support it.
I want to add my weight to the request for a proper review of laboratory technicians, their career structure and pay levels. It is a severe problem in my area and it may well be more responsible than any other single factor for the delays in women receiving a response to a test that they may have had some weeks or months previously.I was approached recently by a dedicated laboratory technician who had been in her present location for many years. She said that on average once every two months she is offered a job in the private sector for about double her current salary. She is dedicated and is staying in the NHS but is seeing staff leave at a considerable rate. That problem needs to be resolved. Advertising has already been mentioned tonight and a call has been made for an advertising campaign to be used to draw attention to the value of responding to the system. I find it intriguing that whenever a call is made for advertising in a matter such as this we hear streams of advice about how advertising is not really effective. I do not find that argument convincing. We all know that the private sector spends millions of pounds. It conducts research on its advertising and its effects and it does that because it works. It would work just as effectively in this area in encouraging women to come forward. We all know that women who read the medical pages in newspapers, watch television programmes and perhaps listen to the valuable work that "Woman's Hour" on Radio 4 has been doing, are likely to be influenced and to come forward. However, there are women who watch television between 7 and 8 pm who are not listening to those programmes or reading the articles, but whose lives may be saved by triggering them into attending. I recommend that that be given serious consideration.
This has been an interesting short debate, and I am particularly grateful for the comments made by my hon. Friends the Members for Portsmouth, North (Mr. Griffiths) and for Norfolk, South-West (Mrs. Shephard). We share the views expressed on both sides of the House about the possibility of saving lives by the mass screening of adult women for cervical cancer. Opposition Members know that I mean that.The major killer of women before their time in this country is not cervical cancer but breast cancer. As hon. Members know, we are developing a full breast cancer screening programme throughout the country, and we shall be the first major country to have such a system. The next largest killer of women before their time is lung cancer. Indeed, in Scotland, it is the biggest killer. Hon. Members know my views about that subject, and I hope that they share them. Cervical cancer is significant, because most deaths from it are unnecessary. In its treatable, pre-cancerous phase, which may last 10 years or more, it is symptomless, and the simple, cheap way to find it is the smear test, which has been available for nearly 25 years. If it is not detected in time it kills, and the number of deaths from it stand at 2,000 per year, although the figure has been dropping slowly over the past decade. For many years, the number of cases of invasive cancer has been about 4,000 per year. If we had not reached those ladies in the way that we have, the death rate would have been much higher. However, our concern continues, because the majority of deaths are among older women who have never been screened and perhaps have not visited their doctor for many years. An opportunistic system, which is the system which has operated in other countries, simply will not do. We agree with the hon. Member for Peckham (Ms Harman) that we need a systematic mass screening service for which all women receive invitations to attend. Our other major concern, which the hon. Lady did not mention, is that there is a new, more aggressive form of cancer appearing in small numbers among younger women. It is relatively rare and may be linked to a virus. Changes in behaviour may assist in preventing its further spread, and links with the increasing smoking behaviour of young women have been implied. That is why the practice that has been extant for more than 20 years of concentrating attention on older women is not enough. Of course large numbers of younger women are tested already—for example, when receiving contraceptive advice—but the bulk of the 4 million tests that are currently being carried out are on younger women. I listened to the hon. Member for Peckham with great interest. I have read the articles that she has written. There was one in the Morning Star this week. For the past few weeks she has been saying that I am wrong in saying that the system is about to be up and running. When people say that I am wrong there are three possibilities: they are right—occasionally that happens—they are being mischievous or they are dim. The hon. Lady is not right, she does not look like the sort to cause trouble, so I am left with the third conclusion—[Interruption.] If the hon. Lady will listen, I shall explain why the thought keeps flicking into my head that perhaps she is being a bit dim about this matter. For over 20 years, Governments have been trying to introduce a comprehensive screening system for precisely the reasons that the hon. Member for Peckham has given, which I endorse. The new clause asks us to introduce a new system, but that is unnecessary because we have already done so. In 1966, the Labour Government said that GPs should be responsible for screening, and they offered incentives for them to do so, and we have continued that system. However, that did not work because the take-up was poor. In 1971, the Conservative Government tried to set up a national recall system based in Southport using manual records. Given the complexity of the task, we should not be too surprised that it did not succeed. In 1981, the Government decided that the system would work better at local level. Many highly successful screening services were set up following the 1981 initiative, such as the one in Cambridge, and there are some excellent, long-established services in Scotland that have been well-researched and written up. By 1985 it was apparent that having a variety of schemes—some manual, others using computers and some having different software—was fine in areas that were well organised and enthusiastic, but they left out large parts of the country, often parts where cervical cancer was a problem. In 1985, my right hon. and learned Friend who is now the Chancellor of the Duchy of Lancaster decided that we should move to a call and recall system, consistent throughout England, so that all women could have a chance of accepting an invitation to be screened. The computer implementation programme was carried out between December 1985 and February 1988. Originally, it was scheduled to take a full three years. It has cost £10 million, involved installing computers at 65 different sites, providing more than 750 VDU terminals for the family practitioner committee staff, and converted over 33 million clerical records. It has been a massive exercise. The entire family practitioner system has been cornputerised, offering many exciting opportunities for prevention of disease in the future. No one has said what I am about to say. We should all thank and congratulate everybody concerned in that major exercise. It has involved an enormous amount of work not,—just as the hon. Member for Lewisharn, Deptford (Ms. Ruddock) said, some years ago, but in recent weeks and months as well.
The Minister says that in 1985, with some burst of insight, the Government decided that schemes should be implemented. Will she say why, with computerised call and recall systems, national standards and national publicity having been recommended in every part of the country since 1981, the Government did not do a damn thing until 1985?
The hon. Gentleman is fairly typical of Socialists in this country. He is interested only in what happened in the past. We are interested in what is happening now.We have completed the computer implementation programme six weeks ahead of schedule. As a result, every English family practitioner committee has a computerised register, and all but nine of the 190 district health authorities have screening systems under way. The rest, which are mainly in one Thames region, will be no more than four weeks behind. We are the only country within the European Community with such a comprehensive programme, and this achievement puts us ahead of all the major nations. France, Italy and even West Germany, which has a much higher spend on health than ourselves, have no nationwide service, and only 30 per cent. of at-risk women are screened in West Germany. Further, America, Spain and Holland do not have such a system. In the western world only Sweden, Finland and tiny Iceland have a similar system. It is time that Opposition Members recognised that we have such a system. They should say, "Well done, and congratulations to all concerned." It is worth pointing out that some of the areas that are not yet on target, but which will be on target within the next few weeks, have had a screening system for some time. Inevitably, implementation of the system is at different stages in different districts. Some areas have had the system for a long time, some are issuing prior notification lists to GPs, some are concentrating first on a particular age group or a particular number of GP practices and others are undertaking a gradual introduction to check the system, particularly where equipment is newly installed. On publicity, we do not rule out a national campaign, but all the evidence shows that local efforts are much more effective. There is plenty of evidence, including a recent edition of the British Medical Journal, that a sympathetic and personal invitation from the GP produces the best response. We are even advised that the colour of the letter should be pink, as it produces a better response. There will be much local publicity. For example, the northern region is considering a publicity campaign to encourage women to respond to the programme. All 16 districts have been live from 1 April. Yorkshire region tells me that its system is up and running. The system is up and running in Trent region, and it became operative in Leicester on 31 March. Mersey region tells me that it held a press conference earlier this year when all five Cheshire districts started up, thus giving women an opportunity to respond. It is clear that we should remind people, including GPs, that we are testing for microscopic changes that are rare. If someone is told that she has an abnormal smear, almost certainly it does not mean that she has cancer. It probably means that there was something wrong with the slide or that she has a mild infection. The microscopic changes that lead to cancer are still very rare; the vast majority of slides are clear. The best advice that the hon. Member for Newcastle-under-Lyme (Mrs. Golding) could give to her constituents is, "Do not worry," and that is entirely right.
Will the Minister give way?
No, I do not have time.European Cancer Week, which will run from the first week of May, will give wide publicity to a 10-point code against cancer. Two of them advise women to be screened for breast and cervical cancer. Therefore, in that particular week and in European Cancer Year—next year—we shall have the opportunity to raise the issue nationally. Opposition Members raised the question of laboratory backlogs. Those are monitored every month and we chase the small number of district health authorities that have backlogs. The vast majority do not. In north Staffordshire, the average delay at 23 March was confirmed at eight weeks. Some slides from before Christmas have been held back because the health authority wanted to distribute batches of slides to other laboratories, but they will all be dealt with in the usual way. The hon. Member for Peckham should remember what I said earlier. The median times between the time when the very first pre-cancer stages are detectable and the point at which cancer becomes inoperable is 12 years. On that basis, I am sure that the hon. Lady's constituents are being well looked after. 8.30 pm As for staff shortages in laboratories, the number of screening staff has increased by nearly 12 per cent. between 1985 and 1986—the last year for which I have details. It is worth reflecting on the fact that the total whole-time equivalent of screening staff in England was 778 at 31 December 1987, and during that year the total number of smears taken was 37 million. The Royal College of Pathologists and the British Society of Clinical Cytology recommend that a screener should deal with 7,000 smears a year. I invite Opposition Members to do their sums. Nationally there are sufficient staff. Occasionally there are local problems and, when there are, we chase them.
Will the Minister give way?
No. I do not have time, because we have a long debate.The hon. member for Peckham said that it will take five years to screen everyone. Of course it will. If the hon. Lady is seriously suggesting that we call in millions of women next week all at one go, then she is dimmer than I thought, or else she is deliberately attempting to mislead the women of this country. As she is a nice lady on the whole, I do not think that she is doing that. In any case, we need a steady throughput for the laboratories and, where necessary, the treatment centres. The same point has been made to us about the breast cancer programmes. As for the hon. Lady's statement that some of district health authorities will not be screening, even in five years, I can say categorically that she is wrong. If she has any information to the contrary, I hope that she will tell me which health authorities are involved and I shall deal with them. I make that promise to the House. I should like briefly to deal with the three-year interval. The new clause would set the recall interval at three years. We have told all health authorities that recall should be at least every five years. That was based on careful consideration of all the clinical and epidemiological data available. A report by the International Agency for Research on Cancer, which was published in 1986, says that efficient five-yearly screening between the ages of 20 and 64 reduced the chances of a woman developing cervical cancer by 84 per cent. That is our target. It is also the advice which I received recently in Finland, which has had a five-yearly system for many years and has seen a sharp drop in its death rate. If we were to move to a three-year system, the number of lives that might be saved would be very small. We want to save those lives as well, but, first, we are keen to save the 84 per cent. of lives that are achievable with five-yearly screening. That is our first target. We are already saving lives. We have said to those health authorities which are reaching a high proportion of eligible women regularly that they are free to increase the frequeny of the screening, and some of them have chosen to do so. That is why the revised guidance which we issued in January to the health authorities and the family practitioner committees said that recall should be at least every five years. The hon. Member for Peckham, who I know is interested and concerned about this issue, should reflect on what would happen if we moved to a three-year system before we have achieved a high overall response. The keen women would come again and those women who are at risk still would not come. 'That is what would happen. In my judgment, and in the judgment of our medical advisers, that is not the way to proceed. The hon. Lady is concerned about take-up. So am I. She will see that we have set up the computer system so that we now get much better information on take-up. There has been mention of the quality of smear tests and of the reading of smears. Many of those points have been covered in the recent circular, a copy of which is in the Library. We are also concerned about the training of staff. The training of staff is being carried forward. The hon. Lady might care to listen to the debate on clause 13 tomorrow for some interesting information. The hon. Member for Lewisham, Deptford asked about spatulas. The Aylesbury spatula is available under the central supply arrangements. The Committee on Gynaecological Cytology will review all the spatulae and the brushes at its next meeting, which is in July. If necessary, the central supply arrangements can be adjusted in the light of its recommendations.
The Minister looks as though she is reaching her last page. I do not want her to sit down before she has answered my points about women in Liverpool who have suffered invasive cervical cancer, unless I am too dim to have noticed her reply. Incidentally, the last time the Minister said that I was too young to understand. Now, apparently, I am too dim. I await to hear the next reason why I cannot understand.
All I can say to the hon. Lady is, if the cap fits, wear it.We understand that some women in the Mersey area have started legal proceedings. Therefore, it would not be appropriate for me to comment at this stage. Lastly, I should like to say that nobody need wait for the invitation. If a woman has never been screened or has not been screened for more than five years, or if she has any problems such as pain or discharge, she should go to her doctor now. If that eminently good advice were to be followed and if Opposition Members could possibly endorse it, we should save lots of lives.
I found the Minister's speech, delivered at a rate of knots, so complacent that it was breathtaking. She gave us a lot of interesting information, and I join her in one thing—in congratulating the people who have undertaken the massive job of computerisation. I do not know that they will thank her for her congratulations, because they had no funds with which to do it. They had to find the money by paring funds for other essential services. In the new clause, we are emphasising the fact that the Government have to fund the health authorities to enable them to provide this essential service.The hon. Member for Portsmouth, North (Mr. Griffiths) also took my breath away when he said that the best way to deal with the problem was to let women look after themselves and not to worry about calling them in: at least that seemed to be the import of what he said. I have to tell him that that would not cut the death rate, but would increase it. Women cannot always get the service that they require when they want it, even if they go for it. I think the hon. Gentleman said that students might take advantage of the system. Many health authorities do not screen women before the age of 35.
I was not suggesting that students need to be tested. My suggestion was that the process of education should begin at school and in college, to remind women of their obligation to supplement the system by their own responsibility.
Obviously I misunderstood the hon. Gentleman slightly. Nevertheless, the point he was making stands—that women should start thinking for themselves. That would be fine if the service was provided in all the regions by the family practitioner committees and if there were well women clinics in every hospital to deal with it. If that were the case, I would accept it.Our new clause responds to current epidemiological evidence and to the recommendations to the Department of Health and Social Security from the British Medical Association's medical services committee. The BMA says
that is very important—"that the introduction of an adequately funded cervical cytology programme which offers a cervical smear test to women over the age of 20 at three-yearly intervals, together with adequate follow-up facilities"—
The Minister has had an opportunity tonight to demonstrate that determination but, sadly for thousands of women, I think that she has shown, despite the information that she has been given, a terrifying complacency that will not satisfy them. From all that has been said, it is clear that the present highly unsatisfactory and, indeed, dangerous, situation is to be allowed to continue."comparable with those of many other countries, would indicate the determination of the Department of Health to reduce significantly the numbers of deaths each year from cervical cancer."
My hon. Friend will know that, although strapped for cash, Newham district health authority has made great strides in this respect. To take up my hon. Friend's point about the BMA, has she noted that the Minister said that a three-yearly test would save a few more lives, but that she does not intend to accept our new clause because, although she has not spelt it out, it would cost too much money? If that is not the reason, I hope that my hon. Friend will invite the Minister to get up and say why she does not accept our new clause.
My hon. Friend has made the point. I should be happy for the Minister to intervene and answer him, and I invite her to do so, but the Government are not prepared to fund such a scheme. It is all very well for the Minister and others to say that some lives will be saved in this way, but it will not be all that many. One life is worth saving. We should not fall into the trap of saying that if there are tests for 83 per cent. it does not matter about the remaining 17 per cent.Arrangements for screening of cervical cancer, which claimed the lives of 2,203 women in 1986, vary widely. The survey carried out by my hon. Friend the Member for Peckham (Ms. Harman) confirmed that, seven years after the recommendation of the Government's own expert committee, lack of money has prevented health authorities from carrying out the committee's advice. More than half the 81 districts due to set up computerised programmes are offering only five-yearly screening. Virtually all are imposing varying upper age limits—from 55 years to 60, 64 or 65 years. Again I refer to what the hon. Member for Portsmouth, North said. If a woman is 56 years old, she might find that she cannot be tested because in her health authority area screening stops at 55. The Minister recently sent a letter to all Members of Parliament on this topic. What she said in her letter has been exposed by my hon. Friend's survey and by the BMA. I quote again from the BMA, because what it says is very important, and the BMA is usually influential in this House. It said:
8.45 pm I recall the 'sisterly warning' that I gave the Minister when she announced her "special responsibility" for women's health. I warned her then that women would not take kindly to sensationalism and publicity stunts in place of well-thought-out policies to improve women's health care. I am pleased that since that time we appear to have won the Minister, at least in word, away from her previously held view—not all that long ago, I remind her—that universal screening was neither desirable or effective. However, in deed, I am sad to say, she has been a sensational flop in securing and directing the resources that are needed for a safe, secure, nationwide call and recall system. She has also, unfortunately, shown a gross insensitivity, in my opinion, to women's well-founded anxieties about some of her pronouncements. Recently the Minister told women not to "sleep around". I do not think that those were the words she used, but, whatever the words, that is not the way to address the problem. That is no way to speak to women, of any age, about their personal sexual relationships. The Minister grins broadly, but I do not think that women take very kindly to such slighting remarks. The Minister should be aware by now of the fact that no one knows exactly the cause of cervical cancer. Although there is some evidence to suggest that there may be a connection between a wart virus passed on during sexual intercourse and cervical cancer, or having sex at a very early age or with several partners, the Minister must remember that only a tiny proportion of women who started having sex at a young age, or who have had many partners, develop cervical cancer. Many women who develop cervical cancer have had only one partner. Such so-called advice is an insult to women and a cheap cover-up by attempting to blame the victims for the Government's abject failure to give a clear lead in providing both the resources and the statutory obligation to provide three-yearly screening on a call and recall basis. The fact is that 96 per cent. of cases that are caught at the pre-cancer stage are curable by laser treatment. The remainder can be cured by other treatment. I refer to a letter that I received recently from a 29-year-old woman in south Devon. She has been able to have regular smear tests because, as she says, she is articulate and able to insist upon her rights, though she does not know whether that applies to other women in her own region or in other regions. She has had abnormal results which at first were regarded as an infection and treated as such, but a few months ago the problem was classified as dysplasia, pre-cancerous cells. She was referred to the colposcopy clinic at Torbay hospital and it was confirmed that she should have laser treatment. However, the laser equipment was broken, and it had been broken for some time. She was told by her consultant gynaecologist that there was no prospect of the laser equipment being repaired. That equipment had been donated by the league of friends of the hospital, which had raised the money for it. A trust had been set up to provide money for the maintenance of the laser equipment, but the money has run out. That young woman wants to know what the Minister intends to do about that equipment. I shall send the Minister that letter, from which she will see that it is a very sad case. If hospitals have to be supplied with laser equipment and other equipment after raising money by jumble sales and coffee mornings, that is not our idea of a National Health Service, and that is not the way to save lives."At present arrangements for screening in health authorities vary widely. Some authorities have introduced programmes based on three-yearly intervals, whereas laboratories in others are refusing to accept specimens more frequently than five years. This is confusing for the public and creates difficulties for doctors in their relationships with patients … Optional flexibility and lack of clear guidance on the nature of local programmes are guaranteed to make matters worse."
I have here a copy of the West Lancashire Evening Gazette, in which one of the local journalists talks bravely about her exceedingly successful treatment for cervical cancer. I hope that we are not going to start trading blows. The hon. Lady has cited a problem. I am equally able to cite a success for our system.
I am glad to hear of the hon. Gentleman's success story. I only wish that there were Success stories everywhere. I do not say that there are not many of them, but my point is that we must not allow any cases to be failures. It is no good saying that, because we have so many successes, a few failures do not matter. That is not the way to deal with women's lives.For the Government to plead that they cannot spare more money in the regions for this specific purpose is rubbish. For them to give away £2 billion in tax cuts to the richest—funding them with social security cuts that take £1 billion from the poorest—and then refuse to implement the kind of scheme that we put in is unforgivable. The Government are constantly crowing that the economy is booming and have shown themselves more than ready to legislate to increase and enforce central Government control where it is neither welcome nor beneficial. Yet they refuse every opportunity to legislate and give a clear commitment and direction where the demand and need for action on cervical cancer screening are glaringly clear. I invite my hon. Friends, and challenge Conservative Members, to join me in support of new clause 1.
Question put, That the clause be read a Second time:—
The House divided: Ayes 205, Noes 279.
