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Orders Of The Day

Volume 131: debated on Thursday 14 April 1988

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Health And Medicines Bill

As amended (in the Standing Committee), further considered.

Clause 7

Dental Services

4.11 pm

I beg to move amendment No. 60, in page 6, line 19, leave out 'and'.

With this it will be convenient to discuss the following amendments: No. 59, in page 6, line 27, at end insert:

'(c) The Secretary of State shall be required to provide dental inspection for pupils in attendance at schools who have opted out of local education authority control'.
No. 61, in page 6, line 27, at end insert:

'; and
(c) the following paragraph shall be added following subsection (2) (services the Secretary of State has power to provide)—
'(3) The Secretary of State shall report annually to parliament on the state of Dental Health and on trends in the incidence of dental disease in each health district, indicating in each case whether the corresponding health authority provides a school dental service.'.'.

Amendment No. 60 is merely a paving amendment. Amendment No. 59 makes it clear that the dental inspection service should be available in all maintained schools, not merely those under the control of local education authorities.

It seems to be the case that the Government's left hand does not know what their right hand is doing and that the Secretary of State for Social Services is not talking to the Secretary of State for Education about the Bill's effect. By moving an amendment to reimpose the duty in this case we are offering the Government an opportunity to admit that they have made a mistake.

Amendment No. 61 is important and is designed to allow Parliament to monitor the effect of the Government's change of policy. We fear that the effect of removing the present duty upon the Secretary of State will be that the dental health of children will deteriorate, or at least will not improve as fast as would otherwise be the case.

By keeping a close eye on what is happening we shall be able to see if that is so. I am working on the assumption that if the Government, or any future Government, discover that the policy is, as we fear, having a damaging effect, they will take action to reverse it.

I would like an assurance from the Minister that such action would be taken should there be any damaging effects. If I receive that assurance, I shall not seek to divide the House.

The Parliamentary Under-Secretary of State for Health and Social Security
(Mrs. Edwina Currie)

I recognise the interest and concern of the hon. Member for Southport (Mr. Fearn) and his colleagues in the community dental service, which we welcome.

Clause 7 amends existing legislation, as the hon. Gentleman has said, to remove the Secretary of State's duty to provide dental inspections and treatment for schoolchildren and replaces it with a power to enable the Secretary of State to provide those services. It also introduces an equivalent provision for Scotland. As I am sure the hon. Gentleman realises, the debate takes place against the background of a dramatic improvement in the nation's dental health, and, in particular, in the dental health of our children.

The discussion document on primary health care set out the need to reconsider the role of the community dental service. Its historical role of providing routine treatment for schoolchildren had once been vital at a time when general dental practitioners were struggling to cope with the demand for their services some 40 years ago in the face of rampant dental disease.

But the responses that we received to the discussion document agreed that emphasis on that role was no longer so appropriate, given the welcome increases over the years in dental manpower and the improvements in our population's dental health. Recent surveys show that the majority of schoolchildren already attend their own dentists for check-ups and the clause is intended to eliminate the undesirable situation where two services are duplicating provision for the same group.

Nevertheless, we see an important continuing role for the community dental service. There are areas, even in those health authorities where general dental practitioners are in good supply, where children are not receiving the best dental care. As we announced in the White Paper "Promoting Better Health", there is a need for increased effort in screening and providing treatment, help and advice in those areas. Therefore, the clause retains the power for inspections and treatments to be carried out where necessary.

4.15 pm

In line with our objective of providing better health, the clause also gives an explicit power to provide dental health education, where the law is rather vague at the moment. We also see a need for the community dental service to monitor the dental health of the general population, not just of children, and to provide services for groups that have difficulty in gaining access to dental care, such as the elderly or the mentally handicapped, who often have considerable difficulties in obtaining the care that they need from their general dental practitioner.

We shall also expect the community dental service to run group prevention and health education programmes for groups of the population, again, other than just for children. There will not be a cut, but we expect to see a major shift of emphasis by the community dental service to reflect the pattern of need in the community now and in the future, not just the pattern of 40 years ago.

Over the years I have repeatedly raised issues that are the concern of the British Dental Association. What is the BDA's attitude to the Government's attitude on this?

I was just coming to that. The British Dental Association has announced that it supports our objectives for the community dental service. It stated its view that they could be achieved without legislative change, but the advice that we have received is that that is not so. If we did not make the change that we have in this clause, we would find ourselves as a Government, on the one hand retaining legislation requiring routine dental inspection and treatment of schoolchildren, and, on the other hand, issuing guidance instructing health authorities to ignore their legal duty by redirecting resources away from that routine treatment of children towards other groups who now have genuine difficulties in gaining access to dental treatment. That dispute with the BDA is a technical one and our discussions with it on this matter have been completely amicable.

Apart from that, we are in close accord with the profession and we shall be discussing with it further the exact terms of guidance to be issued to the health authorities on the future role of the community dental service. I am confident that we shall agree on the outcome of those consultations.

As the hon. Gentleman has said, amendment No. 59 attempts to make it a legal duty that children in opted-out schools be given dental inspections. If the intention was simply to ensure that such children are covered by the general legislation on state schools, I would have complete sympathy with the hon. Gentleman. However, I can reassure him that the Education Reform Bill, which is now going through the other place, is the appropriate vehicle for the discussion of that provision. It already contains a section in schedule 10 which ensures that such schools will continue to be covered. On that basis, the amendment is unnecessary.

I share the views expressed in amendments Nos. 60 and 61 about the need for an annual report and full information. However, an annual report on the state of the nation's dental health is already published in the report of the chief medical officer. The data on dental health analysed by regions are collected every other year and are published in the general household survey. I shall ensure that the hon. Gentleman, who is the spokesman on health matters for the Social and Liberal Democratic party, receives a copy of both, but they are in the Library and always have been.

The fact that we collect and publish that information in the way that I have described demonstrates that we agree with him. I can assure him that we use the data in precisely the way that he has prescribed and I am sure that that will meet with his approval.

Having received an assurance that it will still be monitored and that children in deprived areas will fall into a routine, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Clause 8

Charges For Dental Appliances And Treatment

I beg to move amendment No. 10, in page 7, line 7, leave out clause 8.

With this it will be convenient to take the following: Amendment No. 62, in page 7, line 13, after 'descriptions', insert

'provided that the manner of recovery shall not include the withholding of dentures or dental appliances from the person for whom they were prescribed'.

Amendment No. 63, in page 8, line 17, after 'descriptions', insert
'provided that the manner of recovery shall not include the withholding of dentures or dental appliances from the person for whom they were prescribed'.

Amendment No. 12, in page 9, line 13, leave out subsection (7).

Government amendment No. 38.

The amendment seeks to remove the most offensive clause in the Bill, relating to charges for dental examinations.

Routine dental examinations have been free since the inception of the National Health Service 40 years ago. Clause 8 will mean that National Health Service dentists will become a shade more expensive than solicitors, who, in general, give their advice free.

I appreciate that hon. Members on both sides of the House find the clause offensive. I am modestly encouraged by the press, who have promised me that there will be a revolt of some 20 Conservative Members at the conclusion of the debate. [AN HON. MEMBER: "Where are they?"] Let us not be partisan. We are seeking grappling irons to throw across the Chamber to Conservative Back Benchers.

Yesterday, we had a revolt of only 10 Conservative Members. The press has promised me that matters will be even better than tonight on Monday, when from 10 last night to 20 tonight, we can hope that the number will be 40. That is a pleasing geometric progression that I hope will be borne out.

My only surprise is that apparently the Secretary of State does not intend to join us in our Lobby tonight. On the same day as the Secretary of State's Department produced the Bill, it also produced a White Paper which recorded:
"the Government attaches great importance to the promotion of good health and the prevention of ill-health."
The clause, which provides charges for routine screening, is in flat conflict with that stated commitment to the prevention of ill-health.

It is now four months since the White Paper and the Bill were published. The first question that the Secretary of State has to answer is where in Britain we can find any organisation committed to dental health that supports the proposal and that during the past four months in which the proposals were under debate has been convinced by the Government's argument. If the Secretary of State has to admit—as I suspect he will—that those four months have failed to convince a single organisation of the merits of the proposals, I have to put it to him that the sensible and courageous course would be to pack in and forget this lonely and friendless measure.

There are two reasons why the clause has failed to win friends. First, routine dental examination has to be the basis of any preventive approach to dental health. That statement is so obvious that it does not require elaboration. It is safe to say that all hon. Members have lost their milk teeth. We know that the earlier caries can be detected, the less amount of tooth needs to be destroyed for filling and the less chance there is of teeth being removed.

It is worth stressing and elaborating the extent to which dental examination is important screening, not only for dental health but for general health. My hon. Friend the Member for Cumbernauld and Kilsyth (Mr. Hogg) had a tumour removed from his mouth following referral after a routine dental examination in which it was discovered by the dentist. In some cases, such a referral can be life-saving.

It is worth recording that dental and oral cancer is now almost as common as cancer of the cervix. Last night, the House properly and fully debated arrangements for routine screening for cancer of the cervix. Treasury Ministers know that we have our differences with the Government's record on that matter, but at least the Government have admitted the need for systematic screening for cancer of the cervix.

It would be perverse if, the very next day, the House were to pass a proposal that threatens one of the most effective means of screening for a form of cancer almost as common as cancer of the cervix. Indeed, free dental examinations are possibly the most effective way of screening for oral cancer. A study by the Bristol dental hospital discovered that there were more referrals for oral cancer to the hospital from dentists than from GPs and that the referrals from dentists were at an earlier stage in the cancer. That is a vital point, with which my hon. Friend agrees. With his experience, he is well placed to guide the House.

It is vital that oral cancer is detected at an early stage, because the opportunity for surgical intervention in the mouth is limited by its character. The only chance of success in operations is if the operation comes at an early stage.

Other systematic diseases can be detected by dental examination. Mouth ulcers can indicate the onset of severe diseases such as Crohn's disease or now, tragically, AIDS. I find it odd that we should be placing an impediment on routine health screening, thereby losing one opportunity, however limited, for the early detection of AIDS.

There can be no doubt about the importance of the dental examination. I assume that the Secretary of State will agree. He would be in some difficulty in favouring a preventive approach to health care if he did not support the importance of the dental examination. The Secretary of State has an invidious task to discharge in maintaining that he accepts the importance of the dental examination, but that he can introduce a charge on that examination without discouraging people to attend for it.

That brings me to the second reason why the clause is so friendless. The proposition is such patent nonsense that it cannot seriously be submitted that we can introduce a new charge for dental examination without it affecting the people who attend for that examination.

Some patients will find it difficult to afford the fee. The exemptions from charge for dental charges are much more limited than the exemptions for prescription charges. People on incomes just above the poverty line will find that they are liable for the full charge of £3 for a dental examination.

It is ironic and troubling that the people who will be affected are the same people who, in the past fortnight, have been affected by the cuts in housing benefit. Yesterday, during the debate on social security changes, I referred to constituents on an income of £72 a week who had lost £11 a week in housing benefit. I am advised that it is unlikely that that couple will qualify for exemption from dental charges. They will have to pay for any future routine dental examinations, and it is obvious that will be a significant deterrent to those on a diminished income from coming for a routine examination.

Other patients may be able to afford a dental examination, but simply will not see the sense in paying for it. If they do not feel that there is anything wrong with their teeth, they will not see the importance of having an examination.

I am surprised that I need to point that out to a Government who are so infatuated with market economics. The Secretary of State came to office with something of a reputation as a pioneer of enterprise capitalism, pushing forward the frontier of the market. The Secretary of State will know that one cannot believe in a market unless one accepts that the pricing mechanism works. In other words, an increase in price must lead to a reduction in demand. Nobody with the Secretary of State's faith in the market can really expect us to believe that he thinks that he can increase the charge for dental examinations from zero to £3 without a very serious reduction in demand.

Nor is it necessary for us to reason that proposition only from abstract economic theory; we can prove it from the empirical evidence of history. During the past eight years the Government have persistently increased the charges for routine dental treatment. Yesterday, I noted that comparisons of the record with the last Labour Government were very popular with this Government. Let me remind them of one particular comparison.

In 1979 the maximum charge for routine dental treatment under the Labour Government was £5. The similar charge in 1988 is £115. After this Bill, the charge will be £150. That is an increase of 3,000 per cent., somewhat in advance of the rate of inflation. In the course of those nine years, the biggest leap came in 1985. In that year, the maximum charge for routine dental treatment leapt from £14·50 to £115.

It is instructive to note what happened to the demand for treatment in the subsequent year. The number of fillings completed in the subsequent year was down by 5 million, the number of root treatments was down by 140,000 and the number of treatments for gum disease was down by 1 million. Those figures went down not because the incidence of gum disease and caries went down but because fewer people presented themselves to the dentist because they were deterred by the charge. The only treatment that increased in that year was the number of extractions, for which the charge is relatively cheap. In other words, patients lost teeth that previously would have been saved.

4.30 pm

If the increase in 1985 had that effect, we can expect with confidence that an increase from zero to £3 will also result in a reduction in the demand for dental examinations. That reduction can also be numbered in millions.

What is to be achieved by that lost opportunity and those lost teeth? It is to achieve a revenue saving from this proposal of £50 million. This is not a Government who are strapped for the odd bob or two. We saw only last month just how well financed the Government are. They do not need to sell the principle of free preventive screening for such a paltry price. They do not need to put at risk the dental and oral health of those who will be put off from coming forward because of the charge. Perhaps most importantly, the House does not need to let them do it. Together we can stop them.

Opposition Members are accustomed to voting against the Government. We have had quite a bit of practice since the general election. All we require in order to stop this piece of friendless nonsense is for Government Back Benchers, who know it is wrong and that it will adversely affect the dental and oral health of their constituents, to join us in the Lobby.

It is really a very simple question: do we want to encourage people to have more dental examinations or do we want them to be discouraged from having dental examinations? It is as simple as that.

When I asked my right hon. Friend the Secretary of State and his hon. Friends in debate whether they believed that imposing charges would make it more or less likely that patients would offer themselves for examination, not surprisingly, I did not receive any convincing answer because they knew as well as I do that when a charge is imposed it will make it less probable, not more probable, that people will offer themselves for examination.

The second question is, is it desirable that people should offer themselves for examination? The answer to that is equally clearly yes. It is desirable in the interests not only of dental health but of early treatment for other diseases that become apparent only when there is a proper dental examination. Moreover, it is an examination that general practitioners, despite their very extensive training, are not trained to undertake. That is why I shall vote for the amendment to remove the clause.

I wish to speak to amendments Nos. 62 and 63, which make it clear that the manner of recovery of charges shall not include the withholding of dentures from patients who need them. That would be a cruel and unusual punishment for poverty. We do not like any of the new charges anyway and we shall be voting against them in any Division tonight. It is particularly distasteful that the Government seek to impose a charge for dental inspections, which will militate against the maintenance of the good dental health of the population.