Division No. 255]
|Abbott, Ms Diane||Beckett, Margaret|
|Allen, Graham||Beggs, Roy|
|Alton, David||Beith, A. J.|
|Archer, Rt Hon Peter||Bell, Stuart|
|Ashley, Rt Hon Jack||Benn, Rt Hon Tony|
|Ashton, Joe||Bennett, A. F. (D'nt'n & R'dish)|
|Banks, Tony (Newham NW)||Bermingham, Gerald|
|Barnes, Harry (Derbyshire NE)||Bidwell, Sydney|
|Barnes, Mrs Rosie (Greenwich)||Boateng, Paul|
|Boyes, Roland||Hoyle, Doug|
|Bradley, Keith||Hughes, John (Coventry NE)|
|Bray, Dr Jeremy||Hughes, Robert (Aberdeen N)|
|Brown, Gordon (D'mline E)||Hughes, Simon (Southwark)|
|Brown, Nicholas (Newcastle E)||Illsley, Eric|
|Brown, Ron (Edinburgh Leith)||Janner, Greville|
|Bruce, Malcolm (Gordon)||Jones, Barry (Alyn & Deeside)|
|Buchan, Norman||Jones, leuan (Ynys Mon)|
|Buckley, George J.||Jones, Martyn (Clwyd S W)|
|Caborn, Richard||Kaufman, Rt Hon Gerald|
|Callaghan, Jim||Kilfedder, James|
|Campbell, Menzies (Fife NE)||Kinnock, Rt Hon Neil|
|Campbell, Ron (Blyth Valley)||Kirkwood, Archy|
|Campbell-Savours, D. N.||Lambie, David|
|Canavan, Dennis||Leadbitter, Ted|
|Carlile, Alex (Mont'g)||Leighton, Ron|
|Cartwright, John||Lewis, Terry|
|Clark, Dr David (S Shields)||Litherland, Robert|
|Clarke, Tom (Monklands W)||Livsey, Richard|
|Clay, Bob||Lloyd, Tony (Stretford)|
|Clelland, David||Lofthouse, Geoffrey|
|Clwyd, Mrs Ann||Loyden, Eddie|
|Cohen, Harry||McAllion, John|
|Cook, Frank (Stockton N)||McAvoy, Thomas|
|Cook, Robin (Livingston)||McCartney, Ian|
|Cousins, Jim||Macdonald, Calum A.|
|Cox, Tom||McFall, John|
|Crowther, Stan||McKay, Allen (Barnsley West)|
|Cummings, John||McKelvey, William|
|Cunliffe, Lawrence||McLeish, Henry|
|Cunningham, Dr John||McTaggart, Bob|
|Dalyell, Tam||McWilliam, John|
|Darling, Alistair||Madden, Max|
|Davies, Rt Hon Denzil (Llanelli)||Mahon, Mrs Alice|
|Davies, Ron (Caerphilly)||Marek, Dr John|
|Dewar, Donald||Marshall, David (Shettleston)|
|Dixon, Don||Marshall, Jim (Leicester S)|
|Dobson, Frank||Martin, Michael J. (Springburn)|
|Doran, Frank||Martlew, Eric|
|Douglas, Dick||Maxton, John|
|Duffy, A. E. P.||Meacher, Michael|
|Dunnachie, Jimmy||Michie, Bill (Sheffield Heeley)|
|Dunwoody, Hon Mrs Gwyneth||Michie, Mrs Ray (Arg'l & Bute)|
|Eadie, Alexander||Milian, Rt Hon Bruce|
|Eastham, Ken||Mitchell, Austin (G't Grimsby)|
|Ewing, Mrs Margaret (Moray)||Molyneaux, Rt Hon James|
|Fatchett, Derek||Moonie, Dr Lewis|
|Fearn, Ronald||Morgan, Rhodri|
|Field, Frank (Birkenhead)||Morley, Elliott|
|Fields, Terry (L'pool B G'n)||Morris, Rt Hon J. (Aberavon)|
|Flynn, Paul||Mowlam, Marjorie|
|Foot, Rt Hon Michael||Mullin, Chris|
|Forsythe, Clifford (Antrim S)||Murphy, Paul|
|Fraser, John||Oakes, Rt Hon Gordon|
|Fyfe, Maria||O'Brien, William|
|Galbraith, Sam||O'Neill, Martin|
|Galloway, George||Orme, Rt Hon Stanley|
|Garrett, John (Norwich South)||Parry, Robert|
|George, Bruce||Patchett, Terry|
|Gilbert, Rt Hon Dr John||Pendry, Tom|
|Godman, Dr Norman A.||Pike, Peter L.|
|Golding, Mrs Llin||Powell, Ray (Ogmore)|
|Gould, Bryan||Prescott, John|
|Graham, Thomas||Quin, Ms Joyce|
|Grant, Bernie (Tottenham)||Randall, Stuart|
|Griffiths, Nigel (Edinburgh S)||Redmond, Martin|
|Griffiths, Win (Bridgend)||Reid, Dr John|
|Grocott, Bruce||Richardson, Jo|
|Hardy, Peter||Roberts, Allan (Bootle)|
|Harman, Ms Harriet||Robertson, George|
|Hattersley, Rt Hon Roy||Robinson, Geoffrey|
|Haynes, Frank||Rogers, Allan|
|Heffer, Eric S.||Rooker, Jeff|
|Henderson, Doug||Ross, Ernie (Dundee W)|
|Hinchliffe, David||Ross, William (Londonderry E)|
|Hogg, N. (C'nauld & Kilsyth)||Rowlands, Ted|
|Home Robertson, John||Ruddock, Joan|
|Hood, Jimmy||Salmond, Alex|
|Howarth, George (Knowsley N)||Sedgemore, Brian|
|Howells, Geraint||Sheerman, Barry|
|Sheldon, Rt Hon Robert||Wallace, James|
|Shore, Rt Hon Peter||Walley, Joan|
|Short, Clare||Wardell, Gareth (Gower)|
|Skinner, Dennis||Wareing, Robert N.|
|Smith, C. (Isl'ton & F'bury)||Welsh, Andrew (Angus E)|
|Snape, Peter||Welsh, Michael (Doncaster N)|
|Soley, Clive||Williams, Rt Hon Alan|
|Spearing, Nigel||Williams, Alan W. (Carm'then)|
|Steel, Rt Hon David||Wilson, Brian|
|Stott, Roger||Winnick, David|
|Strang, Gavin||Worthington, Tony|
|Taylor, Mrs Ann (Dewsbury)|
|Taylor, Matthew (Truro)||Tellers for the Ayes:|
|Turner, Dennis||Mr. Alun Michael and|
|Walker, A. Cecil (Belfast N)||Mr. Allen Adams.|
|Alison, Rt Hon Michael||Dover, Den|
|Allason, Rupert||Dunn, Bob|
|Amess, David||Durant, Tony|
|Amos, Alan||Emery, Sir Peter|
|Arbuthnot, James||Evans, David (Welwyn Hatf'd)|
|Arnold, Jacques (Gravesham)||Fallon, Michael|
|Arnold, Tom (Hazel Grove)||Farr, Sir John|
|Ashby, David||Favell, Tony|
|Aspinwall, Jack||Field, Barry (Isle of Wight)|
|Atkinson, David||Fookes, Miss Janet|
|Baker, Rt Hon K. (Mole Valley)||Forman, Nigel|
|Banks, Robert (Harrogate)||Forsyth, Michael (Stirling)|
|Batiste, Spencer||Forth, Eric|
|Bellingham, Henry||Fowler, Rt Hon Norman|
|Bennett, Nicholas (Pembroke)||Fox, Sir Marcus|
|Benyon, W.||Franks, Cecil|
|Bevan, David Gilroy||Freeman, Roger|
|Biggs-Davison, Sir John||Fry, Peter|
|Blackburn, Dr John G.||Gale, Roger|
|Blaker, Rt Hon Sir Peter||Gill, Christopher|
|Body, Sir Richard||Glyn, Dr Alan|
|Bonsor, Sir Nicholas||Goodlad, Alastair|
|Boswell, Tim||Goodson-Wickes, Dr Charles|
|Bottomley, Peter||Gorman, Mrs Teresa|
|Bowden, Gerald (Dulwich)||Gorst, John|
|Bowis, John||Gow, Ian|
|Boyson, Rt Hon Dr Sir Rhodes||Gower, Sir Raymond|
|Brandon-Bravo, Martin||Grant, Sir Anthony (CambsSW)|
|Brazier, Julian||Greenway, Harry (Ealing N)|
|Bright, Graham||Greenway, John (Ryedale)|
|Brittan, Rt Hon Leon||Gregory, Conal|
|Brown, Michael (Brigg & Cl't's)||Griffiths, Sir Eldon (Bury St E')|
|Bruce, Ian (Dorset South)||Griffiths, Peter (Portsmouth N)|
|Buchanan-Smith, Rt Hon Alick||Grist, Ian|
|Burns, Simon||Ground, Patrick|
|Burt, Alistair||Grylls, Michael|
|Butler, Chris||Hamilton, Hon Archie (Epsom)|
|Butterfill, John||Hampson, Dr Keith|
|Carlisle, Kenneth (Lincoln)||Hanley, Jeremy|
|Carrington, Matthew||Hannam, John|
|Carttiss, Michael||Hargreaves, A. (B'ham H'll Gr')|
|Cash, William||Hargreaves, Ken (Hyndburn)|
|Chope, Christopher||Harris, David|
|Churchill, Mr||Haselhurst, Alan|
|Clark, Dr Michael (Rochford)||Hawkins, Christopher|
|Clarke, Rt Hon K. (Rushcliffe)||Hayes, Jerry|
|Colvin, Michael||Heathcoat-Amory, David|
|Conway, Derek||Heddle, John|
|Coombs, Anthony (Wyre F'rest)||Hicks, Mrs Maureen (Wolv' NE)|
|Coombs, Simon (Swindon)||Hicks, Robert (Cornwall SE)|
|Cope, John||Higgins, Rt Hon Terence L.|
|Cormack, Patrick||Hind, Kenneth|
|Couchman, James||Hogg, Hon Douglas (Gr'th'm)|
|Cran, James||Holt, Richard|
|Currie, Mrs Edwina||Hordern, Sir Peter|
|Davies, Q. (Stamf'd & Spald'g)||Howard, Michael|
|Davis, David (Booth ferry)||Howarth, Alan (Strat'd-on-A)|
|Day, Stephen||Howe, Rt Hon Sir Geoffrey|
|Devlin, Tim||Howell, Ralph (North Norfolk)|
|Dickens, Geoffrey||Hughes, Robert G. (Harrow W)|
|Dorrell, Stephen||Hunt, David (Wirral W)|
|Douglas-Hamilton, Lord James||Hunt, John (Ravensbourne)|
|Hurd, Rt Hon Douglas||Patten, John (Oxford W)|
|Irvine, Michael||Pawsey, James|
|Irving, Charles||Peacock, Mrs Elizabeth|
|Jack, Michael||Porter, Barry (Wirral S)|
|Jackson, Robert||Porter, David (Waveney)|
|Janman, Tim||Portillo, Michael|
|Jessel, Toby||Powell, William (Corby)|
|Johnson Smith, Sir Geoffrey||Price, Sir David|
|Jones, Gwilym (Cardiff N)||Raffan, Keith|
|Jones, Robert B (Herts W)||Rathbone, Tim|
|Jopling, Rt Hon Michael||Redwood, John|
|Kellett-Bowman, Dame Elaine||Rhodes James, Robert|
|Key, Robert||Riddick, Graham|
|King, Roger (B'ham N'thfield)||Ridley, Rt Hon Nicholas|
|King, Rt Hon Tom (Bridgwater)||Rifkind, Rt Hon Malcolm|
|Kirkhope, Timothy||Roberts, Wyn (Conwy)|
|Knapman, Roger||Roe, Mrs Marion|
|Knight, Greg (Derby North)||Rossi, Sir Hugh|
|Knowles, Michael||Rost, Peter|
|Knox, David||Rowe, Andrew|
|Lamont, Rt Hon Norman||Ryder, Richard|
|Lang, Ian||Sackville, Hon Tom|
|Lawrence, Ivan||Sainsbury, Hon Tim|
|Lee, John (Pendle)||Sayeed, Jonathan|
|Lennox-Boyd, Hon Mark||Scott, Nicholas|
|Lester, Jim (Broxtowe)||Shaw, David (Dover)|
|Lightbown, David||Shaw, Sir Giles (Pudsey)|
|Lilley, Peter||Shaw, Sir Michael (Scarb')|
|Lloyd, Sir Ian (Havant)||Shephard, Mrs G. (Norfolk SW)|
|Lloyd, Peter (Fareham)||Shepherd, Richard (Aldridge)|
|Lord, Michael||Sims, Roger|
|Luce, Rt Hon Richard||Smith, Sir Dudley (Warwick)|
|Lyell, Sir Nicholas||Smith, Tim (Beaconsfield)|
|McCrindle, Robert||Soames, Hon Nicholas|
|Macfarlane, Sir Neil||Spicer, Sir Jim (Dorset W)|
|MacKay, Andrew (E Berkshire)||Stanbrook, Ivor|
|Maclean, David||Stanley, Rt Hon John|
|McLoughlin, Patrick||Stern, Michael|
|McNair-Wilson, Michael||Stevens, Lewis|
|Stewart, Allan (Eastwood)|
|McNair-Wilson, Patrick (New Forest)||Stewart, Ian (Hertfordshire N)|
|Madel, David||Sumberg, David|
|Major, Rt Hon John||Summerson, Hugo|
|Malins, Humfrey||Tapsell, Sir Peter|
|Mans, Keith||Taylor, Ian (Esher)|
|Maples, John||Taylor, John M (Solihull)|
|Marlow, Tony||Taylor, Teddy (S'end E)|
|Marshall, John (Hendon S)||Tebbit, Rt Hon Norman|
|Martin, David (Portsmouth S)||Temple-Morris, Peter|
|Mates, Michael||Thompson, D. (Calder Valley)|
|Maude, Hon Francis||Thompson, Patrick (Norwich N)|
|Mawhinney, Dr Brian||Thurnham, Peter|
|Maxwell-Hyslop, Robin||Townsend, Cyril D. (B'heath)|
|Mayhew, Rt Hon Sir Patrick||Tracey, Richard|
|Mellor, David||Tredinnick, David|
|Meyer, Sir Anthony||Trotter, Neville|
|Miller, Hal||Twinn, Dr Ian|
|Mills, Iain||Vaughan, Sir Gerard|
|Mitchell, Andrew (Gedling)||Waddington, Rt Hon David|
|Monro, Sir Hector||Wakeham, Rt Hon John|
|Moore, Rt Hon John||Walden, George|
|Morris, M (N'hampton S)||Walker, Bill (T'side North)|
|Morrison, Hon Sir Charles||Waller, Gary|
|Moss, Malcolm||Walters, Dennis|
|Neale, Gerrard||Ward, John|
|Neubert, Michael||Wardle, Charles (Bexhill)|
|Newton, Rt Hon Tony||Warren, Kenneth|
|Nicholls, Patrick||Wells, Bowen|
|Nicholson, David (Taunton)||Wheeler, John|
|Nicholson, Emma (Devon West)||Whitney, Ray|
|Onslow, Rt Hon Cranley||Widdecombe, Ann|
|Oppenheim, Phillip||Wiggin, Jerry|
|Page, Richard||Wilshire, David|
|Paice, James||Winterton, Mrs Ann|
|Patnick, Irvine||Winterton, Nicholas|
|Patten, Chris (Bath)||Wolfson, Mark|
|Wood, Timothy||Tellers for the Noes:|
|Woodcock, Mike||Mr. Robert Boscawen and|
|Younger, Rt Hon George||Mr. Tristan Garel-Jones.|
Question accordingly negatived
New Clause 2
Provisions As To Merit Awards
'Consultants holding maximum part-time contracts, and, undertaking private work, shall not be eligible for distinction and meritorious service awards.'.— [Mr. Robin Cook.]
Brought up, and read the First time.
I beg to move, That the clause be read a Second time.
Order. I am reminded that the hon. Gentleman has not put his name to the new clause. Will an hon. Member whose name is on it please move it formally?
I beg to move, That the clause be read a Second time.
With this it will be convenient to take new clause 3—Private work by National Health Service consultants—
'A consultant holding a whole-time National Health Service contract shall not undertake private work and any consultant who undertakes private work shall be deemed to be holding a part-time contract and his remuneration be adjusted accordingly.'.
I apologise for that slight technical hitch. It is typical of the inefficiency in some hospital operating theatres.In speaking to the clause, I do not want to be seen as making an attack on doctors and members of the medical profession, some of whom remain my good friends despite many of the things that I have said about them in the past. It is an attack on certain doctors and, in particular, on some practices in the medical profession that have been encouraged by the Government, particularly in respect of part-time consultants and the abuses of private practice. I believe that my comments will gain all-party support. I note that even the hon. Member for Darlington (Mr. Fallon) wrote on this matter in the The Guardian of 17 February. He said:
We shall be talking about merit awards, private practice and efficiency. Opposition Members have been talking about inefficiency for a number of years, but the Government have only recently discovered it. They have discovered it not for its benefits, but as an excuse so that they can say that the problems in the Health Service are the fault of someone else, rather than because they have underfunded the Health Service. They have been looking around for scapegoats. I wish to speak first about merit awards. They have all-party support. The hon. Member for Surrey, South-West (Mrs. Bottomley) asked a question about merit awards. She asked:"Porters, cooks and cleaners have been obliged to lay their jobs on the line. But in nine years of radical Thatcherism whoever heard of a consultant sacked for inefficiency?"
Opposition Members wish to echo those sentiments and to develop them at this stage. Merit awards go back to the inception of the Health Service and were set up as a result of the Spens committee, which argued that merit awards were required"Does the Secretary of State agree that with more than 6,000 merit awards now being paid annually and with the top award being worth more than £27,000, thus virtually doubling a consultant's pay, it is in the interests of the public, the patients and the profession that more information should be readily available? It is time for people to know the by whom, the to whom, the how and the why of merit awards. That would end the secrecy and suspicion."—[Official Report, 10 February 1987; Vol. 110, c.144.]
and that"if the recruitment and status of specialist practice are to be maintained, specialists must be able to feel that more than ordinary ability and effort receive an adequate reward"
Four types of merit awards are given, in addition to the consultant's salary, which currently stands at £32,000 per annum. There is a C merit award of £5,790, a B merit award of £13,000, an A merit award of £22,750 and an A-plus merit award of £29,550, virtually doubling a consultant's salary. About one third of all consultants receive those awards, but there are two important factors to consider in respect of their distribution. First, very few women receive them. Women are particularly discriminated against because of the nature and secrecy of the committee."any satisfactory system of remuneration must involve differentiation dependent on professional distinction".
That includes my wife.
I never received a merit award either, when I was working as a consultant.The merit awards are concentrated on the high-profile, high-tech branches. In my unit, there was a 60 per cent. uptake of merit awards. At one time, 12 out of 14 consultants had a merit award. Cardiothoracic surgery received 50 per cent. of the awards. I was disappointed that, even with my considerable distinction, the committee felt that it could not give me an award at that stage. The problem is that, in some important specialties which do not have such a high profile, fewer people receive awards. For example, in occupational medicine, only 7 per cent. of the profession receive merit awards. There is a bias against certain specialties in favour of others, depending on the nature of the committee. That bias is inherent in the structure and it is self-perpetuating. The structure hands out £60 million of taxpayers' money a year, yet we know very little about it. People have asked me about the merit awards system. I have been asked who gives out the awards and I have had to reply that I do not know. I have some vague idea that one or two people may be involved, but I am not sure. I have also been asked who receives the awards, and again I have had to reply that I do not know. Slight changes have been made recently and we can find out from the health board who receives the awards, but it is very difficult for the public to discover what is happening. I have also been asked why people receive the awards and what meritorious work has to be carried out. Again, I have to reply that I do not know. Therefore, £60 million of taxpayers' money is handed out by people we do not know to people we do not know for reasons that are not clear to anyone. Reasons have been given for the granting of the awards. A statement appears in the Official Report on 4 November 1983, stating that the reasons for granting the awards include:
Although we may accept that numerous members of the profession who may or may not fulfil the criteria for merit awards actually receive them, we recognise that many people clearly do not deserve the awards. The reason why they have obtained awards, to which they are clearly not entitled, is that the awards are granted by a secretive system run by a small band of men. That is a form of patronage. I remember that the system was used as a form of patronage. There was always a godfather figure in the region who controlled the system and the money. That medical godfather dispensed patronage. At the end of the day he decided whether someone received a merit award, depending on whether or not that person had been a good boy and supported the various ideas which the godfather wanted to propagate. The merit awards are given for life. At the age of 40, on a salary of £32,000, someone may receive a top-up award of £11,000 or £12,000 for life. It does not matter whether that someone continues to fulfil the meritorious standards to retain the award. Reform must be made. How can we continue to dispense £60 million of taxpayers' money for life when there is no system of control? I am not alone in believing that there is need for reform. Many members of the medical profession believe that there should be reform. Most members of the profession agree that the merit award system needs to be reformed, although they may not all necessarily agree on the precise need. New clause 2 contains our proposals for reforming the merit award system. The awards should be limited to those working full-time for the National Health Service. Only those people perform meritorious work and behave with distinction sufficient to merit the awards. We want the Government to consider our proposal. The awards were originally granted at the inception of the National Health Service to encourage members of the profession to stay within the NHS and not to practise privately. We want to return to that original reason and ensure that the merit awards are given only to full-timers in the NHS. I know that they are given pro rata to part-timers who fill in, but we want the awards to be granted only to full-timers. I have the support of Professor David Anderson, the professor of endocrinology at the university of Manchester. He described the system as "patently indefensible". He said:"direct service to patients or their general practitioners, improvement of the service, training and teaching research, medical administration, and clinical or academic distinction. Hard work and outstanding service to the NHS may alone be sufficient reason for an award, particularly at the B and C levels."—[Official Report, 4 November 1983; Vol. 47, c. 487.]
Therefore, we are asking the Government to review the merit award system and to accept our new clause, which seeks to ensure that these awards will be made available only to full-time consultants. 9.15 pm We would also like merit awards to be reviewed every five years. It is incredible that one can be given this large amount, often doubling one's salary, yet it never again comes up for review. It is vital that, if the awards are to be be retained, they should be reviewed every five years. It is also important—the Minister may wish to reply to this as well—that all those considered for merit awards are told of this consideration and that, if they do not receive an award, the reason is published. If doctors are failing to improve their standards or are developing their efficiency and doing new things, that would be a useful check. At present one cannot find out whether one has been considered, other than by devious means. It would therefore be an advantage to know whether one was being considered, and, if turned down, to be given the reason why. New clause 3 deals with the question of private practice in the National Health Service, the contract and the question of full-timers doing private practice. The contract was changed by the Government in 1980. One of the first things that they did was to take the consultant contract from what was full-time and maximum part-time—nine-elevenths—and to give the maximum part-timers ten-elevenths and allow those who worked full-time to do private practice. We wish to reverse that. We want a full-time consultant to remain a full-time consultant and not be allowed to do private work. The change in contract was introduced by the Government, who now complain about the amount of private practice done by consultants. Perhaps they may like to reflect on that every time they hold up the consultants as the reason for the problems in the National Health Service. When they introduced the change in 1980, the Government said that it was for the effective functioning of the hospital service that consultants should feel that they were fairly treated and that their contributions were appreciated and adequately valued. In making the offer, the Government sought to translate this into action. The Minister made what was described as "an imaginative gesture" to consultants, clearly believing that its effect upon morale could only redound to the advantage of the National Health Service and its patients. That was the comment at the time the Government changed the system and allowed full-timers to do private practice. Opposition Members pointed out that consultants would shift their bias towards private practice, to the detriment of the National Health Service, and campaigned against the move. To counter that, the Government decided to introduce six principles—these "paper principles" that no one really believed in and no one bothered about. But we predicted that, even with the principles, the National Health Service would be damaged. No, said the Government. Yet we find that, come the end of last year, the Government once again believe what we say. Have the Government changed their mind? I read from The Independent of 14 December:"We all know consultans who work incredibly hard for the NHS who do not have an award, or only a low-grade one, while others whose commitment is not what it was continue to enjoy higher awards."
that would not be difficult—"The Downing Street attack came as Mrs. Thatcher, who has a network of Conservative doctors"—
How interesting—the very thing that we were talking about in 1980 when the Government changed the contract. Suddenly we find that the Government agree with what we said then. On 13 December there was a series of articles in The Sunday Times, planted by the Government, developing that theme. On the front page it said:"who brief her independently of official channels, was told last week that hospitals could be 15 to 20 per cent. more efficient if consultants who did private work in NHS time, or spent unnecessary time on committees … were brought to heel."
There was nothing about remunerating them well or about increased morale reflecting on the Health Service and developing it, as there had been in 1980."Thatcher rounds on top doctors."
It sends shivers down my spine. At the bottom of the article, it talks of"Thatcher rounds on top doctors."
Those are the things that Opposition Members talked about and campaigned against for many years. The Government are suddenly agreeing with us. What has happened to cause that change of heart by the Government? Another theme that has been developed by the National Audit Office is inefficiency in the provision of services. The Sunday Times reported:"spending time in Harley Street, 'or wherever', while their clinics and operating lists are looked after by unsupervised junior staff."
"this" is the misuse, the under-use, the 50 per cent. use, of operating theatres—"Inefficiency played a large part in this because of the inadequate forward planning of admissions"—
How surprising. Those are the things that we were talking about in 1980, but we were told to go away, that our fears were silly and that such a situation would never happen because doctors could be trusted, being highly professional members of society. I remember being told to stop casting scurrilous slurs on the medical profession. However, suddenly we find:"lack of coordination between hospital departments, and last-minute cancellations of operations due to the absence of medical staff."
What has suddenly happened? Perhaps the Minister will explain it."Thatcher rounds on top doctors."
The Public Accounts Committee has considered the report of the National Audit Office on the use of operating theatres. In one district health authority, there was 50 per cent. under-use of operating theatre time, half of which was because of cancellations by anaesthetists and consultants, not because of misallocation or mismanagement, but purely because of those people not turning up or not wishing to carry out those operations. It was suggested in Committee that a possible reason was that they were going down the road to do private work.
There is no question but that that is the reason. I have experience of many lists being cancelled, not always because of the surgeon, but because of the anaesthetist also. We must include the anaesthetist in the equation. As a junior doctor, I had experience of patients being on the operating table, anaesthetised, waiting for the surgeon to come from a private clinic. That is not unusual.We predicted all those things when the contract was changed in 1980. We are now seeing them come to fruition, but it is interesting that the Government admit to the problem. They will be keen to accept our new clause 3 so that we can get back to the position that existed before 1980. It is the fact that surgeons perform private work that leads to poor use and inefficiency in the provision of services. If one is a full-timer, one is always there and available to do things as they arise. One is always there to see the X-rays as they are produced, and to see the patients. One produces an efficient service by always being there, fitting into slots that become available. However, if one has a private practice commitment, certain sessions are immediately taken up and shifted aside, and it is impossible to be efficient. Let us consider a parallel. We have a National Health Service in which we allow some doctors to work as private contractors. Let us consider what would happen if we allowed airline pilots to do the same. Let us imagine that we turn up for the British Airways shuttle at London Heathrow, only to find that it has been cancelled, just like an operation, because the pilot has decided to fly for British Midland Airways Ltd. that morning. He probably took the British Airways shuttle with him without telling anyone. That is an absolute parallel—[Interruption.] Yes, or teachers. They are the same, but they would take the blackboard with them. The argument for allowing more private practice was that it would help to reduce waiting lists. It was said that people going into private care would help to reduce waiting lists. There was no evidence whatsoever of that, and there has been no evidence since. Indeed, waiting lists have increased. However, that was the argument. That is similar to the argument that if a large queue is waiting for a bus and a taxi comes along and someone gets in the taxi, the queue becomes smaller. However, they do not realise that there is a large queue for a bus in the first place because the person who is supposed to be driving the bus is moonlighting and driving the taxi. That is the problem that we face with private practice in the National Health Service. I am glad that the Government see the problems that they generated when they changed the contract in the 1980s. They accept that the contract produces inefficiency and encourages absence from the NHS. I hope that they will accept new clause 2, which deals with merit awards, and new clause 3. The system must be overhauled in the interests of fairness, equity and open government.
We have had a riveting expos? of the more arcane features of the merit award system and the functioning of consultants in hospitals from one who knows, in the person of the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith). I only hope, for his sake, that he is not ill in the next week or two.I hope that my right hon. Friend will keep the matters under review in the regular discussions he has with the presidents of the royal colleges. In those discussions he should continue to consider the equally important question which impinges directly on the efficiency and effectiveness of consultants and their involvement in local management processes: that is, the question of their contracts being held at district level. The excuse that is usually given for this not being considered is that many consultants work for several districts. That is hardly an important reason, since the number of such consultants is not known by the DHSS, as I elicited through a parliamentary question not long ago. In the regular discussions and consultations that my right hon. Friend has with the royal colleges, he should consider not only the points that were made by the hon. Member for Strathkelvin and Bearsden, but also a change in where consultants' contracts are held, because it would contribute greatly to the efficiency of the service if their accountability lay where their work is.