Working on the assumption that we shall not overthrow the Government's majority in the cause of civilised behaviour on this occasion, as has been the case so often lately, it would at least be a gesture for the Government to concede that they do not need a power to withhold dentures from a patient who needs them until he or she has scraped together enough money to pay the charges.

I have a great deal of sympathy for those who argue that phasing out free dental examination is not the right step to be taking at this time. However, I ask those who are thinking of joining the Opposition in the Lobby to reflect on the discussions that have been taking place in the dental profession for some months about the need for a new system of remuneration for dental practitioners. I dwelt on that point at length on Second Reading.

If all the diseases that a dentist looks for when undertaking an examination are as important and far-reaching as has been made out, the question we should be addressing is what contractual relationship a dentist should have with his patient. Clearly, the present remuneration system that rewards a dentist, regardless of who pays the charge, with a paltry sum of £3·90 for an examination is ludicrously inadequate.

There is another reason why that is so. In the past, when the dental rates study group has considered what fees to apportion to the various items of treatment that dentists carry out, the examination fee has always received little additional money. The reason is that dentists would be adequately remunerated through the treatment that was necessary. Thankfully, in this day and age, we see improving dental health. It is improving to such an extent that patients who have the good sense to go to their dentist regularly need little, if any, treatment. I can tell the House that many practitioners are increasingly finding that, after a routine examination, their patients require no treatment.

That is why the General Dental Service committee has proposed to the Department the need for a new annual registration contract. That contract would replace the present dental examination and screening arrangements. I warmly commend that scheme to the House. The argument should not be about what charge there should be per dental examination and who should pay it, but about what structure of remuneration we require.

There is not time in this debate to go into that aspect more deeply. However, can I tell my right hon. Friend the Secretary of State that I support what the Government have in mind. I can also tell him that I have lobbied for the contract throughout the dental profession and there is great support for it from many forward-thinking dental practitioners. I am disappointed that formal discussions on the new contract have not yet commenced. I believe that we should pursue the new contract arrangement, which the White Paper sets out, with all urgency, so that if, as I believe will be the case, the House votes to phase out a free dental examination, there could be an opportunity for us to phase out the free examination and introduce the new annual registration contract at the same time. That would send a clear signal to the public that regular attendance is what the Government want to see and to encourage.

On Second Reading, I made reference to a study that was being carried out on the subject of "Barriers to the receipt of dental care". That study—a very small one, based on just over 100 families—has now been completed and it indicates precisely those points which discourage attendance that I outlined to the House some four months ago. In particular, it shows that many people, despite the fact that they would be entitled to free examination and even free treatment on exemption if they went to the dentist now, do not attend because there is no perceived need to see a dentist.

The second thing which the White Paper stresses, and which during the Second Reading debate my hon. Friend the Minister of State said that he would take urgent action upon, is the need to launch a dental awareness campaign. I understand that discussions are already well advanced on a new scheme to be launched in the west midlands later this year. We must pursue that with real vigour.

I say again to the House what I said on Second Reading—that, if the money which the Government raise from the phasing out of free examination is used to encourage more people to visit the dentist and to help dentists to establish bigger and better practice premises, this measure will indeed be worth while.

There is a kernel of reason in what the hon. Member for Ryedale (Mr. Greenway) has been saying. However, accepting that the reduction in the number of treatments required is leading to a potential reduction in the dentist's income, I find it scarcely conceivable that the present system will be improved by bringing in a charge that will discourage people from visiting a dentist at all.

There are many irritating shortcomings in this Bill, and one or two glaring faults. This is one of the latter, for several reasons. I think that it is generally accepted as a principle of preventive medicine that all those at risk of the condition that we are trying to prevent should be encouraged to take advantage of the screening and treatment facilities that will prevent it. We know that dental health is improving in our young people in this country, and I am glad of that. I am sure that the Government will not have the cheek to claim credit for it, although they may well do so, but I do not think that many people outside their own ranks would believe them.

The improvement is due to many factors: to a general improvement in hygiene, changes in diet, the addition of fluoride to water and better screening in schools. It is gratifying that nowadays we have classes of children in secondary schools where one would be hard put to it to find a mouth with the fillings and extractions that were common 25 years ago when I was at school. Now, the broad smiles that we can give owe much more to the care of the dentist than to our own care of our teeth.

It is a principle that people should not be denied access to dental facilities, and it is not for the benefit of dental health alone. As my hon. Friend the Member for Livingston (Mr. Cook) has so rightly said, there are many other conditions involved which dentists, by reason of their long professional training, are qualified to pick up. Oral cancer is certainly the most serious of these. It is a hideous condition, almost always involving major surgery on the mouth and throat if there is to be any chance of survival, and still carrying a very low long-term survival rate, and that with a gross handicap.

It is not only a matter of oral cancer. The dentist can pick up a pre-cancerous lesion in the mouth, called leucoplakia, which is commonly associated with pipe smoking and irritation in the mouth. The Minister is nodding. Fortunately I do not have it. Leucoplakia is a condition which can be detected early and the patient can be advised as to its seriousness, and with the removal of the irritant stimulus it can be treated or reversed. Screening therefore offers us the chance not only to detect a cancer that will require major treatment to alleviate but to detect the pre-cancerous state and therefore prevent all the discomfort that that state could bring, and possibly death.

There are many other serious conditions that may be manifested through symptoms and signs in the oral cavity, including the very common one of anaemia, which may well be picked up, and some serious kinds as well as the common iron deficiency type. So it surely is a basic principle that we should be encouraging people to take advantage of the excellent screening facilities which are available in this country rather than trying to discourage them.

4.45 pm

I said that there was a kernel of truth in what the hon. Member for Ryedale said. In the present situation, in which dentists are increasingly finding that the work that they are doing in order to maintain their income is becoming more and more complicated and difficult to find, there is certainly a case for reviewing the way in which they are remunerated. Perhaps it should be changed to the way in which general medical practitioners are remunerated, with a capitation fee.

We have heard very little about the possibility of actively encouraging people to take advantage of dental screening. It tends to be opportunistic. If a person goes into a dental surgery that person is likely to be called up again at regular intervals, and that is a good thing, but there is no primary call-up system. Perhaps we should be looking at something like that.

It is possible for us to achieve a society in which we perhaps approach perfect dental health at very little additional cost compared with what we are now spending. That should be our ideal and our aim. Alas, this clause does nothing to improve dental health. It will discourage those most in need of the advice and treatment that a dentist can give them to stay away. For that reason, all hon. Members should join us in opposing it.

The hon. Member for Kirkcaldy (Dr. Moonie) speaks with authority and I believe that he makes a powerful case.

The White Paper, which has been mentioned on several occasions, refers at paragraph 1.15 to a number of the measures which the Government propose to introduce, including
"a new contract for dentists which will encourage prevention and promote the quality of treatment provided".

In chapter 4 of the White Paper a more detailed explanation is given as to how that is to be achieved. But in paragraph 2·13 of the White Paper we read:
"As a result of improvements in the nation's dental health greater emphasis is now being given to regular dental examinations, preventive treatment and advice and proportionately less to interventive dentistry. Dental examinations are an increasing proportion of dentists' work."

It then goes on to say:
"The Government believes that it is reasonable for patients to contribute towards the cost of this part of the dental services"
and, of course, that is what subsection (7) of the clause does.

I am sure that there is no dispute about the value of the dental check-up. Members will have received abundant evidence from the dental professional organisations and possibly from individual dentists. The issues were discussed in detail at the Committee stage of the Bill. A check-up detects diseases, including oral cancer. It enables there to be a general check on the general state of oral and dental health of the patient, with an opportunity to halt decay at an early stage and for the dentist, or possibly the hygienist, if he has one, to give advice to the patient on general dental care. It must be right to encourage people to have dental check-ups.

In Committee and in letters to hon. Members the Minister of State has set out the exemptions to charges. He has also explained the proposed charges and how they will fit into the general context of the revised scale of charges for treatment. I accept that he has an argument, but the nub of the case is surely the fear which has already been voiced—whether the imposition of charges will deter people from having check-ups.

In Committee the Minister of State indicated that he was not persuaded that it would do so. We simply have to draw on our knowledge of human nature. I imagine that most of us go regularly to our dentists. I venture to bet that we do not go for a check-up with great enthusiasm and that if we can find a good reason for putting it off for a week or so, we do so. Surely the knowledge that we are likely to be charged for a check-up will hardly encourage us to go. If that applies to hon. Members, how much more will it apply to those who rarely go to the dentist but should, and indeed to some people who have never been at all? Surely there can be few more effective deterrents to them than to know that a charge will be imposed for a check-up.

The White Paper speaks of a new contract for dentists which will encourage prevention. Here the Government are proposing a new contract for patients which will discourage prevention. It is not irrational that those with reasonable means should pay a proportion of the cost of the dental work which needs to be carried out, but the hurdle that we have to surmount in improving the nation's dental health is to get people to be checked in the first place. Here we are proposing to make that hurdle higher.

No doubt my right hon. Friend will argue that the charge will raise money. So it will. But sooner or later the National Health Service will have to meet at least part of the cost of treatment or serious dental troubles which could have been dealt with much sooner and more cheaply if the patient had not been discouraged from having a dental check-up.

There are many very good provisions in the Bill, but it is marred by this proposal and the proposal which we shall discuss later in regard to eye tests. As I read it, the effect of amendment No. 10, which has been proposed by the Opposition Front Bench, would be to remove clause 8 completely from the Bill. That I am not minded to do because I approve of aspects of it. If amendment No. 12, which would delete subsection (7) referring specifically to charges, is put to the vote I will need a great deal of persuading not to support it.

Having listened to the hon. Member for Chislehurst (Mr. Sims) and other Tory Members, I am sure that many of them are sincere in their opposition to clause 8. While I welcome their opposition, I believe that their views are limited and that they are naive about what the Government are attempting to achieve through the clause.

We discussed clause 4 at 1 o'clock this morning, when many Tory Members who oppose clause 8 were probably drinking their Horlicks or were in bed. Clauses 4, 8 and 10 are all about delivering a fundamentally different system of health care. That must be understood. These clauses are not piecemeal provisions, but are part and parcel of a clear Government plan to bring to an end a fundamental principle which has underpinned the National Health Service since its inception in the 1940s—the right of people to free health care when they need it, regardless of their ability to pay.

These clauses should be considered alongside the funding crisis in the Health National Service, which is recognised everywhere in society with the exception of 10 Downing street. My central point is that the crisis is contrived and deliberate. It is geared to creating conditions in which people will accept the need for wholesale changes of the kind envisaged in clauses 8 and 10. Clearly, the Government wish to introduce a market system of health care. Hence the introduction of the charges proposed in clauses 8 and 10.

How has the crisis been contrived? First and foremost, the National Health Service workload has been increased by the Government's economic and social policies, which have vastly increased unemployment and poverty. This week we are all aware of the real difficulties that people are facing. Government policy has exacerbated housing problems and brought about massive increases in homelessness. The problems have a knock-on effect, resulting in earlier illnesses and deaths, which create more demands on the National Health Service. Numerous studies prove the point conclusively. I shall draw attention to just one. A recent study published by Professor John Fox of the City university showed that unemployed men and their wives have mortality rates 20 per cent. higher than those of people in work.

The second issue that has helped create a crisis is the constant obsession of the Tory party with reorganising the management of the National Health Service. The then Sir Keith Joseph, when he was the Member for Leeds, North-East, introduced area health authorities in the 1970s. Subsequently, his successor replaced them by district health authorities. Then we had the management nonsense introduced by the Griffiths structure which caused the problems in my health authority which I outlined early this morning.

Thirdly, as part of the contrived crisis, we have had the deliberate stimulation of private practice by the Government. The Government argue that private practice brings extra resources to the NHS. The truth is completely the opposite. The doctors who staff and run the commercial medical facilities are by and large the same people who are the consultants within the National Health Service. If they are not working in the National Health Service, NHS waiting lists will increase. The knock-on effect is that people see the need to pay to go privately and to queue jump to bribe a consultant so that they may have earlier access to treatment.

Government policy has deliberately set out to create a public expectation of having to pay. The clause follows on from the creation of that public expectation. The Government have created a public belief that we cannot afford a National Health Service. I reject that. The proof that the crisis has been contrived came in the Budget. The Budget proved that we could afford to pay for the National Health Service and that we could afford to fund the £2 billion cumulative under-spending by the Government. What did the Government choose to do? Did they choose to invest more in the NHS? No; they gave the money to people who already have plenty.

Clause 8 paves the way for the wholesale introduction of payment for health care. It is part and parcel of the destruction of the National Health Service, on which the Government are intent. It is part and parcel of the Prime Minister's attempt to eradicate Socialism. The Government may succeed in getting clauses 8 and 10 through, but they will never succeed in destroying people's strongly held belief that a Socialist approach to health care is the only approach that makes sense.

5 pm

I do not subscribe at all to the concluding remarks of the hon. Member for Wakefield (Mr. Hinchliffe). To suggest that the National Health Service should be equated with Socialism would make Beveridge turn in his grave, as he is doubtless doing now, but I want to appeal briefly, Mr. Deputy Speaker, to my right hon. Friend to reconsider this measure.

I do not believe for a moment that my right hon. Friend is hell-bent on destroying the National Health Service. That is manifestly absurd. I believe that, together with his ministerial colleagues and the Prime Minister, he is right to look at the whole structure of the National Health Service and perhaps consider whether those who have benefited the most from the recent Budget should pay more. All these things should be open for examination. There are no sacred cows. When a review is undertaken, it should be done thoroughly. But the proposed review has not yet taken place. We are considering this afternoon the issues of prevention of disease and the plight of those who are least able to help themselves and to afford the necessary care. Whenever there is a doubt, the benefit should be given to the less well-off. I also happen to believe in the old adage that prevention is a hundred times better than cure. It is also a lot cheaper in the short run and in the long run.

There is nothing to be ashamed of for any Minister to say "Yes, we will reconsider. We have got that particular thing wrong." It is a brave and courageous man who is able to change his mind. I hope very much that my right hon. Friend will announce this afternoon that there has been a change of mind, because I see nothing to be gained either for the nation's health or for the Government's health by persisting with this wrong-headed proposal.

Every remark that I make now could equally be applied when we discuss eye tests. I shall not seek to catch your eye then, Sir, because all these observations apply to both issues. I very much hope that when we vote the hon. Member for Livingston (Mr. Cook) will not seek a Division on the amendment that would delete the whole clause, because quite a number of us could not go with him, but if he seeks a Division on amendment No. 12 I shall be in the Lobby with him, unless my right hon. Friend concedes totally. I hope and believe that many of my hon. Friends, who take as much pride as I do in the contribution that the Conservative party has made over the years to the National Health Service, will be with me too.

As the hon. Gentleman knows, I am always happy to seek consensus in the House, and I am happy to give an undertaking that we shall not needlessly divide the House twice. At the conclusion of the debate I shall endeavour to withdraw amendment No. 10 and to divide on amendment No. 12.

That is a most helpful intervention and I am very glad that I gave way to the hon. Gentleman.