In responding to the debate, I can most easily indicate my general approach by saying a word first about what my hon. Friend the Member for Norfolk, South-West (Mrs. Shephard) said about the point at which consultants' contracts are held, because it will cover the generality of the thrust of my reply, which is that we are always prepared to keep these matters under review. I noted with great interest the suggestions that were made by the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) and by my hon. Friend.I shall also take such steps as I can to ensure that the hon. Gentleman's remarks are drawn to the attention of his colleagues in the profession not in the spirit that my hon. Friend implied about what they might do to penalise him, should the occasion arise, but rather that they may reflect on those remarks. I hope that the House will understand why I will comment on only one or two practical points rather than cover the full sweep of the hon. Gentleman's remarks. His proposed new clause 2 would exclude from the receipt of distinction awards all maxirnum part-time consultants, including those who carry out their contractual duties entirely properly and efficiently, while it would make no changes to the position of consultants holding other types of contracts. As he said, maximum part-time consultants are expected to devote substantially the whole of their professional time to their duties in the NHS and to have the same commitment to continuing patient care as whole-timers. That may include being available to give emergency cover at night and at weekends. This is more than a technicality, although I understand that it could be said to be a technicality. If the new clause were adopted in its present form, the most likely outcome would be that most maximum part-timers would not become full-timers, but would change to nine-session part-time contracts to secure their right to be considered for distinction awards and to undertake unlimited private practice. The loser in that would almost certainly be the Health Service.
I wish to clarify the terms of the new clause. As the Minister will be aware, its purpose is to bar from awards consultants holding maximum part-time contracts and undertaking private work. It is not our intention to bar from merit awards those consultants, albeit a minority, on maximum part-time, who become maximum part-timers for other reasons than a wish to carry out private work, such as female consultants who work as maximum part-timers because of family commitments. It is important that I put that on the record; otherwise I dare not go home at the weekend.
I should not want the hon. Members for Livingston (Mr. Cook) and for Strathkelvin and Bearsden to be persecuted by every doctor in Scotland.The comments of the hon. Member for Livingston have left me in some slight difficulty, although I do not mind that. The difficulty is that the clauses are meant to be read together for what they are—two separate and distinct propositions. Unquestionably, the interpretation that I have just given is what new clause 2 states. The hon. Gentleman's interpretation relates to what would happen if new clause 2 and new clause 3 were amalgamated. Nevertheless, it does not significantly alter the point that I sought to make. Indeed, if anything, it may strengthen it. If the position that would be created jointly by the two new clauses were brought about, and possibly by either of them separately, the most likely outcome would be the loss of several consultants to the Health Service or a diminution of their commitment to the Health Service by moving to part-time contracts of fewer sessions than are implied by a maximum part-time contract. I doubt whether that was intended, but it was reasonable for me to make that point. 9.30 pm I am glad that the hon. Member for Livingston made his point. The tears that the hon. Member for Strathkelvin and Bearsden wept over the plight of women in relation to merit awards appeared to be crocodile tears, in the light of the rest of his proposition, which would certainly have made it much more difficult for women to receive merit awards. In view of the time, the desire to make progress, and the slight confusion that has been created by the way in which the clauses were presented and the way in which they were represented, it is probably not sensible for me to say more except to repeat that I shall reflect on what has been said and ensure that, by various means, it is drawn to the attention of the professions, the advisory bodies and, indeed, the review body.
Question put and negatived.
New Clause 5
'(1) Where drugs, medicines or listed appliances are ordered by their brand name for a person by a medical practitioner in pursuance of his functions in the health service, the Scottish health service, the Northern Ireland health service or the armed forces of the Crown (excluding forces of a Commonwealth country and forces raised in a colony), it shall be the duty of the person supplying such drugs, medicines or appliances to supply a generic product approved by the Secretary of State instead of the product by its brand name.
(2) Subsection (1) above shall not apply where the person for whom the drugs, medicines or appliances are ordered requests the product to be supplied by its brand name, and in that case he shall pay any additional cost of such product in excess of the cost of the generic product.'.— [Mr. Wareing.]
Brought up, and read the First time.
I beg to move, That the clause be read a Second time.When the Government talk about savings and value for money in the National Health Service, one aspect is conspicuous by its absence. Some may consider that it may have something to do with the old adage that he who pays the piper calls the tune. As we know, some pharmaceutical companies are adept at providing funds for the Tory party's election expenses. I wonder whether that motivates the Conservative party in relation to generic prescribing and generic substitution. The essence of generic prescribing is that a doctor uses the approved name of a drug—that is to say, the accepted name of the chemical entity that makes up the drug. The purpose of new clause 5 is to ensure that, even if a general practitioner has prescribed a branded drug, it is possible and nearly always cheaper for a patient to be offered a generic substitute. I should have thought that that would be in accordance with Government policy, as indeed it is in accordance with the Opposition's policy. The National Health Service drugs bill is about £2 billion a year. That generic prescribing can bring about a reduction in that colossal figure is proven by the fact that, when the limited list that only partially involved generic prescribing was introduced, the Government were able to claim that £75 million was saved in the first year of operation. The Department of Health and Social Security already advises its general practitioners that they should look to generic prescribing, and hospitals generically prescribe for their patients as a matter of course. We should be looking for real savings in prescribing. Such savings would benefit not only the Government in terms of public expenditure, but those patients who will be even more deprived as a result of many other aspects of the Government's policy, part of which we debated this afternoon. Anything that helps those patients in these days of higher prices in the National Health Service will be warmly received. I shall not cite journals of the Labour movement, but the "Drug and Therapeutics Bulletin" of 30 November 1987 estimated that there could be an overall saving of £100 million to the National Health Service if generic substitution were introduced. That journal, worthy though it may be, was assuming that it would be non-mandatory generic substitution. Even more substantial benefits to the National Health Service in terms of cost-effectiveness could be achieved if the Government accepted the new clause. Incidentally, I was rather pleased that, although the Government did not accept new clause 2, there were signs that it did not entirely offend them. I hope that we shall fare as well with this new clause. The savings would be very great. Let us consider the example of the antibiotic sold by Pfizer under the brand name Vibramycin. A bottle of 50 tablets of Vibramycin costs the patient and the National Health Service £23. Roxycycline, a generic substitute sold by Harris Pharmaceuticals, sells at £10 for 50 tablets. That represents a saving of £13 on every 50 tablets prescribed. It is not excessive to estimate that the overall savings to the National Health Service could be about £400 million if mandatory generic substitution was in operation. Let me give another example. A 100-pack of 100 mg Zyloric costs £16·13, but the generic Allopurinol costs £1·49. On that drug alone there is a saving of 90·7 per cent.—more than £10 million. If the Government are looking for money for the National Health Service, there is no excuse. In the main, the drug companies—many of them foreign multinationals—are waxing very rich in relation to the National Health Service. I am glad to see Conservative Members nodding. I only wish that their nods were nods in the direction of the Aye Lobby. However, Conservative Members are very late learners; some of them had to wait until this afternoon to discover what was happening under other Government legislation. It is very important that patients should have a clear idea of what is being prescribed for them. Under the present system of branded products, many different names are given to the same medicine. I am sorry that we are not able to debate the new clause about benzodiazepines. The most lethal of these is lorazepam, which comes either as Ativan produced by Wyeth or as Almazine produced by Steinhard. I wonder how many people who have been prescribed Almazine knew that they were taking this potentially lethal drug which is exactly the same as Ativan, now going under the name of lorazepam. The benzodiazepine called temazepam, which was prescribed last year over 7 million times at a cost to the National Health Service of more than £11 million, has all sorts of side and withdrawal effects that should be well known to many doctors. According to the British National Formulary, that drug can come in three different forms. The Government were advised long ago in the Greenfield report of 1982 that generic substitution should he in operation in the National Health Service. Of course we know that the Government are deaf to advice, even from their own advisers. The report said:
The report quite clearly approved of the whole idea of generic substitution. The then Minister for Health, the right hon. and learned Member for Rushcliffe (Mr. Clarke), argued against that when he made a statement in the House in December 1983. His argument was not very convincing. Its crux appeared to be where he said:"We consider that many doctors would be quite content for their patients to receive an alternative version of the drug prescribed, but that they tend to prescribe the proprietory brand with which they are most familiar. We therefore suggest the introduction of a simple scheme which would require doctors to indicate a positive preference for the proprietory version by initialling a box provided for that purpose".
that is, the Greenfield committee—"The committee"—
The pharmaceutical industry does very well out of the National Health Service. I have yet to hear of one of the large pharmaceutical firms complaining that it is on the border of liquidation. As I have said, some of them can find extra funds to help to finance the Conservative party. Real benefits can flow from generic prescribing, and that is why we should look for a positive means of giving the National Health Service a monetary boost by cutting its costs. Generic names show the chemical class to which drugs belong and that gives information about properties. Names such as Ativan and Valium do not give such information until it is too late and patients suddenly complain about side and withdrawal effects. Generic substitution would mean a single name and that would reduce the present confusion about the naming of drugs. Normal generic names are used in medical teaching and in medical bulletins, and should be well known to the medical profession. One other economy for the Health Service would result from the economy to pharmacists. Instead of holding the very large stocks that they presently have to hold because of the large number of branded products, they would be able to reduce their stocks and costs. That in itself would be a saving, and costs would be cut all round. There are many arguments about what those costs would be. In answer to my hon. Friend the Member for Peckham (Ms. Harman), the Minister for Health said on 11 February that only 28 per cent. of prescriptions dispensed in Britain are generically dispensed. That was according to the figures for 1986. On the same day, the Minister said that the prescribing of all drugs generically would bring about a saving of about £35 million in England. Obviously it would he more if it included the United Kingdom as a whole. 9.45 pm The Government all too often tell us that they believe in competition. We should ask ourselves what branded goods imply. Branded goods constitute a monopoly practice. They are a way of dividing the market between different consumers of essentially the same product. We have heard of that happening in many other respects. For example, it has happened with detergents. What the great monopolist cannot get with Omo he gets with Tide. The same principles apply to the pharmaceutical companies. General practitioners in our urban areas are often overburdened and are pressurised by the ad-men into prescribing this or that branded product. All too often they have little time to consider the reality that lies behind brand X, brand Y or brand Z. If the Government's belief in abandoning restrictive practices is wider than their belief in simply abandoning those practices in the labour market, they should be looking to some of their friends in the pharmaceutical industry who could be providing a real service to the country by placing their goods on the market for what they are, by providing the public with real information about the chemical composition of a product and by ensuring that there is a cost advantage to the NHS. It seems wrong for a Socialist to be telling Tories what to believe in. However, I strongly suspect that one of the factors behind the Government's thinking is that they dare not offend their monopolistic friends. There is no reason why they should be worried about that. We are not afraid to offend some of our friends when the occasion demands it. I see no reason why a Government as arrogant as this and with such a large majority who say that they fear nowt should not be prepared to take action. I hope that the House will give its blessing to the new clause. I know that there are some Conservative Members who will at least have some sympathy with the notion. I hope that the Government will for once feel it in their bones tonight to say yes to the advice that has been given not only by the official Opposition but by the Government's own advisers."acknowledged that it had not taken account of the wider implications, for example on the pharmaceutical industry, of its recommendation."—[Official Report, 8 December 1983; Vol. 50, c. 474.]
I listened to the hon. Member for Liverpool, West Derby (Mr. Wareing) with interest. It is clear from this and the previous debate that some hon. Members feel that they know much more about medicine than doctors do. That will sound a little odd when one considers what they will be saying on clause 13 tomorrow.Our objective in much of what we are trying to do is to obtain better health and better value for money. Those are the objectives set out in the White Paper. I am sure that the objectives of the hon. Member for West Derby are the same. Therefore, it is a pity that he felt obliged to have a go at the drug companies in the way that he did. When we discussed some of these issues in Committee it was clear that some hon. Members—I am not sure about the hon. Member for West Derby—would solve the problems that he described by nationalising the pharmaceutical industry. Indeed, the hon. Member for Wakefield (Mr. Hinchliffe) admitted that.
No doubt there are Labour Members who believe that they could run the pharmaceutical industry as well as they ran steel and shipbuilding and every other industry that was taken into public ownership but destroyed. The noble Lord Wilson put such rather silly thinking into context during a discussion about nationalising high street shops that sold clothes. He said that he would have difficulty explaining to his constituents how nationalising Marks and Spencer would make it as efficient as the Co-op. Labour Members who think that they could run the pharmaceutical industry more efficiently should give that example some thought.
I know that you, Mr. Speaker, will bring us to order if we stray too far from the new clause, but will the Minister ask her right hon. Friend the Member for Old Bexley and Sidcup (Mr. Heath) about the nationalisation of Rolls-Royce in 1972? Was that a waste of taxpayers' money?
I am delighted that the hon. Gentleman takes such an interest in my constituents. We have handed Rolls-Royce back to the private sector and everybody in Derby is thrilled to bits.Given the philosophies of Labour Members, it is not surprising that a small number of companies have reacted in political terms in the way that the hon. Gentleman described earlier. My Department is the sponsoring Department for the pharmaceutical industry. We should be proud of the industry's achievements, which depend on a strong base and on achieving a reasonable rate of return for its investment, particularly in research and development. If we were to force generic drugs on the National Health Service in the way suggested, the effect on the industry would be substantial and adverse. We are talking about 87,000 people directly employed in the United Kingdom in 1988 by Association of the British Pharmaceutical Industry companies. They estimate that indirect employment amounts to 250,000 jobs. Their capital investment in the United Kingdom will be about £400 million this year and their exports amount to £1·7 billion. The net positive United Kingdom trade balance in pharmaceuticals is about £850 million per year. The pharmaceutical sector, which the new clause would so damage if it were passed, is the most significant contributor to the United Kingdom's balance of trade, after oil and transport. Most significant of all is its research and development spending. The industry estimates that this year it will spend £700 million in the United Kingdom on research and development. Indeed, about 10 per cent. of all British and manufacturing industry research and development spending is contributed by the pharmaceutical sector. The case is always put to us—we take it very seriously—that research and development are strongly linked to our spend with the industry. If the National Health Service had to carry out the necessary research and development, I am sure that the cost would be greater than the amounts that I have just mentioned.
Does the Minister agree that the new clause would not interfere with the patent rights of pharmaceutical firms? Those patent rights, covering a period of 20 years, give full compensation for research and development costs.
The hon. Gentleman is quite right. The new clause does not interefere with existing legislation. He will be aware that there are active and heated discussions going on elsewhere about the length of time for which a patent should apply. The drug companies have strongly expressed the view to us that they would be most concerned if generic prescribing were to be made compulsory. We should be aware of the vast amount of research and development that the industry does, using the money that we pay it—we are the largest purchaser of its drugs—and which we would have to do if we were to match the amount that it is doing at present.The Guardian of 15 March 1988 reported that Glaxo had increased its research and development costs from £67 million to £101 million, which was reported recently to the company shareholders. It is expecting to spend £220 million in the full year, and that is an enormous amount of money. I understand that Glaxo is to spend £500 million over the next five years building a brand new medical research centre at Stevenage, employing up to 2,000 people. That includes some 600 new jobs. I wish that it were in Derby. It will develop new treatment for infectious diseases, cancer and immunology. It will rank among the most advanced research facilities in the world. Companies can do that only if they know that their products will be prescribed in the way that they are now. I was interested to hear that the hon. Member for West Derby is in favour of a selected list. I listened to his eulogies with great interest. I was a Back Bencher at that time and I remember that Opposition Members spoke against the limited list. I also remember that Opposition Members predicted all sorts of dire consequences as a result of what my hon. Friends were going to do at the time. I also seem to remember that Opposition Members voted against it. St. Paul's conversion on the road to Damascus offers a reasonable analogy to what the hon. Gentleman has just said. We will bear his views in mind. The new clause seeks the complete and compulsory use of generic products. We do not agree. The Opposition have argued that it would save money. Once again, I applaud the Opposition's interest in that objective. This evening for the first time, with the possible exception of the merit awards, they are keen that we should get value for money in the Health Service. We believe that we can save money without compulsion and that a better overall objective would be better prescribing. That goes wider than generic substitution. As the hon. Gentleman rightly said, there have been sharp improvements in generic prescription, without any compulsion. He mentioned that the number of prescriptions being written and dispensed generically in Great Britain had doubled from 14 to 28 per cent. in the 10 years between 1976 and 1986. Even more interesting is the fact that the number of prescriptions written generically but not necessarily dispensed generically, as there may not be a suitable generic product and the doctor writes the generic name, has gone up from 20 to 38 per cent. That means, broadly speaking, that some 40 per cent. of prescriptions are being written in a way that would meet with the hon. Gentleman's approval. The percentage is much higher in England than in Wales or Scotland, and perhaps hon. Members might take that on board.
I am a friend of many of the drug companies, yet they deplore what they are doing in relation to pure research. The Minister should consider the concern of the drug companies, which is shared by Sir George Porter and others, that the Government do not put nearly enough into fundamental science. The Minister mentioned Scotland. The understandable and justified squeals from the department of biochemistry—a very distinguished department at Edinburgh—are one example of the shortage of funds for basic sciences. The Minister and her Department should do something to persuade the Government to spend more on pure scientific research at the universities.
The Government will respond in the usual way to the report of the Select Committee in the other place. We will take into account everything that is said.I recall that one of the criticisms that is often put to British researchers is that we are very good at basic sciences but pretty hopeless at getting those excellent discoveries brought into development and use. That is not an adequate criticism of the pharmaceutical industry. This industry does basic science and funds a lot of research, including that in university departments. It puts a heck of a lot of money into first-class research and development and brings to the market marvellous drugs to which many of us owe our lives and for which many of us are very grateful. I take seriously what the hon. Member for Linlithgow (Mr. Dalyell) said; I merely suggest that some aspects of the pharmaceutical industry are a first-class example to other industries for which I do not have direct ministerial responsibility. I agree with many of the points made by the hon. Member for West Derby about local initiatives to improve prescribing. Voluntary measures to improve prescribing are achieving considerable savings. For example, in a group general practice in Scotland, the introduction of a formulary saved about 10 per cent. in terms of cost per person and per item. In Hampshire, the local medical and pharmaceutical committees have estimated that it might be possible to achieve a potential saving of up to £3·5 million. They propose to achieve that saving in a number of ways, including standardisation to 28 days' supply, a two-week trial for new medicines instead of a month, and the greater use of five-day courses for antibiotics, rather than seven.
On that basis—
It being Ten o'clock, the debate stood adjourned.
That, at this day's sitting, the Health and Medicines Bill may be proceeded with, though opposed, until any hour.— [Mr. Peter Lloyd.]
Question again proposed, That the clause be read a Second time.
On that basis, there is considerable scope for other local family practitioner committees and local medical committees to copy. In hospitals, the introduction of a formulary and management system has resulted in substantial savings. Guy's hospital, for example, experienced a decrease in actual spending of 16 per cent. over a four-year period, which is a constant price saving of 29 per cent. From a meeting that I had this morning with the chairmen of a number of family practitioner committees I know that a number of them are interested in using the Guy's hospital formulary.Wandsworth has had a decrease in actual expenditure of 12 per cent. over four years as against a 20 per cent. increase in activity. Ninewells, which is the teaching hospital in Dundee, effected a 15 per cent. reduction in drug costs on the medical wards in the first year of introducing a formulary. Westminster hospital has demonstrated a sustained reduction over seven years and spent 23 per cent. less, in constant price terms, at the end than it spent at the beginning. We take on board, therefore, much of what the hon. Gentleman has said. In other parts of the country, similar initiatives are being taken. There is a great deal of local interest in more economic prescribing. That is the basis on which to proceed, rather than by compulsion and limiting ourselves to generic prescribing. The overall drugs bill for the National Health Service is now over £2 billion, of which £1·6 billion is spent by the family practitioner service. We probably have more influence over the price of the drugs that we buy than many purchasers in other countries. Our negotiations with this important industry are designed to strike a balance between maintaining the strong, vigorous, research-based industry which we have in the United Kingdom and which it is in all our patients' interests to have, and obtaining value for money for patients. Our voluntary system does both. Compulsory generic substitution would probably do neither. Therefore, we reject the new clause.
It is all very well for the Minister to say that she is proud of the pharmaceutical industry. The pharmaceutical industry has far too many blotches and blemishes for that kind of uncritical and complacent attitude.I do not propose to go on about Opren. If I did, you, Mr. Speaker, would say that I was out of order, because Opren is not a generic product. The Minister, with her pathetic and inadequate advice on that subject, ought to know that she cannot say that the pharmaceutical industry is something to be proud of. It is not. The pharmaceutical industry has produced some fine products, it has a fine record and it deserves great praise, but the Minister ought to reconsider her views and look far more carefully and seriously at the pharmaceutical industry's shortcomings. I support new clause 5. When drugs are supplied, they should be generic products. I want to speak about tranquillisers. If generic products are supplied, the effects will be much the same as the effects of those dreadful products that are not generic, such as Opren and, in particular, Ativan which are tranquillisers and have caused such terrible damage to millions of people. The campaign by The Observer in articles by Carmel Fitzsimons has done a great deal to alert the public to the grave and tragic effect of tranquillisers. It is a horrifying story which should disturb the House. On 25 March, in a fairly remarkable answer to a parliamentary question, the Minister for Health said that half a million people were dependent on benzodiazepines in 1986, compared with 28 in 1977. What is the reason for that astounding increase? It is staggering, and demands immediate investigation. In June 1984, the Minister said that the Department was fully aware of the public and professional concern that some people might be dependent on prescribed minor tranquillisers. Although the Department was "fully aware", very little has been done by the Government to deal with this grave medical problem. It is appalling that, in the four years since that answer, there are still 25 million prescriptions of tranquillisers every year, and half a million people are affected. Many are generic products. Some are not sold. I find it shocking that research was not conducted originally into whether those tranquillisers caused dependency, and that general practitioners prescribed them so casually, despite warnings from the Committee on Safety of Medicines. The doctors have nothing to be proud of. I also find it shocking that the British drug industry is not working actively to help and advise those who are addicted on how to reduce their dependency, and that the drug industry of which the Minister says that she is so proud, ignoring all its shortcomings, is not actively seeking research and treatment for addicts. It is also very serious that the Department is not leading, rather than following, the voluntary organisations in tackling this serious drug menace. The pharmaceutical industry of which the Minister is so proud has a major responsibility to help. It should embark on a major research project to help to overcome the problems of addiction. The industry of which the Minister is so proud is mainly responsible for the problem of addiction. It caused the problem, and it should do something to solve it instead of sitting back and enjoying the profits. It should work with the Government in a co-operative endeavour to help. I hope that the Minister will listen to these reasoned, moderate criticisms, and will get together with the pharmaceutical industry and say, "Let us try to do something to help the millions of people who are suffering." Clear warnings should also be visible on all prescriptions, as is done in the United States. Why cannot these innocent people, who are seeking help because their nerves are bad and the stress is so great, see a warning on the bottle? That would be simple, easy and reasonable, and I think that it should be done. It is wrong that people should have to rely on doctors' advice, because far too often doctors do not bother with advice from the Committee on Safety of Medicines. They are too busy, indolent, or sometimes ignorant. There are some fine doctors, but there are some bad doctors. We cannot rely on the bad doctors. Certain notices should be on the bottle. The Minister should launch a vigorous campaign to prevent the further spread of addiction to tranquillisers, in particular benzodiazepines, and ensure that back-up support is available. I know that the Minister's Department is short of cash, but I hope that she will do what she can to finance the marvellous work of voluntary organisations such as Tranx-line, and the one in London whose name I have forgotten.
We already do.
Perhaps the Minister will help them a little more because they are short of money.If the Minister takes my proposals on board, she will help millions of people. I spoke last week to a man who talked of committing suicide because of his addiction to tranquillisers. He has tried to end his addiction, but he has hallucinations and he is driven round the bend. He needs help, support, advice and comfort.
I am obliged to my right hon. Friend for raising that issue. In many respects, he contradicts what the Minister said. I noticed that the Minister was nodding her head vigorously and saying that the Government are funding those voluntary organisations. However, the Government have only pump-primed them, with no more than £333,000. For example, the Council for Involuntary Tranquilliser Addiction in Merseyside has received no money at all. Much more is being spent on combating the abuse of hard drugs. Very little is going to the voluntary organisations which are so useful to the NHS.
I appreciate that point. The Minister has written me a letter explaining what she does for the voluntary organisations. However, the voluntary organisations in Liverpool have said that they receive very little indeed. In fact, they have said that they receive nothing. Therefore, the Minister must face the challenge of whether to help such organisations. The organisations are complaining of poverty and a lack of Government help in their work in assisting addicts.I do not want merely to score points; I want the Minister's help and co-operation. If we all work together we can reduce the suffering of the millions of addicts. Let us help them to beat their addiction. Let us help to prevent addiction. That can be done only if the Minister stops saying that she is proud of the pharmaceutical industry, looks at the blemishes and takes on board the criticisms. The pharmaceutical industry has a fine record, but it also has many blemishes and it is the blemishes that should be examined. The Minister should do something to help those addicts.