In conclusion, I shall amplify a point that I made a moment ago. We on this side of the House have much to be proud of in the National Health Service, as do Members in all political parties. It is a National Health Service which successive Governments since the war have developed from the blueprint of a great Liberal. We acknowledge that; we all should. There is no attempt by this Government to destroy what has been created, which is one of the things of which we in Britain have most cause to be proud in the 20th century. That it needs reviewing is beyond dispute; that there are problems within the Health Service no one can question; but until a review is complete and we have decided what shape the Health Service should take in the 21st century we have a duty in the House today not to impose extra burdens or to deter. If we do not deal with this clause we shall impose extra burdens where they should not be imposed, and we shall deter people from helping to safeguard their own health, and the country's economy in the process.

I cannot agree with the hon. Member for Staffordshire, South (Mr. Cormack) when he says that the Government's review of the National Health Service should not be a matter of great concern to us. I believe that the review is likely to lead to Government proposals to privatise much of the NHS. But I certainly agree with the bulk of the hon. Gentleman's remarks. I, too, take the view that anything that makes people more reluctant to go to the dentist is wrong. There has been a welcome increase in dental treatment and dental health altogether in the past few years.

I have some figures that I received from the Library, which I believe are correct. Whereas in 1976 there were about 26 million courses of dental treatment, 10 years later there were 32 million, although there is an indication of slight decline in the past 12 to 18 months in the numbers receiving dental treatment. That may be due to dental charges. Nevertheless, that substantial improvement in the numbers receiving dental treatment is surely much to be welcomed. I see that the Secretary of State nods his head in agreement.

Certainly, for those on limited incomes who will not be exempted from the charges, there will be greater reluctance to go to the dentist. Not everybody is over the moon about going to the dentist, as the hon. Member for Chislehurst (Mr. Sims) said earlier. Not everyone considers that the treat of the year. Therefore, it is pretty obvious that people who do not go regularly to the dentist would find it difficult financially in many cases, although not all, to meet the charges. They may find an added reason and incentive not to go.

The Secretary of State may well argue that £3 is a modest enough sum. It is not modest enough, however, for many people on limited incomes with family responsibilities. I am concerned that the charge of £3, if it goes into the Act and is not objected to strongly enough today in the Division, will be greater in 12 or 18 months' time. It is quite likely that any increase will be well beyond the rate of inflation. That has happened to prescription charges and several other health charges.

Perhaps I can assist the House with facts, because the hon. Gentleman is a friend of mine. He might like to look at clause 8(4) where he will see the degree to which costs are contained and controlled.

I understand that the Secretary of State is in some political difficulties—I am not being malicious—and if he says he is a friend of mine, although we are friends, I must say that being a friend of mine may not help the right hon. Gentleman in his current political troubles. If I say that I wish him well, I am sure he will take that in the spirit it is given.

It is all very well to say that the sum is set out in the regulations, but the Secretary of State knows very well that the Government could bring in amending legislation, which would increase the sum well beyond the rate of inflation.

Before matters proceed and my hon. Friend the Member for Walsall, North (Mr. Winnick) gives too many concessions to the Secretary of State, I should say that clause 8(4) provides that regulations shall be made, but does not specify what may be in those regulations. As I understand it, the Government are proposing a charge of £3 on the basis that that would be 75 per cent. of the present cost of a dental examination. But nothing in the Bill prevents them from uprating that percentage to 100 per cent. and making a £4 charge.

I am grateful to my hon. Friend. It is perfectly clear, going by what happened to prescription charges and their level when we left office, and now, which my hon. Friend remarked on when he moved the clause, that this Government are determined to put up health charges substantially, way beyond the rate of inflation. Therefore, we cannot be confident—no one can be—that in two or three years' time, and certainly before the end of this Parliament, the sum will not be £4 or higher.

I am one of those people who do go for check-ups every six months. I have been going to the dentist regularly since my late twenties and if I have any regret it is that I did not have regular check-ups at an earlier age. If my teeth are not perfect, and they are not, they are certainly far better than they would have been if I had not gone for six-monthly check-ups in the past 25 years or so. As that has helped me, I want to encourage as many other people to recognise the necessity of dental check-ups.

It gives me much pleasure, understandably, when on a six-monthly visit the dentist gives me the marvellous news that I do not need further treatment. I am over the moon because, although I always have an injection, I do not look forward to the treatment. As I am convinced that six-monthly check-ups have meant that my teeth are in a much better state of health than they would otherwise have been, I want to encourage as many people as I can to have them.

It worries me that a substantial number of people—they may well be in a minority—do not recognise the necessity of six or even 12-monthly check-ups. To the extent that this measure makes people more reluctant to go to the dentist, it is a retrogressive step. It should be objected to strongly and the measure should be dropped from the Bill.

I support the Government because this is a modest clause which will encourage people to value their Health Service.

Last year when the Government originally suggested dental charges for examination and treatment people wrote to me saying, "We were not aware that check-ups were free because every time we go to our dentist he charges us." It came as a surprise that a check-up was free and that it was the treatment that they were paying for. Therefore, we must first bear in mind that people have not been deterred from having a check-up because they were under the impression, as I was until I came to the House, that they paid for it.

No. I should like to develop my speech.

The logic of the remarks of my hon. Friend the Member for Tiverton (Mr. Maxwell-Hyslop) is that we should not have any charges whatever. If we are to charge for treatment, it does not seem logical to object to charging for check-ups. If charges deter people, there should be no charges, yet—

No, I shall not give way. The logic is there and my hon. Friends must follow it through. If charges deter people, hon. Members should be opposed to any charges, but I have not heard that put forward by anybody and I do not believe that that is the case.

The small sums involved, and they are small, must be considered in terms of the relative values people place on other things.

No. I want to be brief and give my hon. Friends a chance to speak.

A charge of £3 is equal to two packets of cigarettes; it would not fill an average family motor car to drive more than 50 miles; and it is less than most people pay to buy a meal for one in a Chinese takeaway. Yet Opposition Members hypothesise that £3 is such a large sum that it will deter people from having a check-up.

The exemptions in the Bill for people on income support and those under the age of 19 deal with my hon. Friend's point. For the average person in work £3 is not a lot of money. Anyone who sees what people spend every day of the week in a supermarket, and what people spend in public houses and on holidays, and who considers that 60 per cent. of the population have a video recorder, yet believes that £3 for a check-up every six months will deter, is not living in the same world as my constituents and me.

An important principle is that those who can should pay towards their health care. The problem with our Health Service in the past 40 years has been that, because it is free at the point of contact, people do not value their health or the Health Service. If we had small charges—I would go as far as to say that we should have charges for visits to the doctor for those who can afford it—it would make people value the Health Service and health care, and it would ensure that our doctors and dentists were more orientated towards the customer.

If anything puts people off going to the dentist, it is not charges, but the times when dentists are open and our natural fear of dental treatment. I do not believe that £3 will deter people from visiting their dentist and I welcome this modest sum which will help people appreciate that their health is worth paying for.

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I wish to make my stand on this issue clear. I have done so in the past and it must he repeated until the word is finally heard.

We are debating the principle that the NHS should be free at the point of use. There is no logic in having an NHS which provides free check-ups for some parts of the anatomy but not for others. We must ask ourselves whether this is an organ-by-organ charging system. If it is teeth and eyes now, what is next on the agenda? What is the logic in charging for check-ups for eyes and teeth but not for other organs? As far as I can see, none.

It has been clearly demonstrated that charging for check-ups acts as a disincentive for people to go for essential tests. The poorer members of our society, for whom a few pounds is the cost of their children's meals for the next couple of days, are far less likely to spend the money on these tests if the alternative is basics, such as food.

It is clear that tests on eyes and teeth prevent diseases. Many diseases are detected which a patient has no knowledge that he is carrying. It is fallacious to say that patients or their general practitioners can make good the gaps that charging for these tests will create. In particular, eye diseases—like other hon. Members I will not seek to be called again because the principle is the same for both eyes and teeth—such as glaucoma, which has no symptoms until it is irretrievable, will cause more blindness if the measure is passed.

We should seek increased, not reduced, screening. If we believe in primary health care, some facilities which are at present available only in the private sector, such as Well Woman screening offered by BUPA, should be considered for the NHS. It makes sense for health, so it makes sense for human beings. It also makes sense in cost terms, because early detection not only means that diseases are cheaper and easier to treat, but that people are not off work for months on end. Moreover, deaths can be prevented, so families are not thrown on to the resources of the state for their future maintenance.

To start charging for check-ups and examinations is completely at odds with the commitment to increase primary health care. It will deny people access to the first inroad to primary health care.

First, I should like to congratulate my right hon. Friend the Minister for Health and my hon. Friend the Under-Secretary of State, the hon. Member for Derbyshire, South (Mrs. Currie), on the courteous and skilful way in which they moved and piloted the Bill through its Committee stage.

In my view, for what it is worth, the Health arid Medicines Bill is an excellent piece of legislation. It is all about preventive medicine, screening, encouraging people to go to the doctor and about doctors screening those people who are most vulnerable—

My hon. Friend the Member for Pembroke (Mr. Bennett) has taken the word out of my mouth—but why do we have to have a measure that many Conservative Members believe will be a positive deterrent to people visiting their dentists? All of us who have contact with dentists will know that dentists can diagnose over 120 different diseases of the oral cavity, including cancer, leukaemia and AIDS. We know that this country, like many countries in the Western world, will be faced in the near future with what might be described—I do not exaggerate—as an epidemic of the AIDS virus. 1f the proposal goes through, it will be a positive deterrent for the diagnosis of that disease.

My hon. Friend the Member for Pembroke made a courageous speech defending the proposal. I commend him for so doing, although I do not agree with him. He put to the House the simple proposition that, if people can afford to pay for treatment, they should do so. I agree with that. I believe in the free market. For what it is worth, I believe that if people go to the dentist and the dentist tells them that they require a certain treatment, they should pay for it if they can afford to do so. The same applies with the optometrist and the optician, but let us get people into the dentist's surgery in the first place. We all know how difficult it is to persuade people to go to the dentist. [Interruption.] I have heard my hon. Friend the Under-Secretary of State intervening from a sedentary position and will be happy to give way to her if she wishes—[Interruption.] My hon. Friend says that there is nothing that she wants to give me. [AN HON. MEMBER: "My hon. Friend is the lucky man."] I know that my hon. Friend the Under-Secretary of State is a strong believer in preventive medicine, but I am not sure whose day she has made.

I advise my hon. Friends, and especially my hon. Friend the Member for Pembroke, that the evidence is overwhelming in relation to what has happened when charges have been imposed. With your leave, Mr. Deputy Speaker, I shall give the figures.

In 1981, a report of the British Dental Association made it quite clear—[Interruption.] If the Under-Secretary of State keeps fluttering her eyelids at me, it is not surprising that I have lost my place. In 1971–72, when there was an increase in charges, the number of courses of treatment decreased by 7 per cent. In 1977–78, they decreased by 4 per cent. and they decreased by 4 per cent. again in 1984–85. My right hon. and hon. Friends on the Front Bench will say, "Just a moment, the volume of treatments as a generality decreased." In fact, the number of courses of treatment decreased. In my respectful submission, that is particularly significant.

In 1987, 2,600 oral cancers were discovered, many by dentists. Many doctors do not receive training in oral anatomy. They do not have that skill or understanding. I am sure that many Opposition Members who are members of the medical profession will accept that view, and I have received several letters from doctors accepting it. I challenge anyone to dispute it with facts and figures. By and large, doctors will not be able to diagnose the cancer until too late.

Many of my hon. Friends will know, and many members of the medical profession will understand, that there is a high mortality rate with oral cancers. Therefore, it is vital that they are diagnosed early. Dentists have the opportunity of screening millions of people who, by and large, are well. Many people visit a doctor only when they feel ill. By that time, it may well be too late. A moment ago, my hon. Friend the Member for Chislehurst (Mr. Sims) said that that would cost the Health Service a great deal of money in the long term.

I do not want to go into the Opposition Lobby against the Government. [Interruption.] I am sorry that my right hon. Friend the Secretary of State laughs at that. I believe that the Government and my right hon. Friend genuinely believe and care about the Health Service and do not want to dismantle it. His record and that of the Government are second to none. However, we would be foolish to deny that there are problems and to add to those problems by ruining a perfectly laudable piece of legislation by slapping on people a charge that would positively deter them from being treated.

If the hon. Member for Harlow (Mr. Hayes) wanders around a dentist's surgery with as much agility as he wanders around the Chamber when he is delivering speeches, it will be difficult for his dentist to get near him to administer any treatment. Nevertheless, I agree with him. He and a number of his hon. Friends are quite right—prevention is better than cure. The best way of preventing dental disease must be to ensure that people attend their dentists and have any problems diagnosed.

It was distressing to listen to the hon. Member for Pembroke (Mr. Bennett) a moment ago. We are used to him being wheeled in to defend the indefensible. If he goes on like this, he could well end up as a Parliamentary Private Secretary. I last heard him defend the Government on the School Boards (Scotland) Bill, which is a long way from Pembroke. However, here he is again. He said that it is right that people should be required to pay for their basic treatment. I suppose that it is just about as logical as saying that there should be a poll tax, and I suppose that he supports that. Perhaps he will suggest that his constituents should have to pay for corresponding with him or for going to his constituency surgery. That may be an appealing thought—

Well, the hon. Gentleman has got the idea now.

I should like to preface my remarks by saying something nice about the Under-Secretary of State for Health and Social Security—

The hon. Lady says "No", but I shall say it anyway. She had a signal achievement some months ago when she persuaded the Government to ban the manufacture or sale in this country of oral tobacco products, such as Skoal Bandits. Having taken a private Members' Bill through the House to ban the sale of such products to youngsters, I am delighted that the Government have achieved that. The hon. Lady did that because she recognised the serious danger of that type of product to oral health. I wonder how on earth she can square that action with the matter that we are debating today. On the one hand, the Government are taking dramatic interventionist action to prevent trade in that kind of poison, but on the other hand they are introducing a charge that will deter people from attending their dentist to have regular examinations to prevent precisely the same diseases from spreading in this country.

I agree with hon. Members on both sides of the House that it is important that we protect this principle, in order to try and improve dental health. Nowhere is it more desperately needed than in the country which I help to represent, Scotland. As my hon. Friends the Members for Kirkcaldy (Dr. Moonie) and for Livingston (Mr. Cook) will know, dental health in Scotland is about the worst in the whole world, for a whole range of reasons: because of people's diet, because of their lifestyles and because they do not attend the dentist's surgery as often as they should.

It would be relevant to put on record some reference to a report that was laid before the Government by the Scottish Health Service Planning Council—a Government body. I am referring to the SHARPEN—Scottish Health Authorities Review of Priorities for the Eighties and Nineties—report, which was submitted to Ministers last year. It says, among other things:
"While the oral health of the Scottish population has improved progressively over recent years it is still considerably worse than it might he and throughout the whole community compares unfavourably with England and Wales."