My hon. Friend the Minister is right to praise the pharmaceutical industry. I shall explain why. In 1840, or thereabouts, the average life expectancy was 27 years. Now people can expect to live deep into their 70s and beyond. In fact, Her Majesty the Queen sends out more telegrams of congratulation to people who have reached 100 years of age than ever before.That is a great tribute to the medics of this country and to the pharmaceutical industry. It is a great credit to all of them, but people must remember that, when pharmaceutical companies put money into research and development for new drugs to sustain life and make people more comfortable, they also put thousands of pounds into unsuccessful research. When they develop a drug that is useful to mankind, they do a tremendous service. They then have to develop a plant, so they have to make capital expenditure on a processing plant to produce and market that research product. The companies also have to think in terms of recovery in two or three years' time to recover that money. It is right, therefore, that they should have the right sort of profit margin for research and development and to recover the capital costs of their plant. They talk in terms of two or three years because, by that time, someone often develops a new drug and puts it on the market. Therefore, the great profit that people say pharmaceutical companies enjoy goes to another company. However, at the same time, it is healthy competition. It is developing drugs for the good of mankind. It is totally unfair to criticise the Minister for saying that we owe—
Will the hon. Gentleman give way?
No, I shall not.It is unfair to criticise the Minister for saying that we owe a great debt to the pharmaceutical industry. I venture to suggest that there is scarcely an hon. Member in the Chamber this evening who has not been thankful to the pharmaceutical industry. We have wonderful medics in this country, some of the best in the world. We have wonderful pharmaceutical industries, some of the best in the world. It is right that they should be developing and researching new drugs to sustain mankind up to and beyond the age of 70, instead of the age of 27, as it was in 1840. That speaks for itself.
I had not intended to intervene so quickly in the debate, but I could not resist the temptation, having listened to the absolute drivel that has been promulgated for the last five minutes.
The hon. Gentleman is the expert on drivel.
Yes, I am, particularly when it comes from the Conservative Benches on my own subject, which is the role of medicine in the health of the community and particularly the role of the medical profession. I cannot understand how anyone with a basic education could imagine that a major percentage of the increase in life expectancy of the human race is due to the medical profession. Even the medical profession would not have claimed that. I have never heard such rubbish in all my life.The hon. Member for Littleborough and Saddleworth (Mr. Dickens) disgressed a little from the subject. The increase in life expectancy is due not to the benefits of drugs, but to the way in which life expectancy from birth is calculated. Almost 90 per cent. of the improvement is due to the change in infant and perinatal mortality, which means that the nine out of 10 babies that used to die early in life no longer do so. That is why life expectancy has increased. In the 1840s, if one was fortunate enough to survive beyond the first or second year, one's life expectancy was little shorter than it is now. The other factors that have played a part are the development of decent wages and conditions, good housing and an adequate diet. Those factors, not the medical profession, have led to an increase in life expectancy. Let us consider the wonderful pharmaceutical industry. Unlike most hon. Members present tonight, I have worked in the industry and in the development of new drugs—the wonderful new products about which everyone talks. I can think of possibly three over the past 10 years that could be dignified with the description of a major advance in treatment. Some 95 per cent. of those drugs are what we call "Me, too." someone develops a new product and someone else comes along, takes the formula, makes minor changes, gets a patent and puts it into animals and man. Lo and behold, the new drug has the same effect as the drug that came before it. Small wonder, because it is effectively the same drug. It is not claimed that the new drug is better. However, largely spurious statistical studies are carried out which conclude that the drugs are equally effective. In fact, the conclusion shows that both drugs have the same effects and the effects are indistinguishable. That means that both drugs might be ineffective, and frequently they are. The drugs used in the vast majority of cases are not terribly effective. They may help us to bear some of the chronic conditions that we suffer nowadays, but they do not cure them. They do not cure any of the modern illnesses like diabetes or arthritis, from which so many people suffer. They cannot cure heart disease, hypertension, arteriosclerosis, or senile dementia.
I realise that the hon. Gentleman is a self-confessed doctor, and I am surprised at his comments. With regard to diabetes, why is the doctor saying that drugs just make people comfortable when he knows jolly well as a medical man that, unless a patient's blood count is right, with the right dose of insulin or sugar, that patient can go into coma and possibly die? How can the hon. Gentleman stand up and give false information when he knows differently from his training?
The trouble is that once one has experience of the subject, one learns that things are not always as they seem. Diabetics certainly do not die as young as they used to, but they are not cured. They receive help to manage their affliction. However, although advances are being made which may change this, at the moment they die in later life from different but related conditions and suffer a great deal in the process. This is a serious matter and we should be careful before we give unrestricted praise to the medical profession or the pharmaceutical industry.
My hon. Friend is making a valuable contribution, which is more than can be said for some of the other contributions this evening. My hon. Friend obviously has experience of the drugs industry from his work as a doctor. Does he have any comment to make on the wastefulness of competition and the wastefulness of very high profit margins enjoyed by the privately owned drug companies at the moment?
The profit margins on successful drugs are extremely high, as I am sure this Government and their predecessors are only too well aware. Hence the restricted list, which was rightly brought in several years ago to restrict prescribing costs. It is legitimate in a society in which drugs are manufactured by private companies to ensure that those companies receive a return on their investment; otherwise we would not have their investment and we might have to look elsewhere for it.We are perhaps over-generous in the amount of compensation that we give private companies. For example, over the past 20 years Hoffman La Roche has produced drugs that are of virtually no benefit to mankind. For many years it has charged the Health Service inordinate prices for those drugs, and it now leads the struggle against the provision of generic substitutes for those very products. It knows full well that the drugs can be made for pence, yet they can be sold by the company under brand name protection for pounds. Generic drugs are sound, safe and subjected to the same, if not more, stringent testing for solubility and type of action—I will not go into that, as it is a highly technical point—and they are as effective, or ineffective, as the products with which they are competing. However, generic drugs have the singular advantage that they are much cheaper. Therefore, they can help our over-burdened Health Service to meet a greater proportion of its increased costs through saving money on its drug bills. For that reason alone, the new clause is worthy of support.
I have listened intently to what the Minister has had to say. While I do not accept many of her arguments, particularly about the worth of the pharmaceutical industry, I would not want to detract from the useful research done by the industry. My hon. Friends have pointed out that more quality control may be desirable, particularly with regard to benzodiazepines. I am not won over by the argument about trade, because we have had the experience of transfer pricing by Hoffman La Roche and other monopoly practices by pharmaceutical companies. I am not at all happy that retail price maintenance, which was abolished over 20 years ago for most commodities, still applies to pharmaceutical products.Having said that, however, I note that the hon. Lady has agreed to some extent with what Opposition Members have said. I am sure that we will return to this matter again and again, until generic substitution becomes the vogue in the National Health Service. Therefore, I beg to ask leave to withdraw the motion.
Motion and clause, by leave, withdrawn.
New Clause 7
Hospital Domestic Services
`(1) Each district health authority and health board shall make such arrangements as seem to them reasonable for the provision of hospital domestic services.
(2) The Secretary of State shall have no power to direct district health authorities or health boards on whether they employ outside contractors in making arrangements under subsection (1).
(3) Notwithstanding subsection (2) the Secretary of State may specify minimum standards of hygiene to be required of arrangements under subsection(1).'.— [Mr. Norman Hogg.]
Brought up, and read the First time.
I beg to move, That the clause be read a Second time.It is right that responsibility for domestic services in the National Health Service should lie with the district health authorities, or, in the case of Scotland, with the health boards. That may seem obvious, but there has been some activity on the part of the Government of late that leads us to believe that they take a different view. The DHAs and the health boards have responsibility for catering and cleaning. My colleagues and I believe it to be right that management should be as close as possible to the delivery of services. The problems associated with domestic services have a great deal to do with poor pay and conditions, and little to do with poor management or lack of motivation. Recently the Government have sought means of privatising services through competitive tendering, and we have seen Whitehall telling the DHAs and health boards how it is to be tackled. There are more problems arising from under-investment in hospitals, low pay and buildings which are not conducive to efficient working than from the fact that the services are run by internal staff. Circular letters have been sent by the Minister responsible for the Health Service in Scotland, the hon. Member for Stirling (Mr. Forsyth), and I am sorry that he is not here. Ah, he has just arrived. This is really something of an occasion, because we had hoped to have the services of the Scottish Health Minister in considering the Bill in Committee, but I can promise him that when we go into Committee next week on the School Boards (Scotland) Bill I will repeat all my speeches on the Health and Medicines Bill so that he will not have missed anything. The Minister sent a letter to the health boards in Scotland telling them how they might proceed to privatise services, or, as he might prefer to say, to introduce competitive tendering. The result has been a fall in the morale of the staff of Scottish hospitals, culminating in days of action, and he must accept some responsibility for the present situation. One needs only to look at the experience of district health authorities in the privatisation of catering and cleaning to see that such a course is not in the best interests of patient care, which is the primary function of the Health Service. The National Health Service provides a high standard of catering at extremely reasonable prices. I checked on that this afternoon and found that University College hospital, London, which has a staff of 72 in its catering service, provides 1,600 meals per day on a budget of just £1·28 per head per day. That shows how efficient the staff can be. 10.30 pm I am sure that the Egon Ronay guide is widely read on the Government Benches, for reasons other than catering in the Health Service. It is certainly not widely read by the Refreshment Department of the House of Commons. The Egon Ronay guide commented favourably on National Health Service meals and concluded that the food at some of the private hospitals that were visited was little better than, and in one case was below, the average standard served by National Health Service hospitals in the same cities, despite the fact the private sector spends on average four times more per patient on food than does the state. The Egon Ronay guide was complimentary about the quality of the food and its presentation in the National Health Service. The same guide criticised private hospitals, describing their meals as "grossly over-priced". Therefore, when it comes to value for money, that is delivered by the staff in the National Health Service. These days we hear a lot about cook-chill. I can remember the Minister telling us a lot about cook-chill in Committee. I believe that this system of providing food could prove misguided in terms of the needs in the National Health Service. Indeed, it could well prove disastrous. It can destroy up to 90 per cent. of the vitamins in the food, as well as reduce its palatability—
The Minister for Health says "Rubbish", but I am sure that if he has been asked to reply to the debate he will explain why. All the evidence that I have been able to gather on this subject suggests that that is not a good way for us to proceed in the National Health Service and that there are considerable dangers from wrongly treated food.There is some evidence that many of the catering staff in the service give up because they find that they are no longer able to earn overtime because of the introduction of that system, which means that they are not able to sustain their standard of living. Indeed, the poverty level wages paid in the National Health Service are not adequate in the first place—
I am not sure whether I should intervene but I addressed a seminar of cook-chill on Sunday evening which was no doubt very good for my soul. The hon. Gentleman will doubtless further explain his concerns for the staff, but I advise him that the purpose of a hospital food system is to provide good quality palatable food for the patient, hot and at the right time. There is little doubt that cook-chill is capable of doing that better than most conventional systems.
I do not know where the Minister delivered his lecture on cook-chill last Sunday evening. I did not realise that he was the Government's answer to the "Galloping Gourmet".My point about the staff is that where they are employed for the job for which they are trained—that is the preparation, cooking, and serving of the food—they have to work overtime to sustain the service and their standard of living. The Government are using the process of cook-chill to achieve savings in the National Health Service, which results in those staff not being able to sustain their earnings and, therefore, leaving the service. There is some evidence that, to fill the gap, cleaning and domestic staff are being brought in by contractors to prepare the food, and there are dangers in that. I make that point to the Minister, and I hope that he will consider it again. Poor pay is a major contributory factor to the problems in the National Health Service and it will not be resolved by privatisation. Low wages lead to low morale which leads to low motivation and low standards. If that was better understood by the Government, perhaps we would begin to get somewhere. Notwithstanding the pay award which is pending, and which I hope the Government will fund fully, auxiliaries in the NHS start at £4,565 a year. A fully trained staff nurse gets £65 a week less than a fireman, and £109 a week less than a policeman. [Interruption.] It has a great deal to do with the problem. About 70 per cent. of nurses are forced to moonlight. The purpose of the new clause is to protect the service from privatisation, but if privatisation is introduced the problems will be aggravated. I do not know why the Government cannot understand that. The underpaid jobs have one redeeming feature. We raised this in Committee, but the point has still not been adequately answered. In the radio programme in which I took part with the hon. Member for Stirling he did not answer the point. If staff have to engage in competitive tendering for their own jobs, and if the tender is successful and they become private employees in the NHS instead of being NHS employees, is it not the case that they lose their superannuation rights? That point should be clarified, because the superannuation right is the only redeeming feature of the underpaid jobs. What happens to the superannuation rights of someone working for a private company who was previously a public service employee? This must be clarified, because superannuation is an important consideration for people with such poor employment conditions. Privatisation threatens the whole of patient care, which is the primary function of the National Health Service. Privatisation moves out of the hospital responsibility for important functions, most notably hygiene. Conservative Members are enthusiastic about the introduction of private services, but they do not realise that work in a hospital is a team job and that everyone has a commitment to achieve the highest standards of hygiene as an aid to patient care. We are discovering a catalogue of horror stories which must be attributed to the fact that privatisation has become such a factor in some places. In Bromley, 351 jobs are documented as having been lost through privatisation. In Greenwich, 150 jobs have been lost, the prices of meals for staff have increased, some kitchens have been closed and more housekeeping duties are being carried out by nursing staff. In Wandsworth, which is famous—or infamous—for privatisation, there were 739 job losses, the majority of which were 402 domestics at St. George's hospital in Tooting. In Ealing 100 jobs were lost as a result of a catering contract being won by a private contractor. In south London 125 jobs were lost in one case alone, in which a private hospital contractor won a domestic contract for Westminster hospital. The Association of London Authorities advises—[Interruption.] The Minister does not care for elected authorities. She much prefers to tell them from Whitehall how to run their affairs. We know that she subscribes to the view that Whitehall knows best. However, in the hospitals in which the Association of London Authorities made inquiries, there were dirty baths and showers, filthy sinks and draining boards, unclean sterile treatment rooms, patient day rooms left unclean, and low staff morale. On top of that, private contractors have not known what is involved in the cleaning of hospitals. They have not been able to find equipment. They have carried out cleaning procedures when it was not suitable to the immediately important task of hospital patient care. Their untrained staff have cleaned wards and clinics while nurses and doctors have been changing wound dressings and treating patients. There was an example of that at Queen Mary's hospital in Roehampton. That stems from the fact that the Government do not recognise that hospital staff work as a team for the promotion of patient care and that they must understand what is required of them in the promotion of patient care. That is simply not possible by having private companies do the job in such a temporary way and with such a turnover of staff. Privatisation has been to the detriment of patient care. One aspect that worries me is the coercion of health boards by the Government. The Under-Secretary of State for Scotland will know what I am about to say. It was deplorable that the chairman of Grampian health board was sent for when he and his board hesitated to act on the Under-Secretary's edict that they were to introduce what he calls competitive tendering in hospitals. The chairman was sent for and given the Star Chamber treatment. On top of that, the Under-Secretary of State for Scotland and the Secretary of State for Scotland are recorded as saying that the role of health boards in Scotland is to be the Government's agent. The onward roll of centralism and central Government is the hallmark of contemporary Conservatism. I do not know where it will end, but we in Scotland maintain that the Under-Secretary of State for Scotland has little authority for insisting on a devolved Government role in Scotland and that it is unacceptable that members of health boards should be addressed in such a way. We are weary of the fundamentalists of market forces, who seem to be determined to shove their doctrines down the throat of an unwilling people, as is the case in Scotland. The Government have no place for patient care in their policies. The House should recognise that by supporting the new clause.
I oppose the new clause. It is always disappointing when the Opposition come forward with ideas which are backward-looking and which in many ways conflict with the principles for which the National Health Service should stand. The NHS should be a national service, and to be a national service it needs common standards, some central direction and mission and some common administration and management purpose. The Opposition propose the opposite and seem to wish for a degeneration into local anarchy with no sense of central direction or management control.
The hon. Gentleman talks about common standards. Does he not recognise that of something like 400 performance indicators—statistics that the Government are now collecting—only about four relate to the quality of service and all the rest relate to throughput and cost-cutting? Are those the common standards to which the hon. Gentleman refers?
I do not entirely agree with the hon. Lady's analysis that only four of the performance indicators relate to the quality of care. Many of them relate to staff usage in relation to patient numbers and many people would suggest that that is a proxy for some elements of the quality of care. The majority of indicators are based on such ratios and calculations.I hope that the House will agree that one should seek value for money in any health system. The Government have introduced proposals that attempt to provide better value for money. The new clause would reverse that process by resisting moves to provide better value for money in hospital domestic services. I hope that most hon. Members will agree, too, that money should be concentrated where it is most needed—on patient care and on the services that go most directly to the patient. The fears that the Opposition express are strange. If it is true that the hospitals themselves can do the job best, they are free to bid for the business and to carry on as before, demonstrating that they are the cheapest and best and having pride in a job well done. It is curious that when competitions have been organised, the in-house services have often had to change their pricing, management style and many of their practices to win the bids. It is also curious that where the services have been put out to tender there have been substantial savings in most cases. That seems to give the lie to the idea that all the in-house services are absolutely perfect. We have then to consider the question of quality. It is argued that quality falls down if services are provided by a private contractor. One of the advantages of a private contract, however, is that one can enforce the contract or sack the contractor. There is no advantage in the in-house system. It is a matter of regret that salmonella outbreaks occurring as a result of conditions in hospitals have often started in kitchens where no private caterers are involved. Such outbreaks would be possible under either system, but it is nonsense to let people believe that they happen only where services have been privatised given that the evidence points in the other direction. If the NHS had a powerful chief executive with the necessary powers to put into place an efficiency drive across a range of activities, it would be quite easy for him, in a relatively short time to deliver £1,000 million of savings which could go straight into patient care. We should all be striving to achieve that. The National Audit Office has identified £300 million to £500 million of savings that could come simply from better use of properties. Several hundred million pounds more could come from the contracting-out of hotel-type services, and that is before considering the broad use of staff, which would be likely to produce savings if a sensible chief executive had the necessary powers. The new clause would be a retrograde step which would stand in the way of better value for money, better patient care and better national management of the service.
I should like to make two specific points to the hon. Member for Wokingham (Mr. Redwood). The first is on efficiency. When Conservative Members speak about efficiency, they use the word as a euphemism for cheapness. When they talk about services being better, they mean services being cheaper. The hon. Gentleman had to add as an afterthought the question whether the service might be better. When we talk about efficiency we mean efficiency in the provision of care, getting patients operations when and where they want them and by whom in the surroundings that they want. We do not mean the sort of efficiency that the hon. Gentleman talks about—cheapness at the expense of already low-paid workers in order to fill the pockets of Members who have interests outside the House.
The hon. Gentleman is lecturing us on efficiency. Does he recall that when the Conservatives came back to power in 1979, the Government asked the regional health authorities for their manning levels and that hardly any of them could give us the up-to-date levels or, indeed, any levels? The ones that did give figures were 18 months out of date. That was the efficiency that was achieved under the Labour Government. How can the Opposition lecture us on efficiency in the Health Service?
I shall resist the temptation to lecture the hon. Gentleman because, even if I spoke to him quietly, he would not understand what I was talking about.When the hon. Member for Wokingham talked about efficiency, he said that we needed to know more about the Health Service and the various factors that operate in it. Nobody disagrees with that, but there is more to efficiency than Conservative Members seem to think. There is more to it than cutting costs and looking at the financial aspect. As Ministers are always telling us, the purpose of the National Health Service is to provide care for patients. That must be the motivating factor, and it is done by increasing efficiency in the provision of care. Financial efficiency is cheapness, but it comes second to efficiency in the provision of care, in patients being seen when they want, by whom they want arid in the surroundings that they want. The hon. Member for Wokingham spoke about releasing money for patient care. I do not think that the hon. Gentleman appreciates the point made by my hon. Friend the Member for Cumbernauld and Kilsyth (Mr. Hogg), that everyone in the Health Service is involved in patient care. If we move anyone, care is affected. Conservative Members must agree, because when porters withdraw their labour they are told that it affects patient care. There is a contradiction in the points made by the hon. Gentleman. We have had enough hypocrisy from Conservative Members. Let us concentrate on efficiency in the delivery of patient care and stop using euphemisms about efficiency when what is meant is simply cheapness. I should like to speak to the new clause, which is more than the hon. Member for Wokingham did. It should commend itself to Ministers because it is all about democracy, devolving power and giving it back to the people. It is about devolution and letting decisions be taken where it matters. The hon. Gentleman talked about central control. How can things be controlled centrally if they are privatised to umpteen companies over which we have absolutely no control? That is the problem. Health boards wish to retain central control and Ministers ought to be keen to accept that, especially in view of the reassurances that they gave us about clause 4. The Minister will remember that in Committee we discussed that clause. Clause 4(1)(g) provides that the Secretary of State
"may give directions—
(i) for the exercise of any of those powers by any body constituted under the National Health Service Act 1977 or the National Health Service (Scotland) Act 1978; and
We wish to remove that power from the Minister, but he says that there is no problem about the matter, because it is power not to direct health authorities to do anything but to prevent them from doing silly things. The Minister said that it was to prevent them from putting up adverts for undertakers and charging money for them. For that reason, I am sure that the Minister will accept the new clause because it goes along with the philosophy that he put forward in Committee. The other reason for the new clause is to prevent what recently happened in Scotland with health boards. Here I come to the hon. Member for Stirling (Mr. Forsyth). Michael Forsyth Ltd.—[Interruption] Michael Forsyth Ltd. has nothing whatever to do with the hon. Member for Stirling. I want to make it clear that, when I mention Michael Forsyth Ltd., it has nothing to do with the hon. Member for Stirling. Here we have the great proponent of democracy who said that he wants parents to have power in education and wants to set up school boards but who will not allow local health boards to do anything. He directs them in a jackboot fashion against their wishes. He calls up the chairmen of the health boards and instructs them to tear up agreements. The health boards had agreements with the trade unions which brought about significant savings for the NHS and the hon. Member for Stirling—not related to Michael Forsyth Ltd.—told them to tear up the agreements. Can you imagine, Mr. Deputy Speaker, what Conservative Members would say if the trade unions were to tear up agreements? I remember Conservative Members saying that it is about time that trade unions stuck to agreements. Well, there were agreements and the hon. Member for Stirling—not related to Michael Forsyth Ltd.—told them to tear them up.(ii) with respect to the manner in which any such body is to exercise any such power".
Well, I am going to bore hon. Members a little longer. As I have said, Michael Forsyth Ltd. is not related to the hon. Member for Stirling.As a result of those agreements—I shall quote the figures of the hon. Member for Stirling—Scotland saved £20 million. The savings from privatisation in England and Wales are £100 million. The equivalent savings in Scotland from agreements with the trade unions are double those from privatisation in England and Wales. Therefore, that is an argument in favour of retaining the arrangements between the health boards and the unions and against privatisation. We want to give the power back to the health boards to ensure that decisions are taken locally, that all people benefit and that decisions are not made by Michael Forsyth Ltd., which is not related to the hon. Member for Stirling.