Quoting from memory, I understand that over one third of our population in Scotland have none of their own teeth. Perhaps the Minister can confirm that abysmal figure. The situation in our country is dreadful and action is needed to do something about it.

5.30 pm

If I may quote again from the report, it says:
"The regular take-up of dental services should be encouraged by every possible means".
How on earth will that be achieved by this measure?

The final paragraph of this section of the report says:
"The proportion of the costs of dental treatment met directly by patients should not increase disproportionately. Nor should they reach a level which discourages regular routine dental care. In the general dental service clinical examination and advice including advice on prevention, diet and oral hygiene should continue to be available to all patients free of charge."
That is what the Scottish Health Service Planning Council told the Scottish Office last year. It was a specific recommendation aimed at dealing with a serious problem which affects far too many of our people in Scotland. We are beginning to make some headway in improving dental health in Scotland. Why on earth are the Government now suggesting, for a paltry financial gain, that we put all that at risk?

The Minister's hon. Friends are right in the warnings that they are giving him about this. I go further than the hon. Member for Staffordshire, South (Mr. Cormack). I sincerely hope that there is not a Division on this. There appears to be a clear consensus tonight that the Government have made a mistake. Everyone can see that, and there would be no shame in the Minister's withdrawing this part of the Bill at this stage. The whole House could then go forward constructively.

Governments, like individuals, are always faced with the question of deciding priorities, accepting costs in the seeking of advantages. When we debated this subject in Committee I started with the point of view of my hon. Friend the Member for Harlow (Mr. Hayes). I listened carefully to the response of my right hon. Friend the Minister for Health when he explained the purpose of the proposal. That is something that has not been picked up in this debate. The Minister pointed out that this was not, as the hon. Member for East Lothian (Mr. Home Robertson) said just now, for a small increase in Government finances: every penny of the money that is raised from these inspection charges and the inspection charges which are to be discussed later will be added to an even larger sum of over £500 million, to be used solely and entirely for improvements in primary health care in the National Health Service. That is the key.

I do not agree with my hon. Friend the Member for Pembroke (Mr. Bennett), who suggests that a £3 charge is not a deterrent. It is to some and, in a working-class constituency like mine, it will undoubtedly deter some people. But it will not be a deterrent to those who do not have to pay, to those who already attend their dentist privately, to those who do not go to the dentist at all or to those who can comfortably afford to pay the charge. A small number of people will find it a burden. I know that and I would not be able to support the Government on this part of the clause, as I told my hon. Friend the Minister in Committee, unless I was given the absolute assurance that the money so raised would be devoted to something more useful.

I disagree with the hon. Member for Greenwich (Mrs. Barnes) who said that there was something wrong with a system of priorities—I think that she called it an organ-by-organ approach. There is a case for such a system. I do not believe that the National Health Service is to spend £50 million on keeping free dental checks for that very small group of people who will be deterred, because it is such a small group and because there are other things that are so much more important. We would all have our own list of priorities.

I do not agree with the comment that individuals do not count, which I hear from the Opposition Front Bench. I am suggesting that each one of us would have his own list of priorities. But I am persuaded, after listening to the Minister's assurance, that the best way ahead would be to allow the Government to use this Bill as a vehicle for the general improvement of primary health care—and one of the costs of that will be this part of this clause. I do not welcome it, but I accept it and shall support the Government in the Lobby.

May I ask the Secretary of State a factual but pertinent question against this background? I am probably the only hon. Member on the Opposition Benches who has experience of the Department of Health, albeit as a lowly parliamentary private secretary to Dick Crossman from 1968 to 1970. If I recall events of 20 years ago, it is simply to ask whether the practice has changed. I well remember that time and in those days. if any proposal was put forward, there would certainly be discussions with Sir Alan Marre, or whoever was the permanent secretary, and the officials. But absolutely crucially important was the view of Sir George Godber. as he then was, and Dr. Henry Yellowlees—but particularly Sir George Godber as chief medical officer.

I understand perfectly well that the House of Commons cannot reasonably ask to be told what civil servants have said to their Ministers, but I think the House is entitled to ask the rather different question: what has the chief medical officer, in his professional capacity, said about any proposal for a change such as this, to levy charges for dental examinations? I ask in general terms, therefore, what is the view of the chief medical officer of this proposal and, in particular terms, whether he has expressed a view on whether dentists will come to rely not so much on their clinical judgment as on their perception of the depth of their patients' pockets?

There is a real human problem here. Dentists are decent people but they are also realistic people. Very often they will make decisions out of kindness which will mean that a patient whom they think cannot easily afford treatment will not have to pay out the £150—the argument against which was deployed by my hon. Friend the Member for Livingston (Mr. Cook).

My question, however, concerns the precise advice that has been received from the chief medical officer and his colleagues. After all, we have here a Department that has turned down the technical advice of its own committee on AIDS. The Department's committee was overturned. Has the chief medical officer, by any chance, been overturned on this matter? Parliament at least has the right to know what the chief medical officer has said about this proposal.

There was a certain amount of levity earlier, which was particularly provoked by my hon. Friend the Member for Harlow (Mr. Hayes). This is quite the most miserable and petty idea that the Government have introduced. My feeling about my right hon. and hon. Friends on the Front Bench is that they tend not to be sufficiently Right-wing in their policies. On this issue, they have made a grave mistake. I very much hope that there is still time to reconsider the proposal to introduce charges for dental check-ups.

I respect the views expressed by my hon. Friend the Member for Pembroke (Mr. Bennett). I believe that he speaks for a number of my colleagues—no doubt this will be a continuing debate—when he says that he would like charges to be introduced for other checks. This proposal should not be allowed to go through without expressions of concern from those who, in every other respect, support and welcome the way in which my right hon. Friend the Secretary of State is promoting sound policies, ensuring a mammoth investment in the Health Service. If we fail to express our concern about the impact of these charges for the sake of this tiny sum of money, my hon. Friend the Member for Pembroke and other hon. Friends, for perfectly sound and logical reasons, given their outlook, may be putting forward next year and the year after charges for other examinations.

I do not take the view that, for five years after a general election, a manifesto must be regarded as being written on tablets of stone. On a number of occasions my hon. Friends on the Front Bench have been able to persuade me to enter the Lobby enthusiastically because, although I may have had reservations about some aspects of what they were doing, it was in the manifesto.

My hon. Friend the Member for Portsmouth, North (Mr. Griffiths) argued that this is a sound proposal because it will make available a complete package that will improve primary health care. If that was such a good idea when my right hon. Friend suggested it in the autumn of 1987, it was a jolly good idea in May 1987, when it could have been included in our manifesto and put forward. I have no concerns or anxieties about the social security system. We passed the Social Security Act 1986 and had the election in June 1987. If this proposal was such an important and vital feature of the Conservative party's approach to primary health care it should have been in the manifesto and we should have knocked on doors saying "This is what we shall do."

5.45 pm

As times change, Governments must respond and come up with different proposals that were not in their manifesto. Every party has done so, and it is an inevitable part of a five-year parliamentary system. If this proposal were coming forward two or three years into this Parliament, I would say that my right hon. Friend the Secretary of State had decided, after examining all the issues, that this was the right thing to do. I cannot understand how it suddenly emerged as a crucial feature of the Conservative party's approach to primary health care in October or November when we did not say in May or June to the voters that this is what we wanted to do.

On that basis alone I am unable to support the Government on this proposal. Most reluctantly, I shall join Opposition Members in the Lobby because on this issue they are right. One of the problems with the Government is their unwillingness to recognise the force of argument and the concern that exists. That has been my profound view over the five years that I have sat in this Chamber. I have sat silent, with enthusiasm for some measures and not so much enthusiasm for others. We are talking about peanuts in a massive programme of investment for the Health Service.

I can do no better than conclude my remarks by observing, please think again. My right hon. Friend the Secretary of State, my right hon. Friend the Minister of State and my hon. Friend the Under-Secretary of State, who did not flutter her eyes at me but left the Chamber, are doing a first-class job. Conservatives throughout the country and many people who do not support our party are proud of what they are doing, despite all the media hype about problems in the Health Service. Why spoil that for this piddling, miserable proposal? I should want to say the same—I probably will not be able to catch your eye, Mr. Speaker—about the eye test charges.

I can do no better than echo the words of the hon. Member for Greenwich (Mrs. Barnes), who identified, as did other hon. Members in Committee, a range of matters that can be highlighted by dental tests. My hon. Friend the Member for Portsmouth, North said that he knows that some people will be deterred and will find it a burden. If that is so—I believe it to be so—no hon. Member can possibly fail to support the amendment.

My main reason for speaking in the debate stems from the remarks of the hon. Member for Portsmouth, North (Mr. Griffiths). One of the most interesting issues that emerged from the speeches of the hon. Members for Tiverton (Mr. Maxwell-Hyslop), for Staffordshire, South (Mr. Cormack) and for Great Yarmouth (Mr. Carttiss)—the hon. Member for Great Yarmouth made a particularly courageous speech, and I commend him for it—was the support they all gave to the need for preventive dental measures. Prevention has received a general welcome and an encouraging degree of cross-party support. Prevention should not become a party political issue; it is too important to be dragged down into the Punch and Judy antics of party politics.

But the hon. Member for Portsmouth, North has sold his support far too cheaply. He seemed to be saying that he has allowed himself to be persuaded by the Government because they have said that money realised by charges will be translated into other preventive sectors. That is not a good argument, because the cost-effectiveness of charging £3 for a check-up is open to serious question. If the immediate saving is £50 million, the total cost, in the fullness of time, to the Government in picking up the cost of subsequent dental treatment, even though they are only partially funding it, will still be far more than £50 million. For that reason, if for no other, the argument that swayed the hon. Member for Portsmouth, North is false. I hope that he will reconsider his position. The position he adopted earlier prior to being persuaded by the Secretary of State was sounder.

The subject before the House is important. I am pleased that the hon. Member for Livingston (Mr. Cook) has agreed to shift the focus of his attack to amendment No. 12 this evening—it goes more to the heart of the argument.

I wish also to pick up something said by my constituent, the hon. Member for East Lothian (Mr. Home Robertson), whose interests I always seek to advance in the House. He made an important point that applies to Scotland, where particular problems arise for people on the margins of benefits and low income earners, who will be most affected by the proposal. It will have a very severe impact, especially in the central industrial belt in Scotland. The traditionally bad diet and unhealthy lifestyles in that area are responsible for some of the problems that manifest themselves in the relatively poor statistics on bad dental health north of the border. So this argument is apposite to Scotland.

The point made by the hon. Member for Greenwich (Mrs. Barnes) was also important. If we allow the Government to introduce this change, what element of the Health Service will be next on the agenda for charges? That is a worrying feature of the charges. A point that had not occurred to me before listening to this debate was the likelihood that these charges will in future be treated by the Treasury just like any others. If extra revenue has to be raised from the health budget in future, the Treasury will not differentiate between money that has been allocated for improvements in preventive medicine and other general revenue, and the charges for the check-ups will spiral in the same way as general charges have in the past. That is inevitable, and it is another reason why the hon. Member for Portsmouth, North should reconsider his view unless the Secretary of State gives us a guarantee that that will not happen.

The increase to £3 is a serious one to some of my constituents and will certainly deter a significant proportion of those who visit the dentist. It is a good idea to encourage people to go to the dentist—

On a point of order, Mr. Deputy Speaker. Will you inform us about the practice of passing notes to right hon. and hon. Members on the Front Bench? The odd discreet note is to be welcomed, but there is a flow of paper. I realise that the Secretary of State and his Ministers may not be fully conversant with their briefs, but would you tell us what the practice normally is?

I see nothing out of order; it is perfectly normal practice.

In any case, I was about to end my remarks.

Far from moving in the direction of imposing charges for dental check-ups, there is an economic case for giving people a positive financial incentive of, say, £3 to have their teeth checked once every six months or so. On a cost-benefit analysis, I believe that would pay dividends in the long run, and would show that the Government have got this aspect of the Bill very wrong.

Of course we can argue about whether people who can afford to pay should make a contribution to other, more general medical treatment, but as Conservative Members in this debate have eloquently said, there is no case for making this insignificant saving, which will make significant and damaging inroads into what we are all trying to establish—a future system of health care which is properly funded and which will encourage people to engage in preventive medicine rather than waiting until treatment is necessary, by which time important dental symptoms and oral conditions may have been missed and cannot consequently be treated properly.

This proposal to introduce a charge is a retrograde step, and I hope that Conservative Members will not only make speeches against the Government but will encourage their colleagues to follow them into the Lobby against the Government and in support of the amendment.

I have been most impressed by some of the speeches by Conservative Members tonight—in particular, that by the hon. Member for Chislehurst (Mr. Sims), who made a reasoned and considered speech about prevention, in which I know he takes an interest. It is difficult for me to add much to what he said, so I shall make only two brief points about what is involved here.

I hope that the Minister will not start talking about who first introduced charges to the National Health Service. We had an agreement in Committee not to do that any more. I admit that I did it first, but I have kept to the agreement since then. An important principle is involved: the difference between charging for treatment and charging for a screening process. Now, for the first time ever, we are going to charge for screening.

I hope, too, that the Minister will not say that we need to target screening and that it is no use having blanket screening. If he has a brief saying that, he should put it aside, for two reasons. Targeting is not applicable in this case. Dental disease occurs at all ages, and unless one identifies a specific disease—that is not the case here—targeting screening is not relevant to the dental examination.

I reinforce the point made by my hon. Friend the Member for Livingston (Mr. Cook) about other diseases, particularly cancer of the mouth. He mentioned the study from Bristol. The important point about that is that the diagnoses were made earlier. That is the important thing about going to the dentist. People go to a general practitioner because of some major problem, but a higher proportion of cases in the Bristol study were picked up at stage one, rather than stages three or four, as is common at a general practitioner's. That is the important point about having the screening test, in which diseases are picked up. It is no good saying that patients have other symptoms and diseases that will take them to the doctor. They often think they have a dental problem and go to the dentist first. If that is prevented by a charge, there will be a delay in the diagnosis.

Finally, the hon. Member for Pembroke (Mr. Bennett) seemed to say that £3 was not much—merely the price of driving a car a certain distance. I do not think he realises how much it is to many people who do not pay charges. Even I did not realise how much it meant to many people until I became a Member of Parliament. Many of us lead slightly closeted, ivory-tower, academic lives, but to a large number of our constituents £3 is a lot of money, and it will act as a disincentive to treatment.

I end by congratulating the hon. Member for Staffordshire, South (Mr. Cormack) on what he said. It would not be a sign of weakness to concede this matter, but rather a sign of strength. As the hon. Member for Great Yarmouth (Mr. Carttiss) said, one of the problems of this Government is that they produce Bills which they regard as being written on tablets of stone and seem to regard it as a sign of virility to change nothing in Committee. That is a sad reflection on our democracy, and, as the hon. Member for Staffordshire, South said, it would be a sign of strength to reconsider this matter. If the Government do not, I hope that as many hon. Members as possible will join in the Lobby tonight.