My hon. Friend the Member for Cumbernauld and Kilsyth (Mr. Hogg) set out coherently the arguments in favour of this clause. I was particularly interested in the fact that he referred to the cook-chill system. I was gratified to hear that the Minister has become an expert on cook-chill. I invite him to stick around until we reach clause 4 because I intend to refer in some detail to the cook-chill system in Wakefield and I would very much welcome his comments on that. I have tried endlessly to get some response from the Government on it. I hope that he will stay around until 3 or 4 o'clock tomorrow morning, or whenever we reach clause 4.My hon. Friends have set out the reasoning behind new clause 7. It is about the need to ensure proper standards of hygiene within the NHS and about the rights of working people to fair wages and decent working conditions. Competitive tendering, as the hon. Member for Wokingham (Mr. Redwood) has said, is advanced by the Government for two main reasons. First, on ideological grounds, bringing private companies into the NHS is a move towards breaking up the state, with which the Government are obsessed. Secondly, there is the issue of financial savings, which the hon. Member for Wokingham referred to as value for money. Those savings are supposedly made by privatising various services. I am sure that the hon. Gentleman will have heard on many occasions, as I have, the figure of £105 million quoted by Government supporters, as being the cumulative saving that has accrued as a direct result of the competitive tendering process. The figures have been used endlessly by Ministers and Government Back Benchers as a justification for turning the screw even further on more and more public services, particularly within the NHS. One can drive a coach and horses through the figure of £105 million; it simply is not accurate. I shall give a few pointers to why it is open to the gravest doubt. First, the supposed savings do not take account of the time spent by district and regional health authorities on preparing and monitoring tenders. I understand that more than a year ago the National Audit Office estimated that that cost was at least £15 million per annum. Secondly, different accounting methods have been used by district health authorities to assess the base-line cost and to measure the so-called savings of competitive tendering. Consequently, the figures are highly unreliable. Thirdly, redundancy costs have not been accounted for in the savings advanced by Conservative Members, which have supposedly been achieved through competitive tendering. In many areas where people have been made redundant because of competitive tendering those costs are high. Fourthly—this is crucial if one is to assess the real figure involved in this issue—there is the financial cost of forcing hospital workers to be dependent on unemployment and social benefit. 11 pm The Prime Minister constantly says that no Government have spent more than the present one on social security benefit. Of course that is true, but it is because they have made so many people redundant. They have put hospital workers on the dole and shoved their jobs out to private contractors. Those people are now claiming state benefit. That should be taken into account when considering the savings made by competitive tendering. About 2,000 jobs have been lost in the Yorkshire health authority since 1985, primarily because of the competitive tendering process. Many of those people are now in receipt of state benefit. That fact should be taken into account when talking about the tremendous savings made through competitive tendering. The savings made through competitive tendering are a fraud; they are a complete con trick. I would argue that it has cost public money to introduce competitive tendering, regardless of the problems of filth, catering difficulties and the major failures of numerous contracts that my hon. Friend the Member for Strathkelvin and Bearsden (Mr. Galbraith) mentioned. I know that on any issue the Government think only in terms of cash, but recently the Prime Minister started lecturing the Church of England and the bishops about morality. Is it morally right that the Budget gave more money per week to some people by way of tax concessions than many National Health Service workers in a year? Is it morally right that people earning less than £70 per week should have their wages driven down? In Committee I gave the example of a taxi driver in Wakefield who collects me who has to moonlight. He showed me his pay slip. He receives £81 per week working as a porter, and that includes a 25 per cent. bonus. He has to keep a family on that sum of money, and when his job is put out to competitive tender shortly, even if the in-house tender is successful, his wages will be driven down further. Is it morally right that people working in the most basic conditions should have them made even worse? Is it morally right that Tory Members, who have interests in private contracts, should speak in debates on the Health Service and vote on issues when they stand to gain financially? That happens time and again because the Government Benches are riddled by people who stand to gain from this issue. [HoN. MEMBERS: "Name them."] It would take me all night to name them. As a policy, competitive tendering has been a complete and dismal failure. It has been a failure for the district health authorities and health boards that have had to bring it in. It has been a failure for the patients, and, most of all, it has been a failure for the loyal and hard-working employees of the National Health Service. I urge all hon. Members with a conscience to give their full support to new clause 7.
At last we have an opportunity to debate the hypocrisy that we have heard so often from Ministers and from the Government about privatisation and the alleged efficiencies that emanate from it. They know that it is complete nonsense. In promoting privatisation they are really after a featherbedded system to produce enormous profits for private contractors for cleaning or catering in hospitals. They know perfectly well that the end result of privatisation is a starvation wage for those who work for those private cleaning companies, and enormous profits for the companies, and filthy hospitals.If the Government bothered to examine the results of the privatisation of cleaning in hospitals, they would find that there are quite appalling and astounding statistics about the number of contract failures. They would discover the number of times that doctors have refused to work in hospitals that are not clean enough, and the number of times that nurses have stopped doing nursing work because the wards are so filthy that the first priority is to clean the wards, not to carry out the necessary treatment of the patients. The new clause, in a very modest way, is trying to improve the situation. Subsection (1) states:
as it wishes for catering services, cleaning services or any other services within a hospital."Each district health authority and health board shall make such arrangements"
Will the hon. Gentleman give way?
I shall complete my point and then give way. The hon. Gentleman may have something useful to say, although I have my doubts.
I am grateful to the hon. Gentleman for giving way. He said that the new clause states that health authorities shall make such arrangements as they wish. That is not what the new clause says. It says:
Will the hon. Gentleman give the House his definition of reasonable?"as seem to them reasonable".
The hon. Gentleman raises an interesting point, as there is a great deal behind it. My idea of reasonable is reasonable wages for the staff, a high standard of cleanliness and a high standard of service. Above all, the motives behind the provision of that service should be a clean hospital and good quality food for the patients, not the motive of rip-off profits for the fly-by-night companies that seek to run away from the Health Service at the first opportunity.The hon. Gentleman knows perfectly well that it is wrong to have a Health Service dominated by private enterprise values that are interested only in making money out of the Health Service. Rather, it should consist of people who are determined to ensure the best possible standards for those who use the Health Service, namely, the patients. The House should be aware of some of the issues referred to by my hon. Friend the Member for Wakefield (Mr. Hinchliffe). A large number of Conservative hon. Members who have substantial shareholdings in contract cleaning companies regularly put pressure on the Government with regard to the Health Service—as they did at the Carlton Club private lunch, and as they do in boardrooms throughout the country and at dinner tables in this building. They try to convince the Government—who are readily convinced about such matters—that the one thing we need is central direction of health authorities by the Government—who are supposed to be against centralisation—to force them to hand contracts to private cleaning and catering companies. It is a corruption of our political system that that is allowed to happen in this building. The lid should be taken off the hypocrisy that accompanies this issue and the claims by Conservative Members that there are great savings to be made in the Health Service if we privatise everything. The savings are to be made in the form of profits for companies at the expense of the standards of treatment for patients, of clean hospitals and of good quality food. The profits are made because of dirty hospitals, poor quality food and a high level of unemployment among people who formerly cleaned hospitals and cooked food there. If the Government doubt my word, they should go to hospitals where private companies now do the cleaning, examine standards and talk to people who previously were able to take pride in their work but who are now doing the jobs of three of four people for a pittance. It is a disgraceful way to treat people who have given long service to the NHS and who are dedicated to it. In reality, Conservative Members have nothing but contempt for manual workers in the NHS, who have kept the hospitals clean for so long. My hon. Friend the Member for Cumbernauld and Kilsyth (Mr. Hogg) said that hospitals cannot be run without catering and cleaning staff. It is about time that hon. Members understood the community of interest in hospitals. Those who clean hospital floors, empty bed pans, wash soiled sheets and do all the unspeakable jobs that Conservative Members would not do in a thousand years, never mind for the wages that manual workers are paid, are every bit as dedicated to the NHS as are doctors, nurses and research chemists. I make no apology for saying that or for reminding the House that I am sponsored by the National Union of Public Employees, which does not pay me one penny piece for making this speech. It exists to represent the interests of low-paid manual workers. It recognises that privatisation is the enemy of decent working conditions, decent staff morale and a good Health Service. I want the Health Service to be free at the point of use and available to all. I also want it to operate on the basis of not causing fear among its staff, not putting low-paid workers' jobs on sale once a year to the lowest bidder and not forcing low-paid health workers to offer their services for even lower wages to some fly-by-night company that will exploit them for a year, after which somebody else will exploit them. Ministers should revert to the direct employment system and end fear of low-paid workers in the National Health Service. I hope that the House will return to this issue again and again, so that the scandal of the appalling standards and working conditions that private cleaning and catering companies provide, their attitude towards their staff and their contempt for the Health Service can be further exposed. Then we shall return to a decent system of centralised employment that guarantees proper working conditions and jobs.
As the hon. Member for Islington, North (Mr. Corbyn) has just reminded us, this is the trade union clause—the NUPE and COHSE clause. It was supported eloquently by the hon. Members for Islington, North and for Wakefield (Mr. Hinchliffe), who is also sponsored by NUPE. They are proud of that, and quite rightly, too. The hon. Member for Cumbernauld and Kilsyth (Mr. Hogg), who moved the new clause, is sponsored by NALGO. It includes among its members many senior managers in the National Health Service and in local government who know that much of what he said is wrong. They are running the system, and they are right to be proud of their achievements.As for the comments of the hon. Member for Peckham (Ms. Harman) on the performance indicators, I cannot resist the comment that what she said suggests that she has not looked at them, any more than she looked at the General Practice Finance Corporation's annual report. I suggest that she takes another look at them. They are all about getting cost-effective patient care. New clause 7 deals with hospital domestic services, which I understand mean services that vary widely throughout the Health Service from basic cleaning to a fully developed hotel service, from internal linen distribution to pest control. Rather than improving the present service, the new clause would stifle the competitive tendering initiative that is being shown by managers, many of them members of NALGO, over domestic support services. I was a little surprised, therefore, to hear all that was said about cook-chill. That is not a domestic service and it has nothing to do with the new clause. It is catering. But perhaps the hon. Member for Cumbernauld and Kilsyth normally eats his dinner off the floor.
I am delighted to give way to the hon. Gentleman.
The Minister is drawing a very narrow definition of "domestic". Perhaps that is because she does not really know much about domestic services. She probably has people to do them for her.
You bet. The hon. Gentleman put down the new clause, and, judging by his opening speech, he clearly did not read it.However, if we are to talk briefly about cook-chill, let me say that, as 387 catering contracts in England were won in-house and only 11 were won by outside contractors, the odds are that all the cooking that the hon. Gentleman and his hon. Friends have described—both good and bad—has been done by NHS staff who won their contracts through open competition. Incidentally, the hon. Gentleman asked what would happen to superannuation. Let me remind him that when NHS staff win a contract they stay as NHS employees, just as local government employees who do the same stay as local government employees. Nothing happens to the superannuation of those employees. They retain all their superannuation rights, and all their other rights as well. If the hon. Gentleman and his hon. Friends are really putting about that kind of rubbish in Scotland, it is no wonder that his constituents—
I shall give way in a moment. I listened to the hon. Gentleman with all the dignity and courtesy that I could muster, and I have not finished my sentence yet.If the hon. Gentleman and his hon. Friends have really been putting about that kind of rubbish in Scotland, it is no wonder that his constituents are upset, but it is not true. Nothing will happen to that superannuation, and if he even hints at it he is going much too far.
One of the Minister's roles in the House is to answer reasonably questions that are put reasonably to her about Government policies as they apply to constituents of hon. Members on both sides of the House. The question was put to her because the position was not clear. No one has been putting about any rubbish in Scotland, and I am sorry that she has addressed me in that tone. She would do better simply to give us the facts. If she stuck to that, perhaps she would manage to win some support for herself in the country.
I always listen to advice, even from Opposition Members. However, if the hon. Gentleman had even tried to consult members of NALGO, his own union, they would have given him the facts as I have given them. Indeed, if he had listened to the speeches of my right hon. and hon. Friends in Scotland, he would have heard the same many times.I listened to what was said by the Association of London Authorities. I felt that I would much rather the authorities used their rates in London to look after local ratepayers—for example, by improving services in the community which might assist patients being discharged from hospital—and not go poking around looking for very thin material to make political points that do no service whatever to the House. The hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) waxed eloquent about democracy. He impressed me during the Committee stage of the Bill because it was clear that he was one of the few Opposition Members who had read the Bill and the White Paper, and he kept surprising himself by saying that he agreed with most of it. We appreciate that very much. Perhaps, however, the hon. Gentleman has not quite understood the new clause. I know that his name was not on it, so perhaps he was not consulted in the way that Opposition Members like. The effect of subsection (1) would be to undermine the powers established under section 17 of the National Health Service Act 1977 and the National Health Service (Scotland) Act 1978 whereby the Secretaries of State can ensure the cost-effective delivery of the whole range of hospital services. Instead, health authorities and health boards would be permitted to act independently of central initiatives for domestic services, and would be able to choose to ignore the Secretaries of State. That is not acceptable, and is not in the interests of either patients or taxpayers. The powers that the new clause seeks to annul were provided by a Labour Government. They are wise and essential, and we want to retain them. On that basis, I feel that the hon. Gentleman has got himself in a bit of a twist. The approach of the sponsors of the new clause is very disappointing, particularly because other Opposition Members are trying to be much more helpful. I do not know whether hon. Members on either side of the House were able to hear the Leader of the Opposition taking part in a discussion over the weekend, which I thought very interesting and helpful. He said that not all public service was good and that not all private service was bad. That is entirely sensible and right and I commend that kind of approach—and perhaps some of that style—to the hon. Gentleman. Competitive tendering arouses strong feelings. That is a pity because, in the end, it is a method of achieving better service and better value for money. Competitive tendering is of proven value. More than £100 million has been saved and ploughed back into other patient services. There is also much greater emphasis now on setting and achieving standards in all these hotel services, and on tighter budgetary discipline and more flexible forms of provision. Eighty per cent. of the domestic service tenders to which this clause refers have been won in-house and, on average, costs have fallen by 23 per cent. That is a tribute to the managers concerned, most of whom are members of NALGO, and perhaps most of all to their staff, most of whom are members of NUPE and COHSE.
The Minister has used the same figure mentioned in my speech—that £100 million had been saved in England and Wales through privatisation. Does she agree that the savings made in Scotland from the agreement trade unions have with the health boards without privatisation is £20 million, which is equivalent to double the savings in England and Wales?
I heard what was said by the hon. Gentleman the first time because, whatever my public reputation might be, I do listen and I have an answer ready for him. He spoke of a figure of £20 million saved in Scotland. That is the accumulated figure over a number of years in Scotland.
Over how many years?
The figure of more than £100 million is the English annual saving, and so the two are not exactly comparable. Even so, I cannot see what the hon. Gentleman is so upset about. The money goes straight back into the National Health Service for patient care. That involves employing people, too, and it involves looking after patients.Indeed, when it comes to the matter of employment and the point made by the hon. Member for Wakefield the National Health Service has more than done its bit in recent years. It now employs some 1¼ million people, which is not only a national record but makes it the biggest employer in western Europe. The NHS now employs far more people than it did in the days when Labour last lost its grip on power, which I believe was way back in 1979. We are now starting the second round of tendering in England. Progress is being made in Wales, and the first round is under way in Scotland. All the health boards in Scotland are now engaged in the preparatory work that is necessary before seeking tenders. Indeed, I understand that some tenders have already been let. We expect that the exercise will be as fruitful in Scotland as elsewhere, and to the benefit of patients. The total amount involved in respect of domestic services in Scotland is more than £50 million, and if the savings are even close to those we have experienced elsewhere many millions of pounds are likely to be involved. The same fears that have been expressed today were expressed in England some time ago when our competitive tendering exercise began. They proved to be unfounded. We believe they will prove to be unfounded in Scotland as well. We deplore the methods by which some views have been expressed outside. Due to industrial action in Scotland, some 3,500 operations have been cancelled; 3,500 Scots people are suffering unnecessarily. Knowing hon. Members as I do, I doubt very much whether some of them—at least the hon. Members for Strathkelvin and Bearsden and for Cumbernauld and Kilsyth—are proud of the fact that 3,500 Scots people have been suffering unnecessarily. They did not intend that it should happen, but it has. During the recent industrial inaction, 90,000 meals were disrupted in Scottish hospitals. I am sure the food there is very good—certainly it was when I was in Scotland recently—but it helps patients if the food is actually served and if meal times are not disrupted. We strongly agree about the importance of public health and hygiene and we have taken strong action in the past 18 months to safeguard hygiene standards throughout Britain through sections 1 and 2 of the National Health Service (Amendment) Act 1986. It gave me great pleasure, as one of my first tasks at the Dispatch Box, to be involved in the passage of that legislation. The result has been a greater awareness of locally determined control of infection policies and improved understanding and collaboration between health staff, environmental health officers and health and safety inspectors, many of whom are members of NALGO. All health authorities have responsibility for maintaining standards, whoever does the work. We have no plans to change that system. I note the comment of Opposition Members about private companies, but, as my hon. Friend the Member for Wokingham (Mr. Redwood) hinted, all the successful prosecutions since the removal of Crown immunity have concerned in-house, not private, contracts. We want the highest standards whoever does the work and we hold the health authorities responsible. The hon. Member for Wakefield commented on catering standards in his constituency. Let me gently remind him that it was the appalling events in the kitchens of one of the hospitals there which were perpetrated by NHS staff and which resulted in a number of deaths of patients which resulted in the changes in the law that I have just described. The health authority in Wakefield was responsible then for the standards achieved—if that is what one could call them—and it is responsible now for the standards that are achieved, and we shall continue to hold it responsible.
The Minister should look again at the inquiry report on the Stanley Royd hospital, because she does not seem to have grasped exactly what it said. It referred to the conditions in the kitchen, which had nothing to do with the staff. The appalling fact was that they were working in an old workhouse building because of lack of investment in the NHS. The Minister might also care to comment on the fact that the new £1 million kitchen has been ready for a year but has not been used because of cuts in the NHS.
I have just made my comments about the previous incident and about current catering in Wakefield. The health authority is responsible and will continue to be so.The new clause seeks to destroy the initiative being shown by Ministers, health authorities and boards in our aim, which I think that some Opposition Members would share, to combine high quality service with value for money. Dare I suggest that some of the dislike of competitive tendering of NUPE and one or two other unions stems from a dislike of open competition, a fear of public scrutiny and a concern about the subsequent disappearance of the so-called Spanish practices which have plagued the NHS for far too long. The fact that the system in England is working should not upset them so, but it upsets NUPE and COHSE because they have most to lose. We are pleased to see the success of competitive tendering and we do not intend to let that be damaged or destroyed in the way proposed. If Opposition Members decide to press the new clause to a vote, we shall vote it down.
Opposition Members have listened carefully to the Minister. I regret that we are far from persuaded that she is anything other than just a believer in what she says, but cannot really substantiate it with fact. Her figure of £100 million, which we have heard endlessly, has been challenged time and again, whereas the figure of £20 million, which has been produced for Scotland. has not been satisfactorily dealt with. That figure was founded on trade union agreements, not on privatisation.However, the Opposition have come to understand that we are never able to persuade the Government of anything because they have closed minds. They do not believe in the NHS, they voted against its formation in the late 1940s, and they are destroying it now. We shall not let them do it and we shall press our new clause to a vote.
Question put, That the clause be read a Second time:—
The House divided: Ayes 202, Noes 307.