I hope that it will not be necessary to divide the House on this issue. It is clear from the strength of argument of all parties that there is a consensus. The arguments propounded by the hon. Member for Great Yarmouth (Mr. Carttiss) reflected the view of the public when he spoke of these measures as being seen as penny-pinching and petty. He echoed the views of the public and of the professions who are most directly involved in dentistry and optical work. They have argued strongly that these parts of the Bill should be withdrawn to enable them to continue with their vital work.

A basic principle is at stake in the amendments. All of us have grown up to see the National Health Service providing equality of access to a service of equal standards. This measure means that a tax is imposed on access to dental treatment, and later on access to optical tests. The Secretary of State may well raise the question of exemptions. The issue is not the people who will be exempted from these charges; it is the people living on the margins of poverty. The £3 charge can mean a difference for many poor families. They see that amount as a way of saving something for school meals and clothing for their youngsters, and this measure will prevent them from taking the opportunity of a free dental examination. That will have many knock-on effects.

6 pm

This group of poor families is the most vulnerable. People who live on the margins of poverty often skimp on what we may regard as basic essentials, such as toothpaste, but they do not see them as essentials. The diet of people living on the margins of poverty can be badly affected by their income. They are the people whom the Secretary of State should ensure has access to free dental examinations. They must be considered, and I therefore hope that the Secretary of State will concede these points.

After the Health and Medicines Bill was published I spoke to many of the dentists in my constituency. There was a sense of outrage and they spoke at length about the various diseases that can be detected by a simple dental examination. During the week in which I spoke to those dentists, one dentist had diagnosed a throat cancer in an early dental examination. That is a significant point. The Government argue that more emphasis must be placed on primary health care and preventive medicine, but these charges will prevent people having access to that.

As the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) said, if the Government concede this point, it will be seen as a strength. It will do a great deal to restore public confidence in where the NHS is going and in the Government's attitudes. It will do a great deal to boost the morale of the professions. There will be loud applause all round if the Government concede this point. The Government should forget the penny pinching and concede that there are valid, widely accepted arguments against these charges.

Amendment No. 38 is a direct response to the activities of the Opposition Front Bench, and I acknowledge the activities of all members of the Committee. In Committee the Opposition tabled an amendment with the same purpose as amendment No. 38, to exempt all 16 and 17-year-olds from all dental charges. For technical reasons we could not accept the Opposition's amendment as drafted, although we undertook to consider it and come forward with an amendment. I am happy to fulfil that undertaking. Amendment No. 38 is effectively identical to the Opposition's amendment except for the technical redrafting. I know that the Opposition would wish me to acknowledge that.

The hon. Member for Southport (Mr. Fearn) has tabled amendments which are linked. Amendment No. 63 relates to Scotland as opposed to England and Wales. Under the regulations governing the general dental services a dentist has the right not to proceed with or complete a course of treatment where the patient is liable to pay a charge or the full charge has not been paid. Most of us would consider that fair and reasonable. After all, dentists are professional people who must balance their books and run their businessess like anyone else. If they provide a service and have reason to believe that payment may not be forthcoming, they have a right to discontinue the provision of that service.

In practice, dentists often rely on good will and do not insist on full payment in advance or they take an initial part payment and collect the balance on completion. The amendments would force them in some cases where dentures or other appliances are involved to carry through the course of treatment to the end, even when they have every reason to believe that they will not receive the proportion of the fee which is payable by the patient. The dentist can only either write off the loans or go to the trouble or expense of recovery through the courts. The NHS cannot make up the loss in these circumstances.

Amendments Nos. 62 and 63 would create considerable difficulties for dentists and cause unnecessary friction between them and their patients. I do not believe that the amendments would serve a useful purpose. If a patient needs dentures and they have been prescribed, all he has to do to receive them is to pay the appropriate charge if he is not exempt or entitled to help on low-income grounds. I hope that the hon. Member for Southport will not press the amendments.

I should like to respond specifically to the fair point made by the hon. Member for Linlithgow (Mr. Dalyell). The White Paper on primary health care was endorsed by the chief medical officer. I draw the hon. Gentleman's attention to the specific dental charges sections, 2.11, 2.12, 2.13 and 2.14, on promoting health.

Is it a fact that the Government's proposals have the full and unambiguous approval of the chief medical officer and his advisers?

I apologise again for my inability to make a loud noise. The White Paper on primary health care, which unambiguously endorses these points, was endorsed by the chief medical officer.

I shall do what my hon. Friend the Member for Portsmouth, North (Mr. Griffiths) did, and very well, when he sought to put the debate in context. The debate's context is how we try to allocate priorities for more spending on the family practitioner services. We should start with that point because it is an important feature which surrounds the nature of this proposal, the controversiality of which I do not for one moment doubt, having sat throughout this debate on Report, let alone the debate during the past few months.

The family practitioner services have already had an increase in real terms expenditure of about 43 per cent., or £1·5 billion, in the past nine years. I do not think that anyone would disagree with that; it is endorsed by both sides of the House. That amount compares with public expenditure increases in a similar period of 14 per cent. As my hon. Friend the Member for Portsmouth, North rightly pointed out, last autumn my right hon. Friend the Chief Secretary announced, in the public expenditure proposals, substantial increases in real terms for the period up to 1991. It is within the context of these family practitioner services that we must consider the general dental service. That service has had its gross expenditure increased by 37 per cent. in real terms, with the Government's gross expenditure increasing in the same period by 20 per cent. in real terms. The Government committed £521 million last year.

I have referred to the White Paper on primary health care, "Promoting Better Health", which my right hon. Friend the Minister for Health introduced on 25 November 1987. I read with great interest all the Standing Committee Hansards, especially the comments of the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith) in support, in a bipartisan way, of many of the aspects of the White Paper. The House will be aware of the Government's ambition, which is shared by many hon. Members on both sides of the House, above and beyond the public expenditure programmes, to spend more on family practitioner services.

The hon. Member for Roxburgh and Berwickshire (Mr. Kirkwood) asked us, rightly, to address the question of the extent to which those aims should be financed by maintaining or changing the present balance between public expenditure and charges within the general dental service and beyond the planned public expenditure. It is a legitimate point that any Government in looking at their priorities should consider on top of the already planned proposals for increases. It is crucial, in that context, therefore, to understand what has been happening in dental health and why; then we can understand why the Government believe that their proposals are fully justified.

The view is almost universally held that dental health has been undergoing major improvements. Valid points have been made about variations in Scotland and elsewhere but the pattern for the United Kingdom as a whole has been one of steady improvement over the past few decades—under Governments of all political parties. Let me give one or two examples which are germane to my argument. In 1973, 29 per cent. of five-year-old children were free of dental decay. By 1983—a decade later—the figure was 52 per cent., showing an amazing and very welcome improvement. Let us take a different date for adults. In 1968, 37 per cent. of adults had no natural teeth. By 1985, that figure had gone down to 22 per cent. Both those examples show a clear pattern of improvement, although I accpt that there are considerable regional variations, which I shall go into in a moment.

Let us also consider the courses of treatment given. The number of courses of treatment, for all ages, has risen by 19 per cent. since 1979. However, what is particularly important is that courses of treatment given to those over the age of 65 have risen by 92 per cent. Another critical factor which has not been mentioned so far—

Perhaps the hon. Gentleman would allow me to finish my point first. A further factor illustrating the change in the nature of Britain's dental health is that since 1979 the number of dentists has risen by 20 per cent.

In his reply to my hon. Friend the Member for Linlithgow (Mr. Dalyell) the Secretary of State stressed that the proposals in the White Paper had been specifically approved by the chief medical officer. I wonder whether he could give us some guidance. Since he made that observation, my hon. Friend the Member for Peckham (Ms. Harman) and I have been trying to find the reference in the White Paper to charges for dental examinations. So far we have been unable to find any such reference. Can the Secretary of State guide us as to where we may find it?

With pleasure. The hon. Gentleman will find the precise reference on page 9, at paragraph 2.13. Let me deal with the changing pattern—

I have sat through the debate, although I have not attempted to take part. Further to the question asked by my hon. Friend the Member for Linlithgow (Mr. Dalyell) and perhaps also to the recent intervention by my hon. Friend the Member for Livingston (Mr. Cook), could the Secretary of State say where in chapter 4 of the document "Promoting Better Health" that reference is to the chief medical officer having given his full support to charging?

I do not think that it is normal practice to include such a reference. The hon. Member for Linlithgow, whose memories go back to the days of the late Richard Crossman, will no doubt know whether that practice has been followed in every White Paper produced by every Government Department. I have specifically answered the question asked by the hon. Member for Linlithgow. We do not include such information when we write White Papers. [Interruption.] As I said, the chief medical officer endorsed it; I could not have been more specific.

Let us consider changes in treatments. That is an important subject especially in relation to a factual error earlier in the debate, which I must correct. The number of extractions has fallen by about 13 per cent. over the past decade and the number of fillings by 21 per cent. Both those developments reflect the pattern of improvement in dental health. Meanwhile, the number of crowns fitted has risen by 83 per cent. and the number of bridges fitted by 535 per cent. That is a clear indication of the changing pattern.

What are the reasons for the improvement? Clearly, it would be quite improper if those of us who visit dentists did not compliment them on their activities first. But another point that emerged repeatedly in Committee was that half the nation does not visit the dentist regularly—a point referred to by my hon. Friend the Member for Ryedale (Mr. Greenway). As hon. Members know, many other critical factors are involved in improved dental health. The first is better diet, although the hon. Member for East Lothian (Mr. Home Robertson) referred to Scotland's particular problems in that regard. The reduction in the amount of sugar consumed has been a key factor in the improvement of dental health.

I appreciate the way in which my right hon. Friend is seeking to reply to the debate and I sympathise with him. Would he not agree that inspections may also have played a significant part?

I shall be coming to that very point in a few moments, and I appreciate my hon. Friend's genuine sympathy.

I have referred to better diet and reduced sugar consumption. Better information is also a critical feature. There is now better information on dental hygiene, on methods of brushing one's teeth and looking after them, and the information given to children is especially important. A crucial factor that has not been mentioned so far is fluoride. I am talking not just about fluoridation but about fluoride in toothpaste. About 90 per cent. of all toothpaste purchased today contains fluoride and most of us are exposed to fluoride in that way. We have a nation of better-informed people taking better care of themselves.

It is very important that hon. Members on both sides of the House should understand that all these improvements have been happening at a time when the percentage of the general dental service paid for by charges has been increasing. The Opposition have disagreed with that pattern over the past few years. The reality is that in 1978–79 20 per cent. of the overall revenue for the general dental services came from charges. By 1986–87 that figure was 30 per cent. That represents a substantial increase in the proportion paid for by charges rather than by the taxpayer. Nevertheless, throughout that period there has been a significant improvement in dental health.

Let me again put the proposals in context. This year, the proposals, including examination charges as well as the proportional charge increases, would take the percentage of care paid for by charges from 30 per cent. to 32 per cent., thus reducing the taxpayer supplement to the general dental service from 70 per cent. to 68 per cent. This is the basis on which we should view the increased public expenditure proposals for primary health care and the increased proportion that the Government propose should come from charges for the general dental service.

Two key questions have emerged from this afternoon's debate in addition to my remarks about improvements in dental health. The first, which my hon. Friend the Member for Tiverton (Mr. Maxwell-Hyslop) has consistently asked, is "Do we have evidence to suggest that charges will deter?" The second concerns the extent to which we are helping those who cannot afford the present pattern or a changed pattern of charges. But the critical question is that relating to deterrence. I start by reminding hon. Members who have not had the opportunity to read what I found to be an extremely good set of Committee Hansards of what my right hon. Friend the Minister for Health said :
"Unless the deterrent argument can be made to run much faster and further than I believe it can, most of the arguments about the effects on the detection of other forms of ill health fall, because they depend on the proposition that large numbers of people will cease to come forward for examination or treatment."—[Official Report, Standing Committee A, 9 February 1988, c. 620.]
Let me examine some of the questions about the deterrent effect of charges. They are valid questions because they reflect the worries surrounding this debate. First, I should remind the House that in 1968—I agreed that I would not say who did what when increasing charges for dental services—came the first increase in routine dental treatment charges since charges for dentures were introduced in 1951. Since 1968 a pattern of increases has been established, and sometimes those increases have been major. Against that background, we can study the pattern of courses of treatment. In answer to my hon. Friend the Member for Harlow (Mr. Hayes) and others, there has been no year since 1968 in which the number of courses of dental treatment has not increased, and I shall deal with both the short-term and the long-term impacts in a moment.

The hon. Member for Livingston (Mr. Cook) made one or two remarks about changes in the number of fillings. I appreciate that it is sometimes difficult to get the exact facts, but let me tell him those facts of which I am informed. The hon. Gentleman is right to say that after the increase in charges in 1985 the number of fillings fell, though by 6 million and not by 5 million. As a result of improved dental care, however, the figure has been declining for many years. The number of extractions did not rise. The number of extractions has been declining steadily since 1979—a total decline of 13 per cent. from just over 4 million to under 3½ million. Moreover, treatment for gum disease rose by 5 per cent. in the year following the 1985 increases in charges.

The hon. Member for Livingston is right to say that short-term changes occur in the pattern of demand from time to time.

Let me finish this point and perhaps obviate the need for hon. Members to ask questions and further delay the debate.

Despite some sedentary interruptions, I have tried not to refer to the massive increases in charges of 35 per cent. in 1976 and 27 per cent. in 1977, but even following those increases there was still an increase in take-up of courses of treatment. The pattern of overall increase with occasional short-term interruptions has meant a steady average increase of 2·7 per cent. per year. That is clear from the data that my right hon. Friend the Minister for Health and I have available, and nothing that was said in Committee sustains any argument to the contrary.

The Minister has talked about the deterrent effect of charging for treatment, but charges for examination are being introduced for the first time. Secondly, does he agree with the British Dental Association and all other independent experts that an increase in charges is followed by a slowing down in the increase in courses of treatment and the graph never actually catches up to the position that would have been achieved if the rate of increase had not been checked by the steep increase in charges?

As I have said, I do not believe that that case is sustained either by the arguments put in Committee or by the data that I have studied.

My right hon. Friend is absolutely right about treatment volumes, but every time charges have risen—in 1971–72, 1972–73, 1977–78, 1978–79, 1984–85 and 1985–86—although treatment volumes have continued to rise, the treatment per course has gone down. That is a British Dental Association statistic. My right hon. Friend will correct me if I am wrong, but I believe that my right hon. Friend the Minister for Health accepted that. The argument is about the rate of recovery.

Like my right hon. Friend the Minister for Health, I have studied all the data carefully. Although the long-term trend line shows short-term fallbacks, and it would be wrong to ignore market reaction, there are also years in which the increase is greater than the overall trend. producing a sustained increase of about 2·7 per cent. per year. Those who do not accept that argument seem to ignore the fact that that has occurred despite massive increases in charges in some years—as high as 35 per cent. under the Labour Government.