Division No. 256]
|Abbott, Ms Diane||Douglas, Dick|
|Adams, Allen (Paisley N)||Duffy, A. E. P.|
|Allen, Graham||Dunnachie, Jimmy|
|Alton, David||Dunwoody, Hon Mrs Gwyneth|
|Archer, Rt Hon Peter||Eadie, Alexander|
|Ashdown, Paddy||Ewing, Mrs Margaret (Moray)|
|Ashley, Rt Hon Jack||Fatchett, Derek|
|Ashton, Joe||Fearn, Ronald|
|Banks, Tony (Newham NW)||Field, Frank (Birkenhead)|
|Barnes, Harry (Derbyshire NE)||Fields, Terry (L'pool B G'n)|
|Barron, Kevin||Flynn, Paul|
|Beckett, Margaret||Foot, Rt Hon Michael|
|Beggs, Roy||Foster, Derek|
|Beith, A. J.||Fraser, John|
|Bell, Stuart||Fyfe, Maria|
|Benn, Rt Hon Tony||Galbraith, Sam|
|Bermingham, Gerald||Galloway, George|
|Bidwell, Sydney||Garrett, John (Norwich South)|
|Blair, Tony||George, Bruce|
|Boateng, Paul||Gilbert, Rt Hon Dr John|
|Boyes, Roland||Godman, Dr Norman A.|
|Bradley, Keith||Graham, Thomas|
|Bray, Dr Jeremy||Grant, Bernie (Tottenham)|
|Brown, Gordon (D'mline E)||Griffiths, Nigel (Edinburgh S)|
|Brown, Nicholas (Newcastle E)||Griffiths, Win (Bridgend)|
|Brown, Ron (Edinburgh Leith)||Grocott, Bruce|
|Bruce, Malcolm (Gordon)||Hardy, Peter|
|Buchan, Norman||Harman, Ms Harriet|
|Buckley, George J.||Hattersley, Rt Hon Roy|
|Caborn, Richard||Haynes, Frank|
|Callaghan, Jim||Heffer, Eric S.|
|Campbell, Menzies (Fife NE)||Henderson, Doug|
|Campbell, Ron (Blyth Valley)||Hinchliffe, David|
|Campbell-Savours, D. N.||Hogg, N. (C'nauld & Kilsyth)|
|Canavan, Dennis||Home Robertson, John|
|Carlile, Alex (Mont'g)||Hood, Jimmy|
|Clark, Dr David (S Shields)||Howarth, George (Knowsley N)|
|Clarke, Tom (Monklands W)||Hoyle, Doug|
|Clay, Bob||Hughes, John (Coventry NE)|
|Clelland, David||Hughes, Robert (Aberdeen N)|
|Clwyd, Mrs Ann||Hughes, Simon (Southwark)|
|Cohen, Harry||Illsley, Eric|
|Cook, Frank (Stockton N)||Janner, Greville|
|Cook, Robin (Livingston)||Jones, Barry (Alyn & Deeside)|
|Corbyn, Jeremy||Jones, leuan (Ynys MÔn)|
|Cousins, Jim||Jones, Martyn (Clwyd S W)|
|Cox, Tom||Kaufman, Rt Hon Gerald|
|Crowther, Stan||Kilfedder, James|
|Cummings, John||Kirkwood, Archy|
|Cunliffe, Lawrence||Lambie, David|
|Cunningham, Dr John||Leadbitter, Ted|
|Dalyell, Tam||Leighton, Ron|
|Darling, Alistair||Lewis, Terry|
|Davies, Rt Hon Denzil (Llanelli)||Litherland, Robert|
|Davies, Ron (Caerphilly)||Lloyd, Tony (Stretford)|
|Davis, Terry (B'ham Hodge H'l)||Lofthouse, Geoffrey|
|Dewar, Donald||Loyden, Eddie|
|Dixon, Don||McAllion, John|
|Dobson, Frank||McAvoy, Thomas|
|Doran, Frank||McCartney, Ian|
|Macdonald, Calum A.||Richardson, Jo|
|McFall, John||Robertson, George|
|McKay, Allen (Barnsley West)||Robinson, Geoffrey|
|McKelvey, William||Rogers, Allan|
|McLeish, Henry||Rooker, Jeff|
|McTaggart, Bob||Ross, Ernie (Dundee W)|
|McWilliam, John||Ross, William (Londonderry E)|
|Madden, Max||Rowlands, Ted|
|Mahon, Mrs Alice||Ruddock, Joan|
|Marek, Dr John||Salmond, Alex|
|Marshall, David (Shettleston)||Sedgemore, Brian|
|Marshall, Jim (Leicester S)||Sheerman, Barry|
|Martin, Michael J. (Springburn)||Sheldon, Rt Hon Robert|
|Martlew, Eric||Short, Clare|
|Meacher, Michael||Skinner, Dennis|
|Michael, Alun||Smith, C. (leton & F'bury)|
|Michie, Bill (Sheffield Heeley)||Smith, Rt Hon J. (Monk'ds E)|
|Michie, Mrs Ray (Arg'l & Bute)||Snape, Peter|
|Milian, Rt Hon Bruce||Soley, Clive|
|Mitchell, Austin (G't Grimsby)||Spearing, Nigel|
|Molyneaux, Rt Hon James||Steel, Rt Hon David|
|Moonie, Dr Lewis||Stott, Roger|
|Morgan, Rhodri||Taylor, Mrs Ann (Dewsbury)|
|Morley, Elliott||Taylor, Matthew (Truro)|
|Morris, Rt Hon J. (Aberavon)||Turner, Dennis|
|Mowlam, Marjorie||Vaz, Keith|
|Mullin, Chris||Walker, A. Cecil (Belfast N)|
|Murphy, Paul||Wall, Pat|
|Oakes, Rt Hon Gordon||Wallace, James|
|O'Brien, William||Walley, Joan|
|O'Neill, Martin||Wardell, Gareth (Gower)|
|Orme, Rt Hon Stanley||Wareing, Robert N.|
|Parry, Robert||Welsh, Andrew (Angus E)|
|Patchett, Terry||Welsh, Michael (Doncaster N)|
|Pendry, Tom||Williams, Rt Hon Alan|
|Pike, Peter L.||Williams, Alan W. (Carm'then)|
|Powell, Ray (Ogmore)||Winnick, David|
|Prescott, John||Worthington, Tony|
|Quin, Ms Joyce||Young, David (Bolton SE)|
|Randall, Stuart||Tellers for the Ayes:|
|Redmond, Martin||Mr. Ken Eastham and|
|Reid, Dr John||Mrs. Llin Golding.|
|Adley, Robert||Bright, Graham|
|Aitken, Jonathan||Brittan, Rt Hon Leon|
|Alexander, Richard||Brooke, Rt Hon Peter|
|Allason, Rupert||Brown, Michael (Brigg & Cl't's)|
|Amery, Rt Hon Julian||Bruce, Ian (Dorset South)|
|Amess, David||Buchanan-Smith, Rt Hon Alick|
|Amos, Alan||Buck, Sir Antony|
|Arbuthnot, James||Budgen, Nicholas|
|Arnold, Jacques (Gravesham)||Burns, Simon|
|Arnold, Tom (Hazel Grove)||Burt, Alistair|
|Ashby, David||Butcher, John|
|Aspinwall, Jack||Butler, Chris|
|Atkinson, David||Butterfill, John|
|Baker, Rt Hon K. (Mole Valley)||Carlisle, John, (Luton N)|
|Baker, Nicholas (Dorset N)||Carlisle, Kenneth (Lincoln)|
|Baldry, Tony||Carrington, Matthew|
|Banks, Robert (Harrogate)||Carttiss, Michael|
|Batiste, Spencer||Cash, William|
|Bellingham, Henry||Chalker, Rt Hon Mrs Lynda|
|Bennett, Nicholas (Pembroke)||Chapman, Sydney|
|Benyon, W.||Chope, Christopher|
|Bevan, David Gilroy||Churchill, Mr|
|Biffen, Rt Hon John||Clark, Dr Michael (Rochford)|
|Blackburn, Dr John G.||Clark, Sir W. (Croydon S)|
|Braker, Rt Hon Sir Peter||Clarke, Rt Hon K. (Rushcliffe)|
|Body, Sir Richard||Colvin, Michael|
|Bonsor, Sir Nicholas||Conway, Derek|
|Boswell, Tim||Coombs, Anthony (Wyre F'rest)|
|Bottomley, Peter||Coombs, Simon (Swindon)|
|Bowden, Gerald (Dulwich)||Cope, John|
|Bowis, John||Cormack, Patrick|
|Boyson, Rt Hon Dr Sir Rhodes||Couchman, James|
|Braine, Rt Hon Sir Bernard||Cran, James|
|Brandon-Bravo, Martin||Currie, Mrs Edwina|
|Brazier, Julian||Curry, David|
|Davies, Q. (Stamf'd & Spald'g)||Janman, Tim|
|Davis, David (Booth ferry)||Jessel, Toby|
|Day, Stephen||Johnson Smith, Sir Geoffrey|
|Devlin, Tim||Jones, Gwilym (Cardiff N)|
|Dickens, Geoffrey||Jones, Robert B (Herts W)|
|Dorrell, Stephen||Jopling, Rt Hon Michael|
|Douglas-Hamilton, Lord James||Kellett-Bowman, Dame Elaine|
|Dover, Den||Key, Robert|
|Dunn, Bob||King, Roger (B'ham N'thfield)|
|Durant, Tony||King, Rt Hon Tom (Bridgwater)|
|Dykes, Hugh||Kirkhope, Timothy|
|Eggar, Tim||Knapman, Roger|
|Emery, Sir Peter||Knight, Greg (Derby North)|
|Evans, David (Welwyn Hatf'd)||Knowles, Michael|
|Fallon, Michael||Knox, David|
|Farr, Sir John||Lamont, Rt Hon Norman|
|Favell, Tony||Lang, Ian|
|Field, Barry (Isle of Wight)||Latham, Michael|
|Fookes, Miss Janet||Lawrence, Ivan|
|Forman, Nigel||Lee, John (Pendle)|
|Forsyth, Michael (Stirling)||Lester, Jim (Broxtowe)|
|Forth, Eric||Lightbown, David|
|Fowler, Rt Hon Norman||Lilley, Peter|
|Fox, Sir Marcus||Lloyd, Sir Ian (Havant)|
|Franks, Cecil||Lloyd, Peter (Fareham)|
|Freeman, Roger||Lord, Michael|
|Fry, Peter||Luce, Rt Hon Richard|
|Gale, Roger||Lyell, Sir Nicholas|
|Garel-Jones, Tristan||McCrindle, Robert|
|Gill, Christopher||Macfarlane, Sir Neil|
|Glyn, Dr Alan||MacKay, Andrew (E Berkshire)|
|Goodlad, Alastair||Maclean, David|
|Goodson-Wickes, Dr Charles||McLoughlin, Patrick|
|Gorman, Mrs Teresa||McNair-Wilson, M. (Newbury)|
|Gorst, John||McNair-Wilson, P. (New Forest)|
|Gow, Ian||Madel, David|
|Gower, Sir Raymond||Major, Rt Hon John|
|Grant, Sir Anthony (CambsSW)||lvialins, Humfrey|
|Greenway, Harry (Ealing N)||Mans, Keith|
|Greenway, John (Ryedale)||Maples, John|
|Gregory, Conal||Marlow, Tony|
|Griffiths, Sir Eldon (Bury St E')||Marshall, John (Hendon S)|
|Griffiths, Peter (Portsmouth N)||Martin, David (Portsmouth S)|
|Grist, Ian||Mates, Michael|
|Ground, Patrick||Maude, Hon Francis|
|Grylls, Michael||Mawhinney, Dr Brian|
|Gummer, Rt Hon John Selwyn||Maxwell-Hyslop, Robin|
|Hamilton, Hon Archie (Epsom)||Mayhew, Rt Hon Sir Patrick|
|Hampson, Dr Keith||Mellor, David|
|Hanley, Jeremy||Meyer, Sir Anthony|
|Hannam, John||Miller, Hal|
|Hargreaves, A. (B'ham H'Il Gr')||Mills,Iain|
|Hargreaves, Ken (Hyndburn)||Mitchell, Andrew (Gedling)|
|Harris, David||Mitchell, David (Hants NW)|
|Haselhurst, Alan||Moate, Roger|
|Hawkins, Christopher||Monro, Sir Hector|
|Hayes, Jerry||Moore, Rt Hon John|
|Hayhoe, Rt Hon Sir Barney||Morris, M (N'hampton S)|
|Heathcoat-Amory, David||Morrison, Hon Sir Charles|
|Heddle, John||Moss, Malcolm|
|Heseltine, Rt Hon Michael||Neale, Gerrard|
|Hicks, Mrs Maureen (WoIv' NE)||Neubert, Michael|
|Hicks, Robert (Cornwall SE)||Newton, Rt Hon Tony|
|Higgins, Rt Hon Terence L.||Nicholls, Patrick|
|Hind, Kenneth||Nicholson, David (Taunton)|
|Hogg, Hon Douglas (Gr'th'm)||Nicholson, Emma (Devon West)|
|Holt, Richard||Onslow, Rt Hon Cranley|
|Hordern, Sir Peter||Oppenheim, Phillip|
|Howard, Michael||Page, Richard|
|Howarth, Alan (Strat'd-on-A)||Paice, James|
|Howarth, G. (Cannock & B'wd)||Patnick, Irvine|
|Howell, Ralph (North Norfolk)||Patten, Chris (Bath)|
|Hughes, Robert G. (Harrow W)||Patten, John (Oxford W)|
|Hunt, David (Wirral W)||Pattie, Rt Hon Sir Geoffrey|
|Hunt, John (Ravensbourne)||Pawsey, James|
|Hurd, Rt Hon Douglas||Peacock, Mrs Elizabeth|
|Irvine, Michael||Porter, Barry (Wirral S)|
|Irving, Charles||Porter, David (Waveney)|
|Jack, Michael||Portillo, Michael|
|Jackson, Robert||Powell, William (Corby)|
|Price, Sir David||Taylor, Ian (Esher)|
|Raffan, Keith||Taylor, John M (Solihull)|
|Rathbone, Tim||Temple-Morris, Peter|
|Redwood, John||Thompson, D. (Calder Valley)|
|Rhodes James, Robert||Thompson, Patrick (Norwich N)|
|Riddick, Graham||Thurnham, Peter|
|Ridley, Rt Hon Nicholas||Townsend, Cyril D. (B'heath)|
|Rifkind, Rt Hon Malcolm||Tracey, Richard|
|Roberts, Wyn (Conwy)||Tredinnick, David|
|Roe, Mrs Marion||Trippier, David|
|Rossi, Sir Hugh||Trotter, Neville|
|Rost, Peter||Twinn, Dr Ian|
|Rowe, Andrew||Vaughan, Sir Gerard|
|Ryder, Richard||Waddington, Rt Hon David|
|Sackville, Hon Tom||Wakeham, Rt Hon John|
|Sainsbury, Hon Tim||Waldegrave, Hon William|
|Sayeed, Jonathan||Walden, George|
|Scott, Nicholas||Walker, Bill (T'side North)|
|Shaw, David (Dover)||Waller, Gary|
|Shaw, Sir Giles (Pudsey)||Ward, John|
|Shaw, Sir Michael Scarb')||Wardle, Charles (Bexhill)|
|Shephard, Mrs G. (Norfolk SW)||Warren, Kenneth|
|Shepherd, Richard (Aldridge)||Wells, Bowen|
|Sims, Roger||Wheeler, John|
|Skeet, Sir Trevor||Whitney, Ray|
|Smith, Sir Dudley (Warwick)||Widdecombe, Ann|
|Smith, Tim (Beaconsfield)||Wiggin, Jerry|
|Soames, Hon Nicholas||Wilshire, David|
|Spicer, Sir Jim (Dorset W)||Winterton, Mrs Ann|
|Spicer, Michael (S Worcs)||Winterton, Nicholas|
|Squire, Robin||Wolfson, Mark|
|Stanbrook, Ivor||Wood, Timothy|
|Stanley, Rt Hon John||Woodcock, Mike|
|Stern, Michael||Yeo, Tim|
|Stevens, Lewis||Young, Sir George (Acton)|
|Stewart, Allan (Eastwood)||Younger, Rt Hon George|
|Stewart, Ian (Hertfordshire N)|
|Stokes, John||Tellers for the Noes:|
|Sumberg, David||Mr. Robert Boscawen and|
|Summerson, Hugo||Mr. Mark Lennox-Boyd.|
|Tapsell, Sir Peter|
Question accordingly negatived
New Clause 8
Prescription By Nurses
The following sub-paragraph shall be substituted for subsection (2)(a) of section 55 of the Medicines Act 1968 (exemptions for doctors, dentists, veterinary surgeons and veterinary practitioners)
"(1) to the sale or supply of all medicinal products that are not prescription only medicines, where the product is sold or supplied by a registered nurse of a category specified in an order made by the Health Ministers for the purposes of this paragraph in the course of her professional practice;
Brought up, and read the First time.(ii) and to the sale or supply of prescription only medicines which, by virtue of an exemption conferred by an order made under section 58(4)(a), may be sold or supplied by a registered nurse of a category specified in an order made by the Health Ministers for the purposes of this paragraph, otherwise than in accordance with a prescription given by an appropriate practitioner; or".'.—[Sir David Price.]
I beg to move, That the clause be read a Second time.
With this, it will be convenient to take new clause 9—Nursing practitioners—
The following subsection shall be inserted after subsection (8) of section 29 of the National Health Service Act 1977:'In subsection (1) of section 29 of the National Health Service Act 1977 (general medical services), there shall be inserted the words "and nursing" after the word "medical" (both in "medical practitioners" and in "personal medical services").
"(9) Regulations may provide—
(a) for the definition, registration and remuneration of nursing practitioners;
(b) for the definition of the personal nursing services to be provided and for securing that the arrangements will be such that all persons availing themselves of those services will receive adequate personal care and attention;
(c) for conferring a right on any person to choose, in accordance with the prescribed procedure, the nursing practitioner to whom he is to be attended, subject to the consent of the practitioner so chosen and to any prescribed limit on the number of patients to be accepted by the practitioner;
(d) for any additional arrangements the Secretary of State may deem to be necessary for the adequate provision of personal nursing services.".'.
New clauses 8 and 9 stand on the Notice Paper in my name and the names of a number of hon. Members who, the House will agree, cover a very wide spectrum of opinion in the House. I hope that this will make the new clauses appeal to hon. Members—[Interruption.]
Order. I wonder whether we might have a little order in the Chamber so that I can at least hear the hon. Member who is moving this motion.
As I was endeavouring to tell the House, Madam Deputy Speaker, new clause 8 pertains to the power of nurses to prescribe. New clause 9 is directed towards nursing practitioners and is relevant to new clause 8. I wish to say a few words in support of each proposition. I am conscious of the desire of the House at this hour to make fairly rapid progress, so I shall endeavour to be brief.The matter of nurse prescribing is not new. I remind the House that at present nurses have no power to prescribe even simple drugs and appliances, including pain-killers which can be bought over a pharmacist's counter. Frequently, district nurses and other nursing staff working in the community waste a considerable amount of time obtaining for their patients items such as new dressings. They must first obtain a prescription from the doctor, who may never have seen the patient in question, then obtain the item from the pharmacist, and take it back to the patient. Delays in treatment and inconvenience to patients can thus occur. Nursing time and travelling costs are wasted. In many instances, the community nurse is, in reality, the prescriber and the general practitioner merely authorises what she advises. Similarly, many community nurses have special expertise in the care of terminally ill patients and are quite capable of using their professional judgment on matters such as varying the timing and dosage of pain-relieving drugs prescribed by doctors. The House will be aware that the increasing development of primary health care teams is breaking down the old division between doctors, traditionally responsible for prescribing, and nurses, traditionally responsible only for administering treatment. With the recognition that individuals from different health professions can provide effective care to patients on their own, responsibility becomes a team rather than an individual approach. I remind the House that some groups of nurses, including occupational health nurses, midwives, and some nurses in the armed forces, already have the powers that we are seeking in the new clause. We are attempting to extend to nurses the power to prescribe. That was one of the recommendations of the Cumberlege report and of our own Social Services Select Committee report. I remind the House that paragraph 61 states:
In their primary health care White Paper, "Promoting Better Health", the Government responded favourably to that general proposition, stating that they will"We recommend that the Government introduce legislation to permit nurses with appropriate training limited powers to prescribe and in defined circumstances to modify dosage."
The new clause offers my right hon. Friend an opportunity to respond to his own White Paper and to our recommendations. I know that there is legal discussion as to whether amendments in primary legislation are necessary. There is a view that all we seek in the new clause can be done by my right hon. Friend under existing powers, by statutory instrument. I am advised that there is doubt about that and that it needs a change in substantive legislation. We are seeking the opportunity of the Bill to get the primary legislation put on the statute book, although the details are obviously still open to negotiation, and it would have to be implemented in the form of a statutory instrument in due course. I hope that I have said enough at this hour to make the case for new clause 8. I turn briefly to new clause 9, which flows from it, and again relates to the changing role of nurses. I can put the case most succinctly by quoting paragraph 59 of the Select Committee report on primary health care, which stated:"consult the Professional Standing Advisory Committees about the professional and ethical issues of prescribing by nurses with a view to producing appropriate guidance."
It is that which has led some of my hon. Friends and myself to push the question with my right hon. Friend. He will know that in Birmingham a research project was set up in 1982 to test the hypothesis behind the concept of nurse practitioners. It was found that nurse practitioners had a valuable role in a number of areas: first, acting as an alternative consultant for the patient; secondly, screening for serious disease and abnormal physical signs and symptoms; thirdly, the management and treatment of minor and chronic ailments and injuries; fourthly, and most important, the health education of the patient; and fifthly, counselling. As I think the House knows, the surveys which were done at the time of the Cumberlege report, and in a way for the report, supported the proposition that more of us would rather discuss our health problems with a nurse than with a doctor. I could go through the figures but the hour is late. I hope that I have said enough to indicate that we are concerned about the development of nurse practitioners and that we feel that they have a positive role to play in the scheme of things, particularly when there is more emphasis on care in the community, on the primary care team and, above all, on good health rather than on running just a sickness service."Nurse practitioners are a relatively new concept in the UK. Other countries such as the USA and most developing countries have had such an element in their medical services for many years. In the UK there is no precise definition at present of their role. At one extreme we have been told that health centres could be run entirely by nurse practitioners. Others see nurse practitioners as more akin to health visitors or district nurses, providing a mainly preventive and health education role. It is clear that with better education of nurses and as primary health care teams develop, the role of nurses is changing fast."
I support the new clauses and thank the hon. Member for Eastleigh (Sir D. Price) for proposing them. I hope that the Government will take them as a spur to action. We have had a lot a discussion about points of controversy and agreement has been reached. The arguments in favour of limited nurse prescribing and of recognising and institutionalising the role of the nurse practitioner have been well advanced.As the hon. Member said, with the development of care in the community the work of both the nurse prescriber and the nurse practitioner will be even more necessary. We had a debate earlier about cervical cancer screening. If the nurse practitioner were to carry out smear tests, that would be a useful role. I hope that we shall hear from the Minister that the Government intend to take action about nurse prescribing and nursing practitioners. We want to hear about specific action, hopefully with a timetable. The discussion should move to a close and we should see action on these two important issues.
I echo the remarks of the hon. Member for Peckham (Ms. Harman) and congratulate the hon. Member for Eastleigh (Sir D. Price) on bringing forward the two new clauses. I was surprised to hear him say that he thought that primary legislation might be necessary. That is not my under-standing from reading the detail of the Medicines Act 1986. In sections 55(2) and 58 there seem to be prima facie powers available to the Government to carry out the proposals in the new clauses. Midwives and occupational health nurses are allowed, in certain constrained circumstances, to prescribe items from the general sales list and some prescription-only medicines. No one is suggesting that there should be anything other than careful training and limitations on the powers.All the evidence available to the experts and commentators shows that the profession is developing substantially in that direction. To move along the lines suggested in the new clause would recognise established best practice. The matter was considered in the Cumberlege report and by the Select Committee. The primary care White Paper considered it in principle, too. There should be no difficulty about the principle of limited nurse prescription and nursing practitioners. There is some evidence that the Government are dragging their feet somewhat on the issue. As the hon. Member for Peckham said, the purpose of the debate is to request the Government to tell us what the up-to-date situation is, and, if there are delays, to explain why they should take place. In particular, after the introductory remarks of the hon. Member for Eastleigh, the Government should tell us whether primary legislation is required. Obviously, the implementation of any schemes will be postponed until parliamentary time is available. Had the hour been earlier, we could have had a much more substantial debate on the detail and practice that are to be worked out. On that basis, my right hon. and hon. Friends and I support the principle and the need to develop the practice and to implement the new clauses.
I congratulate my hon. Friend the Member for Eastleigh (Sir D. Price) on moving the new clause, even though I hope that he will not press it too far.Indeed, I recall one of my early indiscretions, within a day or two of being appointed to my present position. On the radio I stated that nurse prescribing sounded rather a good idea, which caused quite a fit when I got back to the Department that morning. My view that it is rather a good idea has been strengthened in the intervening period. As my hon. Friend will know—we referred to this matter in the primary health care White Paper—we saw merit in giving nurses more freedom to prescribe a limited range of items, such as dressings, ointments and medical sprays, and to exercise their professional judgment on the timing and dosage of drugs prescribed by doctors for the relief of pain. It is not a matter of foot dragging, to pick up the point that was made by the hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood). We have not reached the point at which we can say, "This is what nurses should be able to prescribe and this is how the arrangements will work." But I am glad to be able to report to the House some further progress, which I hope will go further fairly soon. Following an initial approach to the professional standing advisory committees—in the White Paper, we stated that we would do that—we are in the process of setting up a joint working party to examine the professional and ethical issues of nurse prescribing. We expect the working party to begin work next month. I hope that that will give the House some encouragement. Frankly, it is not possible to say—I pick up some other remarks of my hon. Friend and the hon. Gentleman—what, if any, legislative implications there will be, because we need to examine the work of the working party first. It is clear that we can do several things without primary legislation, but I could not put my hand on my heart and say that it is absolutely certain that all that one might want to do can be done without primary legislation.
Who is on the working party, and what will be the representation of nurses on it?
I cannot answer that question without notice, I am afraid. Should an appropriately armed carrier pigeon arrive from a certain quarter in the next moment or two, I shall see whether I can get the message off its leg. Otherwise, I shall see what information can be provided to the hon. Lady and, indeed, to other hon. Members by some other means.I have to be just a fraction less forthcoming about the concept of nurse practitioners. [Interruption.] Before dealing with that, however, I shall return to nurse prescribing. I cannot give names, but the answer to the question asked by the hon. Member for Peckham (Ms. Harman) is that there will be three nurses from the standing nurses' and midwives' advisory committee, two pharmacists from the standing pharmaceutical advisory committee and two doctors from the standing medical advisory committee, plus a chairman. Therefore, while it would not be quite right to say that the nurses will have a majority, there will be more of them than of anyone else, and I think that that position will be regarded as reasonable. 12 midnight I am equally sympathetic to the general principle of nurse practitioners, as the White Paper and the circular that the Government issued following the Cumberlege report suggested, but it is a more difficult subject because, as my hon. Friend the Member for Eastleigh acknowledged by implication—or perhaps even explicitly—in his remarks, the concept is not frightfully well defined. Our first problem, therefore, is to define exactly what we mean by the phrase "nurse practitioner" which we all tend to use in rather generalised terms. The Department is continuing work—again not with the aim of dragging its feet—with a view to deciding how best the work of agreeing a clearer definition can be carried forward with the professions. I shall certainly ensure that that work is undertaken as fast as it reasonably can be, but I cannot say much more this evening. I hope that I have conveyed to the House the Government's continuing sympathy for the concepts, the further progress that we hope to make fairly rapidly in relation to nurse prescribing and the fact that we have by no means forgotten the concept of the nurse practitioner.
I thank my right hon. Friend for that reply. I was encouraged by what he had to tell the House about the working party. I hope that he will be able to persuade it to put a time limit on its discussions, because there is nothing like a time limit to settle the mind. I can imagine the various bodies concerned going on indefinitely, and I hope that my right hon. Friend will get them to agree at their first meeting a time by which they will report. I shall, of course, expect my right hon. Friend to tell us the results. He will certainly have our support if any primary legislation is needed, although I very much hope that provision can be made by statutory instrument under existing legislation.I am encouraged by what my right hon. Friend said about new clause 9, to which I also spoke. It is rather urgent to get a proper definition because the subject has a bearing on the future supply of nurses, nurses' career structure and training and, ultimately, pay for extra responsibility for nurses. The concept is therefore relevant. In considering demographic forecasts of the number of young people with the necessary qualifications coming out of our schools, we must take more very much more seriously than hitherto the optimisation of nurses' professional qualifications. The concept of the nurse practioner is primarily directed towards that. With those few remarks, I beg to ask leave to withdraw the motion.Motion and clause, by leave, withdrawn.
New Clause 17
Complaints (Departmental Hospitals)
(1) Subject to subsection (2) below, the provisions of the Hospital Complaints Procedures Act 1985 shall apply to hospitals directly managed by the Department of Health and Social Security as though they were managed by a health authority.
(2) The Secretary of State shall, after consulting such bodies as appear to him to represent the interests of the public within the National Health Service, by order made by statutory instrument establish Regulations for the application of the provisions of that Act to enable it to apply to those hospitals.
(3) A statutory instrument under subsection (2) shall be subject to annulment in pursuance of a resolution of either House of Parliament.'.— [Mr. Fearn.]
Brought up, and read the First time.
I beg to move, That the clause be read a Second time.
With this it will be convenient to discuss new clause 19—Complaints ( Ministry of Defence Hospitals)
`—(1) Subject to subsection (2) below, the provisions of the Hospital Complaints Procedures Act, 1985, shall apply to hospitals managed by the Ministry of Defence as though they were managed by a health authority;
(2) The Secretary of State for Defence shall, after consulting such bodies as appear to him to represent the interests of the public within the National Health Service, by order made by statutory instrument establish Regulations for the application of the provisions of that Act to enable it to apply to those hospitals;
(3) A statutory instrument under subsection (2) shall be subject to annulment in pursuance of a resolution of either House of Parliament.'.
The Hospital Complaints Procedures Act 1985 has the potential to be a very useful piece of legislation. It is unfortunate that we are still awaiting its implementation and that consultation on the details of its implementation has taken so long. Perhaps the Minister will be able to report some progress in his reply. However, one limitation that has seemed to me unnecessary has been the restriction of its operation to hospitals managed by health authorities.The new clauses seek to extend the terms of the Act to two other kinds of hospital. New clause 17 would extend the legislation to cover hospitals directly managed by the DHSS. These are the special hospitals, and the top security Park Lane hospital, which I recently visited, is one such hospital. The work of the Mental Health Act Commission is of great importance in this context, but it still seems appropriate to include provision for management to take action in the same way as the management of health authorities are required to take action in mainstream hospitals. New clause 19 would extend the legislation to cover Ministry of Defence hospitals. As far as I can see, there is no justification for saying that an NHS patient who is receiving treatment in such a hospital, probably as a result of an NHS arrangement, should not be accorded the same rights as other NHS patients. The new clause enables anyone to debate the rights of service men who complain about things that could go wrong. It seems entirely wrong that a member of the armed services should have inadequate protection against problems that have nothing whatever to do with his employment. The problems covered by the new clause are cases in point. At this stage there is a need to be prescriptive on that more general issue. The matter can be debated before the regulations are laid under the new clause. The Government should have no difficulty in accepting these proposals. We are sure that the Government do not reject the view that all patients should have equal rights, without arbitrary distinction.