I should like to continue as we are getting short of time.

With regard to the second point made by the hon. Member for Peckham (Ms. Harman), all our experience relates to free examinations and in many ways confirms the weakness of the argument that a modest charge will be a deterrent. Although examinations have been free of charge, only half the nation avails itself of the service. As was properly pointed out in Committee, the variations occur by region and social class and have far more to do with factors other than the theoretical possibility of a charge. As my hon. Friend the Member for Ryedale said, the Tidman and Brown study is extremely relevant in this regard.

I was fascinated to read the 19 March editorial of the British Dental Journal, which cited a study entitled, "Barriers to the Receipt of Dental Care". The key point, which is not unfamiliar to most of us as lay people, is fear. The editorial preferred to use the word "anxiety", but it referred to a whole series of factors, beginning as follows:
"A generalised dislike of going to the dentist …
Fear of pain.
Fear focused on an aspect of treatment.
'Guilt' embarrassment …
The possibility of receiving poor or unnecessary treatment."
Only then does it mention the potential cost. I do not suggest for a moment that cost was not a factor, but for most people it was not the major factor.

Members who did not have the privilege of being on the Standing Committee may not realise that a 75 per cent. charge for examinations on a proportional basis will mean that for some of the more modest treatments the charge with the examination will remain the same or even be lower than at present. I accept that the numbers are modest, but they are still significant for those who avail themselves of regular dental care.

The hon. Member for Strathkelvin and Bearsden did not wish me to mention this, but I cannot resist pointing out the actual sum involved. It is a very modest amount for those who are not exempt. I do not deny that £3 has value and is difficult for some people to find, but that sum once or twice a year must be compared, as my hon. Friend the Member for Pembroke (Mr. Bennett) pointed out, with expenditure by the average family of more than £8 per week on alcohol, £4·55 on tobacco, more than £2 per week on toiletries and about £20 per year on toothpaste. Moreover, a large number of people will still be exempt from any charges at all. All the current exemptions will be maintained—for all children under 16, for young people aged 16 and 17, for students under 19, for expectant or nursing mothers and for people on low incomes, not just those on income support and family credit but those just above that level due to the special low-income scheme covering an additional £200,000 on application.

With 38 per cent. of the population exempt, I do riot believe that a shift in charges increasing patient contributions to general dental services this year from 30 per cent. to 32 per cent. will deter people from seeking treatment.

No, I am trying to conclude my remarks.

We shall continue to protect those who cannot afford the very modest examination charge and we shall release additional resources beyond the increases in public expenditure already agreed. That increase will be spent in primary health care. My hon. Friend the Member for Portsmouth, North was particularly concerned about this. The increase will be used especially in dental health to encourage prevention, to increase resources for fluoridation, to improve vocational and postgraduate training for dentists and on a new programme to promote dental awareness, especially among the young. However difficult decisions about priorities may sometimes be for Parliament, I hope that on the basis of what I have said the House will accept the justification for the Government's very solid proposals.

6.30 pm

With the leave of the House, Mr. Deputy Speaker, I should like to respond to the debate. I shall do so briefly, because I appreciate that there comes a time when the House wishes to come to a decision and it can be exceedingly brusque to those who stand in the way at that moment.

We have had an interesting debate. To those sitting on the Opposition Benches it has been revealing to observe the extent to which the Government's Back Benchers are prepared to come out openly in support of this measure. In the course of the debate, eight Conservative Members have spoken. Of those eight, five came out flatly against the proposal for charges on dental examinations. I am rather pained that so many of them had to express such reluctance at joining me in the Division Lobby. but I appreciate, and commend them on, their courage in overcoming that natural distaste.

Of the remaining three Conservative Members, one, if I may say so to the hon. Member for Ryedale (Mr. Greenway), made a speech of sustained agnosticism, at the end of which I found it difficult to know quite where he stood in relation to charges. But two out of eight—one in four—came down in favour of charges for dental examinations. The hon. Member for Pembroke (Mr. Bennett) had the candour and courage to say that he was, broadly speaking, in favour of charging for just about everything, including visits to general practitioners, and the hon. Member for Portsmouth, North (Mr. Griffiths) had the intellectual rigour and honesty to say that these charges will act as a deterrent—to a minority, yes, but nevertheless they will act as a deterrent to some people who will be put off from presenting themselves for a dental examination. Those were the friends of the proposal.

The Secretary of State, reasonably and understandably, sought in response to widen the debate to take in a discussion on the state of the nation's dental health. Of course it will be welcome in all quarters of the House that the nation's dental health is in an improved state. There are a number of different variables for that—diet, better standards of dental hygiene, community education in schools, and, most obviously of all, probably the single largest influence, the fluoridation of our water supply.

But the key question is not whether the nation's teeth are in a better state than before; the key question to which we must address ourselves in the debate is whether charges for dental examinations promote or detract from a further improvement in the state of dental health.

The Secretary of State grounded his argument against charges being a deterrent rather heavily on what happened in 1986. The figures that I have for 1986 are markedly different from the figures that the Secretary of State quoted. Mine come from the Dental Estimates Board. Its account for the year from April 1985 to April 1986 shows that the number of fillings did fall, from 33 million to 28 million—a drop of 5 million—and that the number of treatments for gum diseases fell from 2·4 million to 1·5 million—a reduction of well over a third. That was a reduction, but well ahead of trends. In each of the three years in the past 20 years in which there has been a substantial increase in dental charges, there has, in the following year, been a substantial drop in the graph of upward increases in treatment courses. That is what the Secretary of State referred to in his speech as a market reaction.

We can expect a market reaction to charges being brought in for dental examinations, and I for one do not believe that preventive medicine of this important character should be exposed to a market reaction. Yesterday we debated the Government's proposals for cervical cancer screening. Does anybody imagine that we would take seriously a Government who proposed a fee for screening for cervical cancer? Would the hon. Member for Pembroke be prepared to rise in his place to justify such a fee on the basis that he justified these charges—on the ground that it would encourage women to buy the services more? Of course not.

If any Government were benighted enough to propose a charge for cervical cancer smears, that Government would be laughed out of court by the Chamber because everybody, but everybody, would appreciate that such a charge would deter people from coming forward and would flatly contradict the idea of that screening being a preventive process. Precisely the same argument applies to charges for dental examinations.

If we are serious about making that a screening process to encourage the nation to have a healthy set of teeth, we must recognise that that service must be available free and we should not bring in any charges that will deter anybody, even if they are a minority.

On that basis, we wish to move to a vote. I accept the point raised by those who have taken part in the debate, that it would be more appropriate to divide on amendment No. 12 than on amendment No. 10. Therefore, with the leave of the House, I seek to withdraw amendment No. 10, and will move amendment No. 12 formally.

Amendment, by leave, withdrawn.

Amendment proposed: No. 12, in page 9, line 13, leave out subsection (7).— [Mr. Robin Cook.]

Question put, That the amendment be made:—

The House divided: Ayes 206, Noes 287.

Division No. 258]

[6.35 pm

AYES

Abbott, Ms DianeDunnachie, Jimmy
Adams, Allen (Paisley N)Dunwoody, Hon Mrs Gwyneth
Allen, GrahamDykes, Hugh
Archer, Rt Hon PeterEadie, Alexander
Armstrong, HilaryEastham, Ken
Ashley, Rt Hon JackEwing, Mrs Margaret (Moray)
Banks, Tony (Newham NW)Fatchett, Derek
Barnes, Mrs Rosie (Greenwich)Fearn, Ronald
Barron, KevinField, Frank (Birkenhead)
Battle, JohnFields, Terry (L'pool B G'n)
Beckett, MargaretFisher, Mark
Bell, StuartFlannery, Martin
Benn, Rt Hon TonyFlynn, Paul
Bennett, A. F. (D'nt'n & R'dish)Foot, Rt Hon Michael
Bermingham, GeraldFoster, Derek
Bidwell, SydneyFraser, John
Blair, TonyFry, Peter
Boateng, PaulFyfe, Maria
Boyes, RolandGalbraith, Sam
Bradley, KeithGalloway, George
Bray, Dr JeremyGarrett, John (Norwich South)
Brown, Gordon (D'mline E)George, Bruce
Brown, Nicholas (Newcastle E)Gilbert, Rt Hon Dr John
Bruce, Malcolm (Gordon)Godman, Dr Norman A.
Buchan, NormanGraham, Thomas
Buckley, George J.Grant, Bernie (Tottenham)
Caborn, RichardGriffiths, Nigel (Edinburgh S)
Campbell-Savours, D. N.Griffiths, Win (Bridgend)
Canavan, DennisGrocott, Bruce
Carttiss, MichaelHardy, Peter
Cartwright, JohnHarman, Ms Harriet
Clarke, Tom (Monklands W)Hawkins, Christopher
Clay, BobHayes, Jerry
Clelland, DavidHayhoe, Rt Hon Sir Barney
Clwyd, Mrs AnnHaynes, Frank
Cohen, HarryHeffer, Eric S.
Cook, Robin (Livingston)Henderson, Doug
Coombs, Simon (Swindon)Hicks, Robert (Cornwall SE)
Corbett, RobinHinchliffe, David
Corbyn, JeremyHogg, N. (C'nauld & Kilsyth)
Cormack, PatrickHome Robertson, John
Cox, TomHood, Jimmy
Cummings, JohnHowarth, George (Knowsley N)
Dalyell, TamHowells, Geraint
Darling, AlistairHoyle, Doug
Davies, Rt Hon Denzil (Llanelli)Hughes, John (Coventry NE)
Davies, Ron (Caerphilly)Hughes, Robert (Aberdeen N)
Davis, Terry (B'ham Hodge H'I)Illsley, Eric
Day, StephenJanner, Greville
Dewar, DonaldJohn, Brynmor
Dixon, DonJones, Barry (Alyn & Deeside)
Dobson, FrankJones, Ieuan (Ynys Môn)
Doran, FrankJones, Martyn (Clwyd S W)
Duffy, A. E. P.Kennedy, Charles

Killedder, JamesPendry, Tom
Kirkwood, ArchyPike, Peter L.
Knight, Dame Jill (Edgbaston)Powell, Ray (Ogmore)
Knox, DavidPrescott, John
Leadbitter, TedQuin, Ms Joyce
Leighton, RonRadice, Giles
Lewis, TerryRandall, Stuart
Litherland, RobertRedmond, Martin
Livingstone, KenRees, Rt Hon Merlyn
Livsey, RichardReid, Dr John
Lloyd, Tony (Stretford)Richardson, Jo
Lofthouse, GeoffreyRoberts, Allan (Bootle)
Loyden, EddieRobertson, George
McAllion, JohnRobinson, Geoffrey
McAvoy, ThomasRogers, Allan
McFall, JohnRooker, Jeff
McKay, Allen (Barnsley West)Ross, Ernie (Dundee W)
McKelvey, WilliamRowlands, Ted
McLeish, HenryRuddock, Joan
McNamara, KevinSedgemore, Brian
McTaggart, BobSheerman, Barry
Madden, MaxSheldon, Rt Hon Robert
Madel, DavidShore, Rt Hon Peter
Mahon, Mrs AliceShort, Clare
Marek, Dr JohnSims, Roger
Marshall, David (Shettleston)Skinner, Dennis
Marshall, Jim (Leicester S)Smith, Andrew (Oxford E)
Martin, Michael J. (Springburn)Smith, C. (Isl'ton & F'bury)
Martlew, EricSoley, Clive
Maxwell-Hyslop, RobinSpearing, Nigel
Meacher, MichaelSteinberg, Gerry
Michie, Bill (Sheffield Heeley)Stott, Roger
Millan, Rt Hon BruceStraw, Jack
Mitchell, Austin (G't Grimsby)Taylor, Matthew (Truro)
Molyneaux, Rt Hon JamesTurner, Dennis
Moonie, Dr LewisVaz, Keith
Morgan, RhodriWall, Pat
Morley, ElliottWalley, Joan
Morris, Rt Hon J. (Aberavon)Wardell, Gareth (Gower)
Mowlam, MarjorieWareing, Robert N.
Mullin, ChrisWelsh, Andrew (Angus E)
Murphy, PaulWilliams, Rt Hon Alan
Oakes, Rt Hon GordonWilliams, Alan W. (Carm'then)
O'Brien, WilliamWinnick, David
O'Neill, MartinWinterton, Mrs Ann
Orme, Rt Hon StanleyWorthington, Tony
Owen, Rt Hon Dr DavidYoung, David (Bolton SE)
Parry, Robert
Patchett, TerryTellers for the Ayes:
Pattie, Rt Hon Sir GeoffreyMrs. Llin Golding and
Peacock, Mrs ElizabethMr. Frank Cook.

NOES

Adley, RobertBowis. John
Aitken, JonathanBoyson, Rt Hon Dr Sir Rhodes
Alison, Rt Hon MichaelBraine, Rt Hon Sir Bernard
Allason, RupertBrandon-Bravo, Martin
Amery, Rt Hon JulianBrazier, Julian
Amos, AlanBright, Graham
Arbuthnot, JamesBrittan, Rt Hon Leon
Arnold, Jacques (Gravesham)Brooke, Rt Hon Peter
Arnold, Tom (Hazel Grove)Brown, Michael (Brigg & Cl't's)
Ashby, DavidBruce, Ian (Dorset South)
Aspinwall, JackBuck, Sir Antony
Atkinson, DavidBurns, Simon
Baker, Nicholas (Dorset N)Burt, Alistair
Baldry, TonyButcher, John
Banks, Robert (Harrogate)Butler, Chris
Batiste, SpencerCarlisle, John, (Luton N)
Bellingham, HenryCarlisle, Kenneth (Lincoln)
Bennett, Nicholas (Pembroke)Carrington, Matthew
Biggs-Davison, Sir JohnCash, William
Blackburn, Dr John G.Chalker, Rt Hon Mrs Lynda
Blaker, Rt Hon Sir PeterChannon, Rt Hon Paul
Body, Sir RichardChope, Christopher
Bonsor, Sir NicholasClark, Dr Michael (Rochford)
Boswell, TimClark, Sir W. (Croydon S)
Bottomley, PeterClarke, Rt Hon K. (Rushcliffe)
Bowden, A (Brighton K'pto'n)Colvin, Michael
Bowden, Gerald (Dulwich)Conway, Derek

Coombs, Anthony (Wyre F'rest)Key, Robert
Cope, JohnKing, Roger (B'ham N'thfield)
Couchman, JamesKing, Rt Hon Tom (Bridgwater)
Cran, JamesKirkhope, Timothy
Currie, Mrs EdwinaKnapman, Roger
Curry, DavidKnight, Greg (Derby North)
Davies, Q. (Stamp'd & Spald'g)Knowles, Michael
Davis, David (Boothferry)Lamont, Rt Hon Norman
Dickens, GeoffreyLang, Ian
Dorrell, StephenLatham, Michael
Douglas-Hamilton, Lord JamesLawrence, Ivan
Dover, DenLee, John (Pendle)
Dunn, BobLightbown, David
Durant, TonyLilley, Peter
Eggar, TimLloyd, Sir Ian (Havant)
Evans, David (Welwyn Hatf'd)Lloyd, Peter (Fareham)
Evennett, DavidLord, Michael
Fallon, MichaelLuce, Rt Hon Richard
Farr, Sir JohnLyell, Sir Nicholas
Favell, TonyMcCrindle, Robert
Fookes, Miss JanetMacfarlane, Sir Neil
Forman, NigelMacGregor, Rt Hon John
Forsyth, Michael (Stirling)MacKay, Andrew (E Berkshire)
Forth, EricMaclean, David
Fowler, Rt Hon NormanMcLoughlin, Patrick
Fox, Sir MarcusMcNair-Wilson, M. (Newbury)
Franks, CecilMcNair-Wilson, P. (New Forest)
Freeman, RogerMajor, Rt Hon John
Gale, RogerMalins, Humfrey
Garel-Jones, TristanMans, Keith
Gill, ChristopherMaples, John
Glyn, Dr AlanMarlow, Tony
Goodhart, Sir PhilipMarshall, John(Hendon S)
Goodlad, AlastairMartin, David (Portsmouth S)
Goodson-Wickes, Dr CharlesMates, Michael
Gorman, Mrs TeresaMaude, Hon Francis
Gorst, JohnMawhinney, Dr Brian
Gow, IanMayhew, Rt Hon Sir Patrick
Gower, Sir RaymondMellor, David
Grant, Sir Anthony (CambsSW)Miller, Hal
Greenway, John (Ryedale)Mitchell, Andrew (Gedling)
Griffiths, Sir Eldon (Bury St E')Mitchell, David (Hants NW)
Griffiths, Peter (Portsmouth N)Moate, Roger
Grist, IanMonro, Sir Hector
Ground, PatrickMoore, Rt Hon John
Grylls, MichaelMorris, M (N'hampton S)
Gummer, Rt Hon John SelwynMorrison, Hon Sir Charles
Hamilton, Hon Archie (Epsom)Morrison, Hon P (Chester)
Hampson, Dr KeithMoss, Malcolm
Hanley, JeremyMoynihan, Hon Colin
Hargreaves, A. (B'ham H'll Gr')Neale, Gerrard
Hargreaves, Ken (Hyndburn)Needham, Richard
Harris, DavidNelson, Anthony
Hayward, RobertNeubert, Michael
Heathcoat-Amory, DavidNewton, Rt Hon Tony
Heddle, JohnNicholls, Patrick
Heseltine, Rt Hon MichaelNicholson, David (Taunton)
Higgins, Rt Hon Terence L.Nicholson, Emma (Devon West)
Hind, KennethOnslow, Rt Hon Cranley
Hogg, Hon Douglas (Gr'th'm)Oppenheim, Phillip
Hordern, Sir PeterPage, Richard
Howard, MichaelPaice, James
Howarth, Alan (Strat'd-on-A)Parkinson, Rt Hon Cecil
Howarth, G. (Cannock & B'wd)Patnick, Irvine
Howe, Rt Hon Sir GeoffreyPatten, Chris (Bath)
Howell, Ralph (North Norfolk)Patten, John (Oxford W)
Hughes, Robert G. (Harrow W)Pawsey, James
Hunt, David (Wirral W)Porter, David (Waveney)
Hunt, John (Ravensbourne)Portillo, Michael
Hurd, Rt Hon DouglasPrice, Sir David
Irvine, MichaelRaffan, Keith
Irving, CharlesRaison, Rt Hon Timothy
Jack, MichaelRathbone, Tim
Jackson, RobertRedwood, John
Janman, TimRenton, Tim
Jessel, TobyRhodes James, Robert
Johnson Smith, Sir GeoffreyRiddick, Graham
Jones, Gwilym (Cardiff N)Rifkind, Rt Hon Malcolm
Jones, Robert B (Herts W)Roberts, Wyn (Conwy)
Kellett-Bowman, Dame ElaineRoe, Mrs Marion

Rossi, Sir HughThompson, Patrick (Norwich N)
Rost, PeterThornton, Malcolm
Rowe, AndrewThurnham, Peter
Rumbold, Mrs AngelaTownsend, Cyril D. (B'heath)
Ryder, RichardTracey, Richard
Sackville, Hon TomTredinnick, David
Sainsbury, Hon TimTrippier, David
Sayeed, JonathanTrotter, Neville
Scott, NicholasTwinn, Dr Ian
Shaw, David (Dover)Vaughan, Sir Gerard
Shaw, Sir Giles (Pudsey)Viggers, Peter
Shaw, Sir Michael (Scarb')Waddington, Rt Hon David
Shephard, Mrs G. (Norfolk SW)Wakeham, Rt Hon John
Shepherd, Richard (Aldridge)Waldegrave, Hon William
Skeet, Sir TrevorWalden, George
Smith, Sir Dudley (Warwick)Walker, Bill (T'side North)
Smith, Tim (Beaconsfield)Walters, Dennis
Soames, Hon NicholasWard, John
Spicer, Michael (S Worcs)Wardle, Charles (Bexhill)
Squire, RobinWarren, Kenneth
Stanbrook, IvorWells, Bowen
Stanley, Rt Hon JohnWheeler, John
Stern, MichaelWhitney, Ray
Stevens, LewisWiddecombe, Ann
Stewart, Allan (Eastwood)Wiggin, Jerry
Stewart, Ian (Hertfordshire N)Wilshire, David
Stokes, JohnWinterton, Mrs Ann
Sumberg, DavidWolfson, Mark
Summerson, HugoWood, Timothy
Tapsell, Sir PeterWoodcock, Mike
Taylor, Ian (Esher)Yeo, Tim
Taylor, John M (Solihull)Young, Sir George (Acton)
Taylor, Teddy (S'end E)Younger, Rt Hon George
Tebbit, Rt Hon Norman
Temple-Morris, PeterTellers for the Noes:
Thatcher, Rt Hon MargaretMr. Robert Boscawen and
Thompson, D. (Calder Valley)

Question accordingly negatived.

Amendment made: No. 38, in page 9, line 16, at end insert—

'(8) In paragraph 2(4)(a) of Schedule 12 to the National Health Service Act 1977 and paragraph 2(4)(a) of Schedule 11 to the National Health Service (Scotland) Act 1978 for "16" there shall be substituted "18"'.—[Mr. Moore.]

Clause 9

The Dental Estimates Board And The Scottish Dental Estimates Board—Change Of Name And Extension Of Functions

I beg to move amendment No. 39, in page 10, line 5, leave out

'in the exercise of this power'
and insert 'conferring such a right'.

The amendment is consequential on our acceptance of amendments in Committee, and I trust that it will be acceptable to the House.

Amendment agreed to.

Clause 10

General Ophthalmic Services And Optical Appliances

I beg to move amendment No. 13, in page 10, line 26, leave out subsections (1) and (2).

With this it will be convenient to consider the following: Government amendments Nos. 31 and 33.

Amendment No. 14, in page 12, line 44, leave out subsection (4).

Government amendments Nos. 32 and 34.

Amendment No. 13 seeks to remove from the Bill the provisions for charges for the eyesight test. There is a degree of common ground between this debate and the debate that we have just concluded about charges for dental examination. I shall take as read the position on the general principles. [Interruption.] I have had occasion to mention that the Tea Rooms in this building are provided for people to gossip and that the Chamber is where we debate important matters. I wonder whether you, Mr. Deputy Speaker, would draw that to the attention of hon. Members.

The hon. Gentleman is quite correct. Will hon. Members who wish to make conversation do it elsewhere. and will those who remain in the Chamber allow the hon. Gentleman to move his amendment?

I am obliged to you, Mr. Deputy Speaker.

There is much common ground between this debate and the one that we have just concluded. I shall take as read the general principles that underlie both debates. The clause provides for another reduction in health services which are free at the time of use. For that reason. it is objectionable. The clause also provides a charge that will discourage people from attending for a screening process. It is being put forward by a Government who proclaim their commitment to preventive medicine. It is impossible to square that paradox.

I shall not rehearse the debate on the general reasons for rejecting the clause. Instead, I shall concentrate on the specific and substantial damage that the measure will cause. First, it is misleading to describe an eyesight test merely as an eyesight test. It involves a full eye examination: an examination of the back of the eye for systemic disease as well as for eyesight. Indeed, the objectives of the examination are laid down in regulations issued by the DHSS. They prescribe the diseases that have to be looked for.

In the previous debate I asked the Secretary of State what evidence had emerged since Second Reading that would support the case that the Government are making for charges. I have to say to the Minister for Health, who I understand is to respond to the debate, that evidence has emerged since Second Reading that is appropriate and relevant to the clause, but it buttresses the powerful case against introducing a charge for such tests.

The first piece of evidence, and perhaps the most powerful, is provided by the survey carried out by the British College of Optometrists. It carried out a survey of 1,500 optometrists in the first week of January this year. That is a massive survey and it covered an enormous sample 70,000 eye examinations. From that survey it emerged that in the five working days of that week 6·1 per cent. of those examined were referred to a general practitioner or hospital for further examination for a medical condition. A total of 2·5 per cent. of examinations resulted in a notification to a general practitioner of a medical condition which the optometrists believed should be reported. In other words, 8·6 per cent. of the sample revealed some sort of medical condition, not immediately related to eyesight, that was worthy of further medical investigation.

To put that figure into perspective we should bear in mind that 12 million eye examinations take place each year. If 8·6 per cent. of those examinations require referral, that means that over 1 million people are referred to their doctor or hospital for a further medical investigation as a result of the routine screening.

Some of the medical conditions discovered during eye examinations are serious. The two most common to emerge in the survey were cataracts and glaucoma. Both those conditions can result in total blindness. One can be operated upon and the other can be treated, but both can be irreversible if left untreated for too long. It is an interesting fact that the majority of cases of glaucoma are detected not by GPs but by optometrists using the routine NHS eye examination.

It is perverse to suggest that that screening operation is likely to be done better by GPs who remain free; or who remain free for as long as the hon. Member for Pembroke (Mr. Bennett) is content to allow them to do so. It is not the case at present that GPs carry out that screening better than optometrists, and it is not likely to be the case in the future, as, by and large, GPs do not have the same experience as optometrists and are unlikely to have the equipment that is available to optometrists. The examination is vital and can result in the identification of serious medical conditions.

The question that remains is whether the charges in this case will deter people from coming forward for examination and preventive screening. I believe that they will. On this occasion I am happy to say that I have substantial and influential supporters for my contention that charges for eye examination will deter people from coming forward.

First, I should like to pray in aid the Prime Minister. She wrote a letter in June 1980 to an optometrist in London concerning the then proposal by the Government to charge for eye examinations. That proposal was abandoned at the time. The letter stated:
"The Government have decided to drop this proposal in response to strong representations that such a charge in a service that has a preventive function would be wrong in principle and could deter patients from seeking professional advice."
Those are the words of the Prime Minister, the senior Minister of the Government, who now, eight years later, are coming forward with a charge for that very examination.

The question that I have to ask the Minister—I hope that he will be able to answer it—is why did the Prime Minister consider that charges for eye examinations in 1980 would be a deterrent, when in 1988 we are told that they will not be a deterrent?

A suggestion was made by a spokesperson from Downing street which was quoted in the newspaper that revealed the Prime Minister's letter. It said:
"Most people are better off nowadays. If people spend so much on luxuries, surely they can afford £10 for an eye test."
Let us examine that proposition and see whether it convinces us. I believe that the charges in this case will be an even greater deterrent than the charge for dental examinations. They will be a greater deterrent for three reasons. First, such examinations are likely to be more expensive. Optometrists are currently paid £9·30 for every eye examination. If they are to recoup that income in full, they will have to set a charge of about £9 or £10. Therefore, the charge will be substantially greater than that currently proposed for dental examinations.

Secondly, the client group to whom the examination is most relevant is the elderly. As one grows old, one's eyes degenerate. The optometrists survey to which I referred earlier discovered that half of all referrals were people over the age of 60. Yet the exemptions for people who have an income too low to pay are drawn in such a limited fashion that, of the 9 million pensioners in Britain, 6·5 million will not qualify for exemption. Those 6·5 million will have to find the full £10 for the examination, although they may well be the people who have just lost £10 of housing benefit as a result of the changes that we have seen this month.

Thirdly, those who require eye examinations are likely to require them periodically. As one gets older and one's eyes start to fail, one needs to have one's spectacles adjusted regularly. Such people should have their eyes tested regularly to ensure that their spectacles are appropriate for the condition of their eyes. The elderly, who are least likely to be able to afford the £10 charge, are in the invidious position of having to go more often and pay that charge.

Diabetics are another group of people who ought to go regularly for an eye examination. To their credit, officials at the DHSS are seeking to encourage greater screening for diabetic retinopathy. This condition can result in blindness among diabetics. It requires regular examination to ensure that retinopathy is not developing from the diabetic condition. Diabetics are not exempt from the £10 charge. They will have to pay that charge every time they present themselves for examination. There is every reason why every hon. Member would wish a diabetic to attend for a full eye examination as often as possible because with that condition, as with others, sight can be retained by treatment, but that treatment can be successful only if there is an early enough intervention.

7 pm

I stress that the decision whether to go for that examination will inevitably be taken by people who have no idea at the time how important that examination might be to them. Of course, any member of the public, however poor, who believed that the examination could result in his or her sight being saved would scrape together, borrow,, find, beg or steal the £10 to pay for that examination, but: it will not appear that way to many people. Many of them will not be aware until too late that, by passing up the chance of an examination because they did not want to pay £10, they have seriously jeopardised their eyesight—perhaps worse.

My hon. Friend the Member for Fife, Central (Mr. McLeish)—who will seek to catch your eye, Mr. Deputy Speaker, in the course of this debate—has with him the details of a constituent who developed a problem with her eyes, went along for a full eye examination and, as a result. was referred immediately to the local hospital and was treated within days for secondary cancer from breast cancer. She had no idea, as she considered whether she would go for an eye examination, that her life was at risk and would be saved by that examination. Indeed, she has, said that she is doubtful whether she would have gone for the examination at that time had she been obliged to pay £10 for it.

How many more people will respond perfectly rationally to the price signal, will not present themselves for an examination and will suffer the tragedy of discovering when they do eventually go for an examination that it is too late for their life or too late for their sight?

There is an irony here, and it is that the Government are expecting individuals to show prudence by investing, and investing early, in an eye examination and spending a substantial sum as a preventive health measure. They expect individuals who may not be in a position to make an informed decision to make that prudent investment. Yet the Government themselves are not prepared to show a similar prudence by investing in a free screening facility that is excellent value and of proven quality.

I want to conclude by looking at what good value it is. It is reckoned that the cost of blindness to the state is some £3,500 per person per annum. That figure was last used by Professor Yudkin in the British Medical Journal. That is a substantial sum per annum. I hope that my hon. Friends will forgive me if I put a cash figure on such a deep personal tragedy as the loss of sight, with all that that implies for the loss of witness of life and the life that then has to be lived in darkness, but that may be the best way to get through to the Treasury Bench.