As the hon. Member for Southport (Mr. Fearn) said, his new clause seeks to apply the provision of directions issued under the Hospital Complaints Procedure Act 1985. He may know that I was associated with that Act, because, as a Back Bencher, among other things, I took it through the House on Third Reading. I agree with the hon. Gentleman's implication that it is a useful and valuable piece of legislation.We are about to issue a circular to the National Health Service. It has been delayed to secure final consultation with the Health Service Commissioner, the ombudsman, and the joint consultants' committee. Comments have been received and it is planned shortly to issue the circular under that legislation. Very minor modifications to the text of the circular are being made. It is expected that the directions will come into effect possibly in June or July. Of course sufficient time must be given for the health authorities to prepare for their responsibilities under the Act. New clause 17 is unnecessary. The directions will apply to hospitals managed by the Department of Health and Social Security. They will be required to follow the provisions of the Act in exactly the same way as hospitals in the National Health Service. Therefore, it is not necessary to establish a separate statutory instrument for the special hospitals. They will be covered by the Act, the circular and the directions that we are about to issue. New clause 19 deals with Ministry of Defence hospitals. Each hospital for which the Ministry of Defence is responsible already has well established procedures under which complaints may be made by or on behalf of patients at that hospital. These complaints are taken very seriously and are thoroughly investigated either locally or by the Ministry of Defence itself. Booklets explaining these procedures are supplied to patients on admission to hospital and notices giving information on the complaints procedures are displayed in out-patient areas at each hospital. Although Ministry of Defence hospitals do not come within the provisions of the National Health Service Act 1946, the Ministry's complaints procedures were reviewed in the light of the provisions of the Hospital Complaints Procedures Act. It was concluded at that time that while the provisions of the Act were not binding on the Ministry of Defence, they had already been implemented by the Ministry. My right hon. Friend the Secretary of State for Defence tells me that he is satisfied that these arrangements ensure that patients treated in Ministry of Defence hospitals have adequate means by which to make complaints. On that basis, we feel that new clause 19 is also unnecessary and the hon. Gentleman might not wish to press it.
In view of what the Minister said, I beg to ask leave to withdraw the motion.Motion and clause, by leave, withdrawn.
New Clause 18
'(1) It shall be a duty of the Secretary of State for Scotland to allot to each Health Board, after consultation with that board and with such bodies as appear to him to represent the interest of the public in the area of the Board within the National Health Service, an additional allocation sufficient to meet the cost of allowances paid pursuant to subsection (2).
(2) The Secretary of State shall by order made by Statutory Instruments provide that allowances in addition to any allowances otherwise payable be paid to general medical practitioners satisfying criteria:
(3) A Statutory Instrument under subsection (2) shall be subject to annulment in pursuance of a resolution of either House of Parliament.'.— [Mr. Kirkwood.]
Brought up. and read the First time.
I beg to move, That the clause be read a Second time.I should explain the purpose of the new clause from the outset because its wording does not make it as clear as it might be. It is an attempt to focus attention briefly on the plight and potential difficulties faced by rural practitioners in Scotland. Rural practitioners have problems throughout the length and breadth of the United Kingdom, but I think that the House would accept that, given the geographical disparate nature of large sections of the Scottish mainland, it is appropriate to focus attention specifically on the problems of rural practitioners in Scotland. The problems faced by general practitioners in Scotland relate, as much as anything else, to the question of list size. We know that the United Kingdom target is an average list size of 1,700 for general practitioners. In Scotland that is the average list size but the figure is due largely to the number or rural practitioners in the highlands and islands who have extremely small lists because of the nature of the geographical area they cover. In our urban and deprived inner city areas the list sizes remain too high and there is a need for more general practitioners. I had an interesting answer to a question that I tabled some time ago. It gave the number of small practices in Scotland. I was told that at 1 October 1986, the latest date for which information was available, there were 779 doctors with a list size of less than 1,000, 982 with a list size of less than 1,200 and 1,316 with a list size of less than 1,500. Therefore, there is a difficulty about the list size in rural practices. Having a large number of rural practices—often single-handed practices—with such small lists there are certain peculiar difficulties for the doctors. The proposals contained in the new clause and the thinking behind it seek to redress some of the working conditions they face, particularly the direct reimbursement of local allowances for GPs taking study leave, the introduction of functional group allowances and special assistance to enable doctors to take on a partner. That is the background and provenance of the new clause. I was prompted to table the clause, having received a letter from a Dr. Macleod in Inverness, whose permission I sought to advise the House of the contents of the letter he sent earlier this year. He said:
which is a fabrication and construction yard—"We have a relatively small list, so have never expected to make as much money as most of our colleagues. We have, however, time to give to our patients. We cover an area from Smithton to Brodie and Dulcie Bridge to Fort George. Our practice area includes the high risk areas of Dalcross Airport, McDermotts (Scotland)"—
"and the A96. For the convenience of our patients we operate branch surgeries in Croy and Nairn. We have patients in the local GP hospital and cover there for casualty. We have a Recall System for cervical smears and a Call Up system for immunisations. We provide a Well Woman Clinic and a Well Man Clinic. We undertake some minor surgery. We have a policy of regularly visiting our elderly patients. To avoid the unacceptable delays experienced elsewhere we have not operated an appointments system. We are each available for consultation for an average of 75 hours per week and many more during normal holiday periods. We do not delegate any of our work to deputies. We are a teaching practice.
We think we run a good practice. Geographically there is no scope for increasing our list size. For whatever reason, the patient demand is increasing well beyond that which one would expect from the pathology exhibited.
During discussions with Dr. Macleod it became clear that the implications for some practices in Scotland, which are small by United Kingdom standards, were severe indeed. I wonder whether the Government understand the full implications of their proposals. The new clause aims to make a reality of what the Government claim as being their target in their White Paper, "Promoting Better Health," to try to help rural areas. Far from helping rural areas, cash limiting general practices and plans to increase the size of lists and surgery hours before they qualify for basic practice allowances will have a devastating effect, particularly in Scotland. Under the new clause, the Secretary of State for Scotland would be forced to take into account the large number of rural practices, which are often single-handed practices. 12.15 am GPs who work in isolation, such as Dr. Macleod and his colleagues, must spend more time working for their patients than their urban colleagues because of increased travelling and home visiting. They have little contact with colleagues and experience difficulty in obtaining time off. Rural GPs often play a wider role, as I know from my constituency work, by substituting for other services that are lacking in rural areas. The new clause would require an additional allocation to be made, which would include inducement payments to cover the cost of employing high-calibre partners, study leave and improvements to surgery and medical facilities. This would ensure that GPs and their patients in isolated areas do not suffer professionally. Rural primary care saves resources by prevention and treatment in the community. The Government do not understand this matter and do not appreciate the needs and difficulties of isolated practices. If the new clause were to be accepted, it would go some way to addressing those problems and to improving health care for people in remote communities. I understand that some of these subjects are being discussed and that the Government are still considering what to do to confront the problems. I urge the Minister—a man for whom I have a high regard, even in Scottish matters—to take these matters seriously and to ensure that we get a fair deal and proper allocation for GP services in rural areas.In recognition of all this the proposals on list size in the White Paper will cut our income by something between £4,000 and £11,500."
I support the new clause, because it relates to a matter about which I have received representations. The Minister should give attention to those representations.The matter has been brought to my attention by a single-handed practitioner in my constituency who has been trying to promote the collective development of his practice along with neighbouring single-handed practioners—one in my constituency and two in the constituency of the right hon. Member for Kincardine and Deeside (Mr. Buchanan-Smith). He has been suggesting that it would be much better for individual practices and their patients to join forces to recruit a partner to the four practices to provide cover when the GPs are away on study leave or holiday. The obvious advantage is that patients would know the doctor standing in for their normal doctor in a way that they could not know a locum who has been brought in for short-term purposes. I think that the Minister will acknowledge that what tends to happen is that patients suddenly manage to contain their illness when their doctor is away, unless it is desperately urgent. When their doctor returns from study leave or holiday, he has a huge queue of patients who were not willing to see a locum whom they did not know. That is the essence of human nature and I think that the Minister will understand that that is what happens. It seems to me that the proposal of that practitioner and his colleagues is sensible and practical. It will help his practice, neighbouring practices and patients. Yet so far he has been unable to get support from the Scottish Office for his suggestion. When I first raised the matter with the Scottish Office, officials replied that they were not able to support the proposal because it was likely to be rather more expensive to operate than allowing each individual practitioner to retain his own locum. I then asked the Scottish Office to give an indication of the breakdown of costs, and the officials said that they had analysed the costs and there was no significant difference between supporting the doctors' wishes and simply requiring them to continue with the existing practice of hiring locums as and when they needed them. We managed to debunk the argument that it would necessarily cost more, although the new clause states that, even if there is a cost, it should be supported. In spite of having proved that particular point, the Scottish Office continues to resist this practical and constructive suggestion. I am sure that the situation is not peculiar to Scotland. There are parts of England to which this suggestion would be relevant and helpful. I have been mystified as to why it has been resisted so far, as indeed have the doctors in question, who feel that they are making a constructive suggestion in the best interests of their own working practices and of their patients. I believe that the new clause is sensible and constructive. It will not necessarily lead to enormous costs, and it will ultimately ensure that there is good health provision in thinly populated areas. It is not always easy to get dedicated doctors to come to rural areas and operate a single-handed practice. Only a particular type of doctor is willing to take that on. Doctors have come in and have not survived. Within a year or two they have felt unable to sustain the practice. With no disrespect to the doctors who have come to rural areas, it is interesting to note that two of the four practitioners that I mentioned are not British. They are very good doctors, they are very welcome and we are very glad to have them, but that situation is indicative of how difficult it is to attract people into those practices. The new clause would go a long way towards maintaining viable practices, ensuring that practitioners can have some relief from the constant pressure and can work with neighbouring practitioners in a constructive and helpful way. I hope that the Minister will take on board this suggestion. If he cannot accept the new clause tonight—we understand that—I hope that he will undertake to consider the thinking behind it and come back at a later stage having considered it. The proposals are constructive and serious and certainly should not be rejected out of hand.
When I first read the new clause, I was unclear as to its exact intent, but, having heard the explanation, its purpose is now clear to me. I am not sure that the new clause would fulfil all its intentions. Heaven forbid that amateur drafters such as ourselves should always be able to do that. However, the intention is excellent and we should like to record our support of it.It is a problem in rural areas, particularly in the highlands and islands and other parts of Scotland, but I am sure that it is also an important issue for some parts of England. A constant problem that affects general practitioners and surgeons who are on continuous 24-hour call for seven days a week is the inability to get away and go to postgraduate meetings. I realise that the new clause applies not to hospital doctors working single-handedly but only to general practitioners, but the principle is extremely important. Numerous ways have been considered to give doctors working in such practices time off so that they can keep tip to date with what is happening in medicine and have some relief from being on call for 24 hours. When they go home at night, they never know whether they will have to go out again. There is no respite from the continual ringing of the telephone. Various methods have been tried, and a roving practitioner was used for a while, but that did not really work. The purpose behind the new clause is that money should be provided for various things that general practitioners now have to provide for themselves. My hon. Friends and I support the new clause.
I have to confess that the Government and I collectively face the same difficulty as was experienced by the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith)—that we had not spotted the purpose of the new clause. Most of my brief is therefore scrap paper. I do not think that a carrier pigeon will come to my rescue on this occasion.I am encouraged by what has been said about the new clause. We thought that it amounted to a general attack on the system of reimbursing general practitioners that was proposed in the White Paper, but I now understand it to be a perfectly rational suggestion about how the system should be geared to meet the particular problems of particular areas. The suggestion is just as relevant to some parts of England as it is to some parts of Scotland. The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) kindly said that he would understand if I was unable to accept the new clause. I am unable to do so, but I shall ensure that the points that he has made are sympathetically considered. It is not for me to commit the Scottish Office, but I have no doubt that my colleagues there will want to study what has been said, and I undertake to do so in relation to England. I hope that it will be encouraging if I point to two quite clear-cut references in the White Paper to our awareness of the problem. I shall not weary the House by reading them at length, but paragraph 3.38, which refers to the possible introduction of a new allowance for areas of deprivation, goes on in the next sentence to say:
Paragraph 3.39, which is side-headed "Rural Areas," deals with the extent to which doctors, especially those who practise single-handed in rural areas, can be affected by a number of factors that can contribute to professional and social isolation. The final sentence reads:"The effect of these arrangements will be examined and if necessary other changes in the remuneration system will be introduced, for instance to help doctors in sparsely populated areas."
I hope that the spirit of those positive commitments in the White Paper, which are very much in line with the generality of what hon. Members have been urging on me, demonstrates that the Government are willing to look seriously at the points that they have raised."To take account of the particular pressures on these doctors, the Government will examine, in consultation with the profession, the scope for introducing measures aimed at alleviating their social and professional isolation, for example so that they may have more opportunities to attend post-graduate courses."
We have stumbled on a new tactic. If the Minister is naturally a fairly reasonable chap, the obvious tactic is to table a completely incomprehensible amendment that he has to think through for himself and to which he then, without any help from his civil servants, has to respond. It is a ploy that can be developed and used on future occasions.I appreciate what the Minister said, but at the risk of appearing churlish I hope that he will not mind if I press the new clause to a Division. It will demonstrate the importance that we attach to the subject. I understand that conversations are to take place, but a Division may help to concentrate people's minds. I propose therefore to press the new clause to a Division.
Question put, That the clause be read a Second time:—
The House divided: Ayes 43, Noes 194.
Division No. 257]
|Ashdown, Paddy||Lloyd, Tony (Stretford)|
|Beith, A. J.||McAvoy, Thomas|
|Brown, Nicholas (Newcastle E)||McFall, John|
|Bruce, Malcolm (Gordon)||McKay, Allen (Barnsley West)|
|Campbell, Menzies (Fife NE)||McLeish, Henry|
|Campbell, Ron (Blyth Valley)||Marshall, Jim (Leicester S)|
|Campbell-Savours, D. N.||Michie, Mrs Ray (Arg'l & Bute)|
|Carlile, Alex (Mont'g)||Morgan, Rhodri|
|Cook, Robin (Livingston)||Morley, Elliott|
|Corbyn, Jeremy||Mowlam, Marjorie|
|Cummings, John||Pike, Peter L.|
|Cunliffe, Lawrence||Robertson, George|
|Dunnachie, Jimmy||Rooker, Jeff|
|Ewing, Mrs Margaret (Moray)||Salmond, Alex|
|Galbraith, Sam||Skinner, Dennis|
|Graham, Thomas||Spearing, Nigel|
|Harman, Ms Harriet||Steel, Rt Hon David|
|Henderson, Doug||Turner, Dennis|
|Hinchliffe, David||Walley, Joan|
|Hogg, N. (C'nauld & Kilsyth)||Wareing, Robert N.|
|Hughes, John (Coventry NE)||Tellers for the Ayes:|
|Hughes, Simon (Southwark)||Mr. Archy Kirkwood and|
|Lewis, Terry||Mr. Ronnie Fearn.|
|Allason, Rupert||Arnold, Tom (Hazel Grove)|
|Amess, David||Ashby, David|
|Amos, Alan||Atkinson, David|
|Arbuthnot, James||Baker, Rt Hon K. (Mole Valley)|
|Arnold, Jacques (Gravesham)||Baldry, Tony|
|Batiste, Spencer||Hughes, Robert G. (Harrow W)|
|Bellingham, Henry||Hunt, David (Wirral W)|
|Bennett, Nicholas (Pembroke)||Hunt, John (Ravensbourne)|
|Body, Sir Richard||Irvine, Michael|
|Bonsor, Sir Nicholas||Jack, Michael|
|Boswell, Tim||Janman, Tim|
|Bowden, Gerald (Dulwich)||Jessel, Toby|
|Bowis, John||Jones, Gwilym (Cardiff N)|
|Brandon-Bravo, Martin||Jones, Robert B (Herts W)|
|Brazier, Julian||King, Roger (B'ham N'thfield)|
|Bright, Graham||Kirkhope, Timothy|
|Brittan, Rt Hon Leon||Knapman, Roger|
|Brooke, Rt Hon Peter||Knight, Greg (Derby North)|
|Buck, Sir Antony||Knowles, Michael|
|Burns, Simon||Latham, Michael|
|Burt, Alistair||Lawrence, Ivan|
|Butcher, John||Lee, John (Pendle)|
|Butler, Chris||Lennox-Boyd, Hon Mark|
|Carlisle, Kenneth (Lincoln)||Lester, Jim (Broxtowe)|
|Carrington, Matthew||Lightbown, David|
|Carttiss, Michael||Lilley, Peter|
|Cash, William||Lloyd, Peter (Fareham)|
|Chapman, Sydney||Lord, Michael|
|Chope, Christopher||Luce, Rt Hon Richard|
|Clarke, Rt Hon K. (Rushcliffe)||Lyell, Sir Nicholas|
|Colvin, Michael||Maclean, David|
|Conway, Derek||McLoughlin, Patrick|
|Coombs, Anthony (Wyre F'rest)||McNair-Wilson, P. (New Forest)|
|Coombs, Simon (Swindon)||Madel, David|
|Couchman, James||Malins, Humfrey|
|Cran, James||Mans, Keith|
|Currie, Mrs Edwina||Marshall, John (Hendon S)|
|Curry, David||Martin, David (Portsmouth S)|
|Davis, David (Boothferry)||Mates, Michael|
|Day, Stephen||Mawhinney, Dr Brian|
|Devlin, Tim||Maxwell-Hyslop, Robin|
|Dorrell, Stephen||Mayhew, Rt Hon Sir Patrick|
|Douglas-Hamilton, Lord James||Meyer, Sir Anthony|
|Dover, Den||Miller, Hal|
|Dunn, Bob||Mills, Iain|
|Durant, Tony||Mitchell, Andrew (Gediing)|
|Dykes, Hugh||Mitchell, David (Hants NW)|
|Eggar, Tim||Monro, Sir Hector|
|Evans, David (Welwyn Hatf'd)||Moore, Rt Hon John|
|Fallon, Michael||Morrison, Hon Sir Charles|
|Favell, Tony||Moss, Malcolm|
|Forman, Nigel||Neubert, Michael|
|Forsyth, Michael (Stirling)||Newton, Rt Hon Tony|
|Forth, Eric||Nicholls, Patrick|
|Fox, Sir Marcus||Nicholson, David (Taunton)|
|Franks, Cecil||Nicholson, Emma (Devon West)|
|Freeman, Roger||Onslow, Rt Hon Cranley|
|Gale, Roger||Page, Richard|
|Gill, Christopher||Paice, James|
|Goodhart, Sir Philip||Parkinson, Rt Hon Cecil|
|Goodson-Wickes, Dr Charles||Patnick, Irvine|
|Gorman, Mrs Teresa||Patten, John (Oxford W)|
|Gorst, John||Pattie, Rt Hon Sir Geoffrey|
|Gow, Ian||Peacock, Mrs Elizabeth|
|Greenway, John (Ryedale)||Portillo, Michael|
|Gregory, Conal||Price, Sir David|
|Griffiths, Peter (Portsmouth N)||Rattan, Keith|
|Grist, Ian||Rathbone, Tim|
|Ground, Patrick||Redwood, John|
|Gummer, Rt Hon John Selwyn||Riddick, Graham|
|Hamilton, Hon Archie (Epsom)||Roberts, Wyn (Conwy)|
|Hampson, Dr Keith||Roe, Mrs Marion|
|Hanley, Jeremy||Ryder, Richard|
|Hargreaves, A. (B'ham H'll Gr')||Sainsbury, Hon Tim|
|Hargreaves, Ken (Hyndburn)||Sayeed, Jonathan|
|Harris, David||Shaw, David (Dover)|
|Haselhurst, Alan||Shephard, Mrs G. (Norfolk SW)|
|Hayes, Jerry||Sims, Roger|
|Heddle, John||Smith, Sir Dudley (Warwick)|
|Hind, Kenneth||Smith, Tim (Beaconsfield)|
|Holt, Richard||Spicer, Sir Jim (Dorset W)|
|Howard, Michael||Stanbrook, Ivor|
|Howarth, Alan (Strat'd-on-A)||Stanley, Rt Hon John|
|Howarth, G. (Cannock & B'wd)||Stern, Michael|
|Howell, Ralph (North Norfolk)||Stevens, Lewis|
|Summerson, Hugo||Ward, John|
|Taylor, Ian (Esher)||Warren, Kenneth|
|Thompson, D. (Calder Valley)||Wells, Bowen|
|Thompson, Patrick (Norwich-N)||Wheeler, John|
|Thurnham, Peter||Whitney, Ray|
|Townsend, Cyril D. (B'heath)||Widdecombe, Ann|
|Tredinnick, David||Wilshire, David|
|Trippier, David||Winterton, Mrs Ann|
|Trotter, Neville||Winterton, Nicholas|
|Twinn, Dr Ian||Wood, Timothy|
|Vaughan, Sir Gerard|
|Waddington, Rt Hon David||Tellers for the Noes:|
|Wakeham, Rt Hon John||Mr. Robert Boscawen and|
|Walden, George||Mr. Tristan Garel-Jones.|
Question accordingly nagatived
New Clause 22
Allocation To Regional Health Authorities
`It shall be a duty of the Secretary of State each year to
allocate to each Regional Health Authority and to each Family Practitioner Committee in England an allocation sufficient to meet the costs of existing services, including the increase in costs arising from pay rises and price inflation on National Health Service purchases.'.— [Mr. Fearn.]
Brought up, and read the First time.
I beg to move, That the clause be read a Second Time.New clause 22 seeks to establish the principle that the Government have a duty to maintain the funding of the NHS at least in real terms. That has not happened in the past. Despite Government rhetoric, often at its most strident during Prime Minister's Question Time, the fact is that the NHS is suffering from cumulative underfunding over the years. For example, the Government have repeatedly argued that their so-called efficiency savings are the same as providing new money for the NHS. That is palpably untrue. The repeated failure of the Government fully to fund NHS pay awards to which they have consented and their failure to recognise the full effect of price rises in NHS supplies have meant that health authorities have been squeezed. People working on the ground know from their own experience that the Government's claims do not reflect reality. Moreover, there are particularly regional problems. The principle of equalising the level of health service available throughout the country is correct, but whereas the resource allocation working party strategy was established on the assumption that the provision would be levelled up, the Government have turned it into a matter of robbing Peter to pay Paul. The new clause would prevent the worst effects of Government policy. I should have liked to write into the new clause a duty for the Government to fund the additional demands for services from the increasing number of elderly people in the population and for improving clinical techniques, generally estimated at about 2 per cent. per year at present. However, the drafting of such a provision would inevitably be complex and almost certainly flawed. Therefore, I have compromised by including the words "at least". The formula set out in the new clause is not intended as a ceiling; it is merely a floor. The purpose of the new clause parallels that of the so-called Rooker-Wise amendment for personal taxation. It sets a basic demand for NHS funding, any breach of which would require primary legislation. We believe that the extra protection which would result from the fear of adverse publicity will protect the NHS generally, and each regional health authority and family practitioner committee in particular, from the worst potential effects of Government policies. I commend the clause to the House.
One effect of the new clause would be to impose on the Secretary of State a statutory obligation to anticipate the effects of NHS pay and price inflation in determining the financial allocations to regional health authorities and family practitioner committees. No sensible employer would ever guarantee to pay in advance all and any pay bill without knowing what it amounted t o. We await the reports of the review bodies on pay, and when they have reported and the various details have been gathered in my right hon. Friend the Prime Minister will make a statement.Generally speaking, the hon. Gentleman should be aware that the new clause, which we reject, would signal a return to volume planning throughout the public sector. The success of the Government's medium-term financial strategy, in particular the reduction of public expenditure as a proportion of gross domestic product, is based on the discipline of cash planning and the adherence, wherever possible, to cash limits. 12.45 am If accepted, the clause would reduce the Government's flexibility in reaching decisions on public expenditure programmes as a whole by pre-empting money for the health services ahead of, for example, programmes for pensions, and would remove the cash planning controls that have been such a successful feature of the Government's management of the economy. In any event, the clause is not practicable. The effects of pay and price inflation cannot be measured until after the end of the financial year in question. My right hon. Friend the Secretary of State could, therefore, perform the statutory duty that would be imposed on him by the clause only by ensuring a substantial margin of over-provision. There has been concern about the uncertainty created because health authorities enter the financial year before the review body recommendations are finalised. We have responded to that. As the Chief Secretary to the Treasury announced on 24 February, the Government are taking steps to change the timetable from 1989 for deciding the pay review body awards to provide greater certainty for health authorities when they draw up their budgets. We hope that decisions on the 1988 awards will be macle shortly, but in future years the timetable will be brought forward and we hope that decisions will be announced by the end of January. The basis of the Government's economic strategy to which I have just referred has given us the low inflation and rapid growth which have enabled us to fund the National Health Service to record levels, to employ record numbers of staff and to look after record numbers of patients, both inside and outside the hospital service. The new clause is uncalled for and not practicable, and I urge the House to reject it.
Question put and negatived.
New Clause 23
Access To Information
'(1) Subject to subsection (2) below, the provisions of the Local Government (Access to Information) Act 1986, shall apply to Regional Health Authorities, District Health Authorities, Health Boards, Special Health Authorities and boards of Governors as they apply to local authorities.
(2) The Secretary of State shall by order made by statutory instrument establish regulations for the interpretation of the provisions of the Local Government (Access to Information) Act to the extent that is necessary for the Act to apply to the bodies specified in subsection (1).
(3) A statutory instrument under subsection (2) shall be subject to annulment in pursuance of a resolution of either House of Parliament.'.—[ Mr. Fearn]
Brought up, and read the First time.
I beg to move, That the clause be read a Second time.The clause seeks to bring open government into the Health Service. Health authorities spend billions of pounds of public money and comprise people of whom only a small minority are directly accountable to the public. The formal accountability to Parliament, through the Secretary of State, is remote and capable of being enforced only in a pinprick manner. The clause seeks to establish a less formal but more effective form of public accountability, achieved by publicity. There is no justification for Health Service decisions being taken behind closed doors, except in the circumstances recognised by the Local Government (Access to Information) Act 1985. At present, different health authorities have different traditions of openness or otherwise, but in too many cases it remains the case, as used to apply in some local authorities, that administrative convenience or the wish to avoid embarassment is the real reason for choosing to debate an issue in private session. I have noted the private Member's Bill of the hon. Member for Warley, East (Mr. Faulds), which makes similar provision in respect of community health councils. That is fine so far as it goes, especially if the Government are prepared to fund the additional costs which community health councils will incur, but management decisions are taken by health authorities. The public needs access to the proceedings and documents of the health authorities. It is a principle, therefore, of good administration that decisions affecting people's lives should be taken in an open manner and that decisions on the spending of public money should be taken in public. It is that principle that the clause seeks to put into effect.
In saying why the Government do not feel able to accede immediately to the request of the hon. Member for Southport (Mr. Fearn), I wish to make the position as clear as possible. As I am sure he is aware, health authorities are already subject to the Public Bodies (Admission to Meetings) Act 1960.
Does the Minister know who put that on the statute book?
I know who was in the Government in 1960—
It was our right hon. Friend the Member for Finchley (Mrs. Thatcher).
but I had not realised that it was my right hon. Friend the Prime Minister who put that measure on the statute book. That persuades me even further that it must have been a splendid Act.The 1960 Act applies to health authorities and it requires them to give public notice of the time and place of the meeting with a notice on the door of the health authority office. Secondly, it requires them to supply copies of the agenda to any newspaper that requests it.Beyond that, some health authorities—although we are not sure that this is true of all—routinely send out agendas to newspapers and local radio. Thirdly, under the 1960 Act, they are required to open the meeting to the public. The slight impression that the hon. Member for Southport conveyed of all health authorities operating without any constraint in a completely hole-and-corner fashion was something of an exaggeration.
Is the Minister aware that some health authorities regularly and routinely use the procedure of going into private session to discuss what are supposed to be private matters but which in some cases are matters that should be dealt with in the public domain? While I recognise that individual patients' rights must be discussed in private, does the Minister concede that there is a case for examining more closely the propensity of health authorities to go into private session to discuss financial matters which should be brought into the public domain?
I was going to conclude by saying that I would certainly not rule out the possibility of giving further consideration to this matter. However, the new clause was tabled only on Monday and therefore appeared on the amendment paper on Tuesday, Frankly, we have not had a great deal of time to consider its implications which could be quite substantial.I was about to say that if the new clause was accepted, alongside or in addition to the duties that health authorities already possess in respect of public notice and public attendance at meetings, there would be added the following obligations. First, reasons would have to be given for closing a meeting, or part of it, to members of the public. I accept that that is not an unreasonable proposition. Secondly, copies of agendas and reports would have to be open for inspection by members of the public in advance. Thirdly, copies of minutes, agendas and reports would have to be available after the meeting for public inspection for six years. Fourthly, copies of background papers would have to be available for public inspection for four years. Finally, all the four items that I have just mentioned would also apply to sub-committees. I would not care to rule out one of those conditions within the circumstances of our discussions tonight as a matter of principle. However, the implications, including the administrative implications and the possible costs, are considerable. They would properly need to be carefully considered as there are so many other demands on the resources available to health authorities. I cannot advise the House to accept the new clause tonight. I want to refer to the point made by the hon. Member for Southport about community health councils. As he said, there is a private Member's Bill before the House at present concerned with applying the provisions in the Local Government (Access to Information) Act 1985 to community health councils. Community health councils, as the representatives of the public in an area, have substantial powers under regulations to receive information from health authorities. That is relevant when we consider how far health authorities can operate in the kind of hole-and-corner fashion to which the hon. Member for Southport referred. Although I do not feel able, for the reasons that I have given, to advise the House to accept the new clause, I would not rule out further consideration being given to the matter. However, I would not promise that consideration being given at a particular time, for example, during later stages of the Bill.
In view of what the Minister has said, I beg to ask leave to withdraw the clause.Motion and clause, by leave, withdrawn.
Vesting Of Property Etc Of Corporation In A Company Nominated By The Secretary Of State And Dissolution Of Corporation
Amendments made: No. 20, in page 1, line 20, at end insert—
'(3A) Shares issued to the Secretary of State in connection with the vesting of property, rights and liabilities in the successor company by virtue of subsection (1) above shall be issued as fully paid and treated for the purposes of the Companies Act 1985 as if they had been fully paid up by virtue of the payment to the successor company of their nominal value in cash.'.
No. 21, in line 21, at end insert—
`not later than the day on which an order is made under subsection (1) above,'
No. 22, in line 24, at end insert—
'(4A) Nothing in subsection (4) above shall be construed as limiting the operation of section 14 of the Interpretation Act 1978 (implied power to amend) so far as that section relates to the revocation of an order under subsection (4) above.
(4B) The Secretary of State may by order made by statutory instrument provide that provisions of the memorandum or articles of association of the successor company which have been specified in an order under subsection (4) above shall be alterable without his approval.'.—[Mr. Newton.]
Powers Of Secretary Of State
Amendments made: No. 24, in page 2, line 14, leave out from 'State' to first 'the' in line 16 and insert
`may by regulations made by statutory instrument with the consent of the Treasury make provision— (a) for guaranteeing'.
No. 25, in line 22, leave out 'to indemnify' and insert 'for indemnifying'.
No. 26, in line 26, at end insert—
'(3) A statutory instrument containing regulations under this section shall be subject to annulment in pursuance of a resolution of either House of Parliament.'.
No. 27, in line 26, at end insert—
'(4) Any power conferred on the Secretary of State by the articles of association of the successor company shall be exercisable in the national interest notwithstanding any rule of law and the provisions of any enactment.'.—[Mr. Newton.]
Corporation's Powers Pending Dissolution
Amendments made: No. 28, in page 2, line 30, leave out paragraph (a) and insert—
'(a) for valuable consideration to assign the benefit of a contract for a loan or to extinguish, or vary, by agreement an obligation under a contract for a loan;'
No. 29, in line 46, leave out from 'may' to end of line 47 and insert
(a) prohibit the making by the Corporation after a date specified in the direction of offers to lend money;
(b) prohibit the making of loans by the Corporation after a date so specified; and
(c) make any prohibition contained in a direction under this subsection subject to such exceptions as may be specified in it.'.—[Mr. Newton.]
Extension Of Powers Of Secretary Of State
I beg to move amendment No. 15, page 3,line 12, at end insert—
'(dd) to provide instruction for any person;'.
With this we will take Government amendment No. 19.
Amendments Nos. 15 and 19 are necessary to ensure that the National Health Service Training Authority is covered by the provisions of subsection (1) of the clause. The original drafting of clause 4 inadvertently created a situation where the NHSTA would have been able to recover only the full costs of services to non-NHS customers and not to make a profit. That is because the NHSTA's powers to charge for training come from different legislation—the Health Services and Public Health Act 1968. If we do not make the specific amendments that are before us today, the NHSTA will not be able to charge outside customers at commercial rates. The amendment merely brings the NHSTA into line with other health authorities. It does not permit the NHSTA to impose any sort of charge on health authorities.
Amendment agreed to.
I beg to move amendment No. 2, in page 3, leave out lines 21 to 28.
With this, we will take the following amendments: No.45, in page 3, line 31, at end insert⤔
'( ) The directions may not apply to any action taken or commenced by the body so directed before the day following that on which the direction is given.'.
No. 46, in page 3, line 31, at end insert—
'( ) The directions may not be given to Community Health Councils nor to Local Health Councils.'.
No. 47, in page 3, line 37, after 'satisfied,' insert—
'after consulting such bodies as appear to him to represent the interests of the public within the National Health Service".
No. 49, in page 3, line 41, at end insert—
(b) will not be to any significant extent prejudicial, directly or indirectly, to the health of any person or group of persons;'.
No. 50, in page 3, line 48, at end insert—
'(6) In exercising the powers conferred by subsection (1) above, the Secretary of State shall have regard to the value of management time likely to be used in any proposal under consideration, and to the viability of the proposal under normal commercial circumstances having regard to the rate of return of the capital value of assets employed in whole or in part to the proposal'.
No. 51, in page 4, line 5, after 'determine', insert
'after consulting such bodies as appear to him to represent the interests of the public within the National Health Service'.
No. 52, in page 4, line 6, after 'determine', insert
'after consulting such bodies as appear to him to represent the interests of the public within the National Health Service'.
No. 54, in page 4, line 12, after 'satisfied', insert
'after consulting such bodies as appear to him to represent the interests of the public within the National Health Service'.
No. 55, in page 4, line 43, after 'satisfied', insert
The amendment seeks to negate the very wide-ranging powers to be given to the Secretary of State under the various provisions of clause 4. It is a matter of some concern to Opposition Members that the Health and Medicines Bill has been generally presented as containing a series of reforming measures, designed to improve health care provision, and a number of largely unrelated provisions and proposals geared to making the National Health Service more efficient and effective. In reality, the Bill has a consistent and worrying theme—the further advancement of the market forces approach to health care.While most attention has been given to clauses 8 and 10 of the Bill, particularly because of the threatened rebellion of Tory Members tomorrow—we will wait and see what happens then—by far the most serious implications for the future of the National Health Service are contained in clause 4. It is very sad that we should be discussing an issue as serious as this in the early hours of the morning, with so few hon. Members present. The stated aim of clause 4 is to devolve fund-raising powers to district health authorities. The aim of the Government is clear. We discussed it in some detail in Committee. What they want to do with this particular clause is to get themselves off the hook as regards the under-funding of the National Health Service. I recall that the most recent report of the all-party Select Committee indicated that the current cumulative under-funding is in the region of £2 billion—a shocking indictment of present Government policy. So they want to get off the hook of their failure to invest in the health care of this country. Clause 4 is a deliberate attempt to divert attention away from the Government's responsibility to fund the National Health Service because, if the clause goes through, district health authorities can be blamed for failing to tackle under-funding at local level through the powers that they will have if the Bill passes into law. I already find that whenever I write to the Minister about Health Service issues she blames the local district health authority, no matter what subject I mention. I am primarily writing to her about under-funding and the lack of resources, and she puts the ball squarely in the court of the district health authority. I do not think that that is fair, but she will have an even greater opportunity to do that if this clause is passed. The second aim of the Government in this clause is to gear district health authorities and area health boards to being more concerned with profit-making ventures than with provision for patient care. That worries me very much. 1 am To be fully understood, clause 4 needs to be considered in the context of several developments. I shall specify two to which some consideration should be given. The first is the introduction into the Health Service in the last couple of years of business-style general management since the Griffiths report on management structure and, in many areas, the arrival into the Health Service of personnel who have been brought directly from private business operations. The second issue, which ties in with that and is worrying when one considers what could happen as a result of clause 4, is the introduction of performance-related pay, which will give financial incentives on the implementation of clause 4. When I ask the Minister how many general managers in my area have received incentive payments, it worries me that I am told that that is confidential. People in many areas are worried that those incentive payments are paid to managers for closing hospitals and wards and discharging patients who should not be discharged. I was grateful that my hon. Friend the Member for Cumbernauld and Kilsyth (Mr. Hogg) raised earlier the issue of cook-chill because, as the Minister is aware, I have pursued that matter with some vigour since last summer because of concern about it in my area. I am sorry that the Minister for Health has left the Chamber because he now professes to be an expert on the issue, but I hope that he will read my brief comments on it. One reason why I feel so strongly about the provisions of clause 4 is that in Wakefield we have had a foretaste of the kind of situation to which I believe clause 4 will lead. The Minister will be aware that one of the first ideas that the new Griffiths-style general manager in Wakefield introduced when he was appointed a couple of years ago—a gentleman by the name of Brian Birchall who, I understand, used to work for United Biscuits Ltd.—was that of generating income and saving money through sacking catering staff and adopting a cook-chill system. Now, nearly three years later, it is interesting to see what has happened. A newly built £1 million kitchen has been standing empty, doing absolutely nothing, for over a year because of concern about the safety of that system, which has been condemned as unsafe by the district health authority's own microbiologist. The DHA is currently having to divert money from patient care to pay for the new system. The most recent example—I hope that the Minister is listening to this because I want a response on this point later in the debate—is that Wakefield district health authority has been directed by the regional health authority to spend its additional allocation of £230,000 on making its cook-chill system safe. That money, which was begrudgingly allocated by the Government way back in November or early December, had been earmarked for the purchase of vital surgical equipment and for urgent roof repairs at Fieldhead hospital, which was designed by a gentleman who, I am sure, would be a supporter of the Government's philosophy. His name was John Poulson. That hospital roof is collapsing and needs repairing urgently. However, money is being diverted from those urgent repairs by the RHA to deal with the cook-chill problem. The Government have turned down the authority's demand for an inquiry into that issue. I have a good idea why. Clearly, it would expose the nature of the policies that are being pursued by the Government on privatisation and the proposals contained in clause 4. Frankly, the position in Wakefield is a shambles and a complete farce. It is precisely the position that we can anticipate when men of enterprise, who are now in general management, get their hands on the provisions in clause 4. It is vital that the hidden agenda of clause 4 is fully understood, because it evidences the clear aims underlying the Government's policies. It is about establishing the framework for moving substantial parts of current National Health Service provision into the private sector. There is no doubt that the powers contained in the clause will allow that. That is what they are designed to do. It is about deliberately boosting private care within the National Health Service and privatising yet more essential services, with the obvious consequences for standards of service and employment conditions which we discussed earlier. It is about creating the right climate for the wholesale introduction of the private health care market. If the Government were honest, they would admit that that was their real agenda. Amendment No. 2 seeks to delete dictatorial powers which the Government are taking on themselves to deliver what we regard as the real aims of the clause.
Amendment No. 45 seeks to prevent the Secretary of State making retrospective directions. It would be most unfair to health authorities and their managers if retrospective directions were made. I am sure that this is not the Minister's current intention—at least, I hope it is not—but we all know what happens as events develop. Eventually conditions will arise in which a future Minister may be tempted to make a retrospective direction. I am endeavouring to take that temptation away from him or her.Amendment No. 46 removes the right to give directions to community health councils and to local health councils. It is of the essence of these bodies that they are independent and free to represent the public in their districts. At present the only sphere in which anyone can issue directions to CHCs is in respect of their spending only the sums allocated to them. The effect of putting CHCs under potential ministerial control as regards the priorities for activities would be to detract from that independence. I am as sure as one can reasonably be that the Government have no intention of ever issuing directions to CHCs and LHCs. I believe that the fact that the bodies were covered by clause 3 did not occur to the draftsmen. I invite the Government in all seriousness to accept the amendment. The five amendments in this set provide for the Secretary of State to consult such bodies as appear to him to represent the interests of the public within the Health Service before he takes action. Community health councils have this responsibility for the public in their districts, and national and local politics both have local effects. Of course, the National Association of Community Health Councils and the Scottish association would be available as channels for consultation, and the Secretary of State may have other bodies in mind. Consultation would give a local input where the Secretary of State is making a detailed intervention in local services. Amendment No. 47 requires him to consult before saying that he is satisfied that there will be no adverse effects from his proposals. The clause as drafted says that the Secretary of State may not fail in carrying out a duty laid upon him by the National Health Service Act 1977. Amendment No. 49 writes in the other side of the same coin. Under it he would be proscribed from doing anything that had adverse side effects for the health of the community. Health promotion and the prevention of ill health are important. It is essential that the search for money should not finish up damaging the health of individuals and, incidentally, increasing the workload of the NHS. Amendment No. 50 seeks to impose on the Secretary of State the same criteria of commercial viability as the Government impose on local government direct labour organisations. It would be wrong if subsidiary activity—which fund-raising must be in NHS terms—ate up a significant amount of management time and NHS resources. The function of the NHS is to improve the health of the population. All else is subsidiary If the Government are unwilling to abide by the same constraints as they apply to local government, we have the right to ask why. The amendments do not set out to reverse the principle of the Government's proposals, which will inevitably go through. We seek to ensure that the proposals do not detract from mainstream health services and that they operate in a civilised manner. It is to be hoped that the Government will accept these minor amendments.
My remarks will be brief, because the Minister will go to the Dispatch Box replete with quotations from my good self about support for clause 4.I support the methods by which the NHS can recoup funds that have been spent on its behalf through the intervention and behaviour of people and companies. In other words, the NHS is losing money that rightfully belongs to it. It is certainly time that the NHS was able to recoup that money. The Minister will remember that I suggested several methods by which the NHS might be able to recoup some money. Perhaps amendment No. 86, which deals with overseas patients, might have taken that point on board. Despite liking some parts of the clause, I find it difficult to accept it, for two reasons. One is the point that was raised about health boards being instructed and not being given options. The other reason was raised by my hon. Friend the Member for Wakefield (Mr. Hinchliffe). Throughout the debate about the under-funding of the NHS, we have heard that, somehow, all problems will be solved by income generation. That is not the case. They are minimal amounts of money. Next year the figure will be about £10 million. and in the best possible year about £70 million. That is unacceptable, bearing in mind the inherent dangers in the clause. Therefore, it is worth making the position clear before the Minister reads out my quotations.
I shall not detain the House for too long, as some hon. Members probably wish to go home. We are dealing with the heart of the Bill and the most serious part of it. It is based on the false notion that the solution to the Health Service's financial problems is simply to turn each local health authority into some kind of income generation unit—that is, a local company—and start charging and recharging between various hospital departments and, indeed, within health authorities. Frankly, the whole matter is complete nonsense.The Health Service exists to provide a health service for the people of this country. A district health authority exists to ensure the best possible provision of health care within its community. Income generation is not the business of a health authority. It is not competent to do it. It should not be asked to do it. It has nothing to do with it. Yet health authorities are being told that they must examine the commercial potential of everything that they do. They must examine the commercial potential of each piece of land that they own and each facility that has been built on it, state whether it was given by charity in the past or built more recently, and consider ways of income generation from such nonsense as advertising on nurses' uniforms to opening shops within hospitals, and so on. It is complete and utter nonsense. I hope that the House will at least look carefully at the amendments, which will minimise the kind of nonsense that is proposed. Essentially, the Bill is quite clever. It claims to promote a form of local decision-making, autonomy and democracy by allowing a local health authority to make charges, to commercialise, to sell, to buy, to trade, or whatever else, but, at the same time, by a convenient sleight of hand, it effectively moves what remaining powers district health authorities have straight into the Minister's hands. In effect, the Minister can direct certain forms of sale or charging merely by withholding central grant from local health authorities. First, I hope that the House will accept that the Minister's power of direction is wholly wrong. Secondly, the effect of the proposals within the clause will not be an improvement of local health care, but will be the appointment of a whole new generation of business managers and the establishment of a business advice centre within the DHSS. It will effectively make local health authorities commercial organisations that are more interested in balancing their books than in improving health care and examining the health problems of people in their communities and cause them to move away for ever from the real purpose of the service. Rather than this nonsense about book-keeping exercises in local health authorities, we should be discussing the way in which central Government have consistently denied local health authorities sufficient funds to deal with the problems that they face and have sought to abuse them when they have criticised the Government for giving them insufficient funds. We should be talking about shifting power in the direction of some form of democracy in the Health Service rather than destroying it, as the Minister intends to do. 1.15 am I hope that the House will consider the proposals and that the Minister will think again and realise that charging is not the solution to the financial problems of local health authorities. The only solution to those problems is a very large injection of central Government money into local health authorities rather than handing that money out in tax relief to those in our society who already have a great deal of wealth, which is no doubt the option that the Minister prefers.
As hon. Members will know, in very general terms, clause 4 is directed at giving health authorities more freedom to raise income for the good of the National Health Service. Indeed, the opening words of the clause are:
I should have thought, therefore, that the clause would be widely welcomed. We were a little surprised and disappointed that the reception to it has been less than enthusiastic in one or two quarters. However, I am grateful to the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) for what he has said. I shall desist from embarrassing him further, except to point out that he said in Committee that the clause had some good parts to it. From him, that is not damning with faint praise; it is an enthusiastic response, and we are grateful to him for it. I listened with care to the hon. Member for Wakefield (Mr. Hinchliffe). He said that clause 4 is the most important part of the Bill. The Government think that it is very important, although the hon. Gentleman's hon. Friends clearly do not agree with him, as most of them appear to have gone home. The hon. Gentleman thinks that the clause is awful. We do not agree with that, and nor does NUPE. NUPE thinks that clause 4 is not bad at all. I wonder whether in his busy week the hon. Gentleman managed to come to terms with NUPE's submission to the Select Committee on Social Services, reported in The Guardian on 5 April this year. NUPE supports some ideas for income generation and says:"in order to make more income available for improving the health service".
That is NUPE's point of view. I am not sure how seriously I should take what NUPE says because later it says that the main cause of illness in this country is malnutrition, which is perhaps something that we should refer to the hon. Member for Kirkcaldy (Dr. Moonie). It is interesting to see how attitudes have shifted. In Committee I said that I could hear the sound of a troglodyte moving on this matter. When clause 4 first appeared, the Opposition parties jumped up and down and objected. When they read it and thought about it, however, they gradually realised that raising money for the Health Service, as provided for by the clause, is a good idea and very sensible. The hon. Member for Wakefield talked a lot about cook-chill. I cannot quite see what the catering system that they use in Wakefield has to do with income generation. The system to which the hon. Gentleman refers is not generating income; it has cost a lot of money. What we expect to have it generate fairly soon are some decent meals for the people who have paid for it through their taxes."It would add considerably to the attractiveness of hospitals if shops and banks were on the premises. There are also advantages in health authorities marketing some of the services they provide (eg laundry, catering) to other public bodies and the private sector."
I mentioned cook-chill in the context of clause 4 because that system was introduced by the new general manager as a means specifically of saving money but also of generating income—just as the Minister suggests clause 4 will generate income to local district health authorities. I used cook-chill as an illustration of what can go wrong under clause 4.
We do not expect 100 per cent. success with all the things that we get up to in the largest business in western Europe, and I am sure that the hon. Gentleman has accurately described what will happen in the future in Wakefield. Surely any measure that helps us to increase the resources available for health care is welcome. We estimate that the income generation initiative will raise about £20 million a year at the beginning, rising to perhaps £70 million in three years. I say quite honestly to the House that I hope that our estimates are wrong and that health authorities will raise much more than that. The money raised will help us to provide better patient services. This is National Health Service money and it will stay in the National Health Service to go on buying patient services and patient care.
Will the Minister give her estimate of the cost of taking on new management staff in order to promote this income generation? Can she tell us specifically what work she has done and how much money has been spent on setting up the advice unit that the Minister said would be established in the DHSS to advise district health authorities on income generation schemes?
The new income generation scheme is not yet costing us much money. The person we have appointed, Mr. Kerr, is working on it at the rate of one day a week. That is partly because his powers depend on the passage of the Bill. We have every expectation that not only will he earn his peanuts but that he will help us put a great deal of money into the Health Service. That also applies to all the other staff.