Taking the cost of screening as £9·30 per patient, we can calculate that the total cost of screening 1,000 patients would be £9,300. If the survey to which I referred at the beginning of this speech provides an accurate guide—and it was certainly a very comprehensive, large-scale survey—the examination of 1,000 patients would produce 60 patients to be referred to doctors or hospitals for conditions such as glaucoma, cataract and retina—

I am most grateful. I knew that my hon.

Friend would be a great asset in this debate. I rest on his guidance. Possibly he could check Hansard for me when I have concluded my speech.

Of those 60 cases, many of them with serious conditions that threaten blindness, it is far too modest to suspect that one in 10 would have their sight preserved as a result of that referral to medical attention. If only six were saved from going blind as a result of that examination, the annual saving to the state would be £21,000—over double the cost of paying for the screening of the 1,000 patients in the first place. It is a bargain. Only a Government obsessed with counting the petty cash of public expenditure would be prepared to put such a bargain at risk. This is the last chance that the House of Commons has to save the Government from their own folly. Many hon. Gentlemen on the Government Back Benches know that it is folly. It needs only a sufficient number of them to show the vision and courage to join us in saving the Government from their own folly and saving an excellent free Health Service for our constituents.

It will be no surprise to my hon. and right hon. Friends on the Front Bench that I feel impelled to speak in this debate. Indeed, I have travelled many thousands of miles to do so. I rise particularly to support amendment No. 13.

I can understand the need to find more money for the Health Service, even if it is to be moved to be spent in a different part of the Health Service. There are many needs, and I acknowledge them all and would wish money to be spent. So I can understand the Government's view that they should find more money for the Health Service. But the proposition now before us will cost the Health Service far more that it will save. I can understand the Government's view that primary medical care, on which they are to spend a lot of these dubious savings, as I understand it, and preventive medicine, are of great importance. But clause 10 as it stands will be a powerful instrument against early diagnosis of a number of diseases, and early diagnosis is surely the core of preventive medicine.

I can understand the soundness of the economic theory that people who can afford to pay for medical aids should be asked to do so, but such people are already paying for glasses and other appliances, such as contact lenses, that they may need. We are dealing not with the principle of their paying for something that they need but with whether they should pay for the check to find out whether they need it. It has always been a fundamental concept of the National Health Service that medical examinations must be free. If those examinations indicate that some appliance, such as glasses, contact lenses or dentures, as we were discussing earlier, are necessary for the patient, fair enough; we have conceded that they should be paid for. Most people who originally thought, happily and with misty eyes, looking through rose-coloured spectacles, that we could make health service free have accepted that if appliances are needed they must be paid for. But the argument advanced in the earlier debate by my hon. Friend the Member for Pembroke (Mr. Bennett) was absolutely shot to pieces by hon. Members on both sides of the House, because if we once say that the principle of free testing for anything is to be breached, what is the reason for stopping anywhere? That is what worries us.

I have no doubt whatsoever that a very substantial number of people will he deterred from having their eyes tested. On the Government's figures, a quarter of pensioners will be eligible for free tests. That leaves three quarters who are not eligible. I have to admit that I have never accepted the theory that every gentleman over 65 or lady over 60 is automatically a pauper; there are some who are very wealthy, but I do not think that three quarters of pensioners fall into the category. Many are on a very difficult line between managing and not managing and for them that £10—and we know that it has to be at least £10—is going to be a very powerful deterrent. And, as the hon. Member for Livingston (Mr. Cook) said, this comes just at the time when they need to have their eyes examined more often than at any other time in their life. They will find it very difficult to work out where the £10 is to come from out of their budget. After all, 78 per cent. of people between the ages of 78 and 85 have major eye diseases and obviously need to have their eyes tested very regularly. I am worried about those pensioners.

I am also worried about the parents of growing children. The children will be safeguarded, as they should be, but I am talking about the parents themselves. I have read all the debates and nothing I have seen has convinced me that I am wrong when I say that parents will put the needs of their children above paying for their own eye tests. I would have done it myself. We all would, if we were short of money when our children were growing up. A parent will say, "I may not need to have my eyes tested. They may be all right. It will cost £10 and Johnny needs a new winter coat." That is where the money will go. The parents will not go to have their eyes checked and early signs of the onslaught of such things as heart disease, cancer and diabetes will be missed.

It is all right for hon. Members. We are in receipt of a salary and we do not mind paying. We will pay even though we do not like the principle of the free test being eroded. I am making a plea not for us but for the people who will find it extremely difficult to pay. Because the early signs of some diseases will he missed, the whole operation will cost far more than it will save in the long run because it is much more expensive to treat these things at a later stage.

Nothing I have yet heard convinces me that I am wrong when I warn about the implications of the clause for ophthalmic departments in hospitals. This is serious. A person will go to his doctor and say "I am having headaches." The doctor will tell the patient that his eyes should be tested and that he can go to the high street and pay the optometrist £10 or £11, or he can go to the hospital and have it done for nothing. It stands to reason that people who find it difficult to get the money together will go to the hospital. There is no way that the Government can tell doctors that they are not to send these patients to hospital. That is not on the cards. It cannot be done. People have a right to have their eyes tested in hospital.

Again I come to the point about the extra cost of the proposal. Whereas the Government have been paying optometrists £10 to test a person's eyes, if the person goes to a London hospital it will cost at least £35 for each test. I am using a conservative estimate. Some people have given me higher figures, but at the moment in London the Government pay £10 to the optometrist and will pay £35 at least to the hospital. Outside London the cost is slightly less. As I understand it, it is in excess of £27 or £28. That is the lowest figure I have heard. I am trying to be fair, but that means that we are bound to pay more in the long run.

Again, the most conservative estimate of the current waiting list for care in the eye department of a hospital is nine months. If this goes through, I warn the House that we shall all get shoals of letters from constituents complaining that they have to wait two or three years to have an eye test. Crowding in hospitals has led the people in charge of some hospital eye departments to write to some of us already. Their worries about the extra people who will come to their departments are severe. We should understand this.

I read with interest some of the speeches made in Committee. On 16 February my right hon. Friend the Minister for Health said:
"Regular checks of, for example, blood pressure or urine samples arc a far more reliable way of diagnosing the conditions—especially diabetes …—than is the occasional eye test. In any event,"—
he said cheerfully—
"people go to their opticians much less frequently, if at all, than they go to their doctors."—[Official Report, Standing Committee A, 16 February 1988; c. 733.]
I wonder whether that is so. I was interested to see that my right hon. Friend was challenged to produce figures but I did not see any figures.

7.15 pm

If a person goes for an eye test, something positive is done. Many of the people who go to their doctors and who, I am sure, are in the lists of patient attendances may be going simply to have their inoculations updated. That counts as a visit to the doctor. So do a host of other things. Many people need glasses from the time they are children. We all know children who have to wear glasses. Those people have to go regularly to the optician throughout their life. Do they really go more often to the doctor than to the optician? I have tried to remember, and I think that the only time that I have been to my doctor in the last 20 years has been to have a jab, whereas I have been to the optician to have my eyes tested far more often. People who wear glasses for reading or for distance vision have to go regularly to the optician.

My right hon. Friend's statement was mirrored by my hon. Friend the Parliamentary Under-Secretary of State for Health and Social Security in a most important contribution:
"We would not seek to deny that opticians may detect signs of diabetes or hypertension during the sight test,"—
that is magnanimous because they do it all the time—
"but primary responsibility for the diagnosis and treatment of all medical conditions rests with the patient's GP. The GP has a better opportunity to detect such conditions than the optician has. Doctors normally see about three quarters of the patients on their list within a 12-month period."
I wonder whether those are the same patients or whether some of them have gone along to have jabs, as I did.

It stretches my credulity to impossible lengths to imagine that if someone takes a child with, for example, measles to the doctor there will automatically be a test for diabetes. What doctor takes a urine sample for a wrenched ankle, a broken arm, a tummy upset or flu? There will be many complaints from general practitioners if they have to carry out blood and urine tests on patients in those categories. It is unrealistic to think that doctors would do that.

Later in Committee, my hon. Friend the Parliamentary Under-Secretary of State said:
"We wish to use our funds to encourage GPs to do that kind of screening more effectively in future."—[Official Report, Standing Committee A, 16 February 1988; c. 751–752.]
The GP should not be asked to do all this screening at the same time as he is dealing with a condition which has nothing to do with eyes. The optometrist, who has trained for three or four years, and sometimes more, is looking at the eyes alone. Because he knows what he is doing he can detect early signs of trouble. The doctor will not do that if he is examining another part of the patient's body.

The idea that doctors should test eyes should be exploded here and now. It is different if the doctor is an ophthalmic medical practitioner, but the ordinary GP knows less about eyes than the trained optometrist. That may come as a shock and surprise to the Government, but it is true. The ordinary GP has not specialised in eyes because he has many other parts of the body to look after. If the Government suggest to the British Medical Association that all GPs should carry out this screening free instead of it being done by optometrists, there will be a loud outcry. Doctors are not trained to do it. If they are going to do the same job as optometrists they will have to train, and to buy a great deal of very expensive equipment. I gather that it costs at least between £3,000 and £4,000. Doctors do not have that equipment in surgeries at present. If a doctor is told that he must test eyes it will be no more practical than the suggeston that charges will have to be made for hospital eye checks. It is not realistic to suggest that.

I resent, on behalf of trained optometrists, the suggestion that they do a really rather unimportant job. They provide us with a cheap and very cost-effective means of doing a very good job on eyes. We should not write them down. After all, only about five years ago, the Government introduced the rule that optometrists should do refractions and give the prescription to the patient. who could then trot off down the road to a boutique and get some snazzy glasses at reasonable cost. At one stroke, one means of an optician earning money was cut off.

Here we have cut off his other source of income. The Government will say, "We are not stopping him asking for money." But suppose that patients do not turn up or a prescription is taken elsewhere, or, as happens in very many cases, the test does not reveal any need for spectacles? Who will pay then? I think it is unrealistic to say, first, that an optician may or may not get his money from spectacles, and then to say that he may get money from patients, but not from the Government, to do his job of testing eyes.

Clearly, the Government do not want to have late diagnosis of disease when it could be done early. Obviously, the Government do not want to pour out more money on the Health Service, yet get a worse service for it. And surely the Government are not intending to flood hospitals with patients who could be dealt with perfectly well elsewhere, for a great deal less money. I cannot believe that the Government need to place new money worries on people who already have problems making ends meet. Those who need to have regular tests will have problems.

In the previous debate, the hon. Member for Pembroke said that £3 was the cost of a few cigarettes. We are talking about at least £10, so I wonder what new figures we shall hear. But let nobody in the House be in doubt but that people will find it very difficult to pay to have their eyes tested. I do not believe that my right hon. Friends are guilty of all these things: of intending to flood hospitals, or to pour out money only to get a worse service. Nor do I believe that they are trying to place money worries on people. Yet that is exactly what they are doing. All those points will be covered by clause 10, unless it is amended.

I cannot quite understand why this matter has not been thought through, or why difficulties about its implementation have not been foreseen. Should the clause be accepted, we shall have a great deal of trouble on our hands. I shall be first in the Lobby to vote for amendment No. 13 tonight.

I am glad to follow the hon. Member for Birmingham, Edgbaston (Dame J. Knight). The hon. Lady's well-informed speech was supported by considerable experience, and has been of much help to the House in considering this serious matter.

I should like to follow the hon. Lady by drawing to the attention of hon. and right hon. Members a letter that I have received from a consultant physician at Chester royal infirmary. The hospital, just the other side of the Welsh border, cares for many of my constituents. The consultant says:
"While I welcome many of the initiatives, for example, retirement of GPs at the age of 70, I am on the other hand very concerned about the plans for introduction of a charge for an NHS sight test with opticians."
He went on:
"It was reported in The Times on 26 November 1987 that charges for dental examinations and sight tests would raise £170 million for 'development of the Health Service' and the 'promotion of better health'. Such a statement is a strange paradox when the major thrust of the White Paper is towards preventive medicine to provide better health care."
He says:
"Eye disease due to diabetes has to be detected before development of symptoms…to enable provision of effective treatment. Strenuous efforts are being made to provide such screening and yet the hospital service can only cope with, at best, around 50 per cent. of such patients at risk of losing their vision. Most general practitioners declare that they do not have the necessary expertise to carry out such a task."

That was a central point of the hon. Member for Edgbaston's contribution. The consultant emphasised it strongly. He continued:
"Opticians are therefore ideally placed to carry out this task. It was therefore unfortunate that on the morning of 25 November 1987 I was invited to speak to the local optical committee and received their enthusiastic support for opticians in the area in carrying out screening for diabetic eye disease. Later the very same day such plans were effectively shattered by the proposed introduction of a charge for sight testing."
He goes on to say:
"Hopefully such charges will not be introduced but if this should happen I would like to make a plea for an exemption from a sight testing charge for patients with diabetes. Obviously this will result in other patients with as yet undiagnosed conditions…for instance glaucoma and high blood pressure, going undetected with inevitable serious consequences on occasions."
That consultant is not embroiled in the party political scene, but he felt so strongly that he made this case to me by letter, which I have also put to Ministers.

One principle is undeniable. Free sight testing is a cheap and effective method of preventive medicine. If a charge is introduced, I believe that the White Paper's emphasis on preventive health care will be undermined, as other hon. Members have said in relation to dental charges. The Government's stance in the White Paper will be contradicted. The proposed measure will not help any of my constituents.

I say to the Secretary of State and his Ministers that their proposals to put a charge on eye tests is a serious error of judgment. I also advise them that it will damage the Government politically. It puts them in a very unfavourable light at a time when they are struggling on various political fronts. The measure debated today is far from helpful, even in the interests of the long-term life of the Government. It is also morally wrong to put a charge on eye tests a month after massive Budget handouts were given to the richest in our society. This is an unjust proposal and I hope that the Government will think again.

In the course of our earlier debate, Mr. Deputy Speaker, several of my hon. Friends said that they would not seek to catch your eye in this debate because they felt that the arguments were much the same. I apologise for rising again, but I hope that I shall not be unduly repetitious. Indeed, some of the arguments are much the same, except that in this instance they are rather stronger than those put forward in the case of dental health.

As the hon. Member for Alyn and Deeside (Mr. Jones) said, the thrust of the Government's health policy is prevention. Indeed, the White Paper is specifically entitled, "Promoting Better Health", and the third of the Government's six objectives laid out in the foreword to the documents reads:
"to promote health and prevent illness."
The proposals to make charges for dental and eye checks seem incompatible with those admirable aims.

I agree with the hon. Member for Alyn and Deeside that the proposals seem politically inept. The controversy that they have aroused has diverted attention from the many good points in the White Paper and the Bill. It is unfortunate that we have been diverted by those two issues.

7.30 pm

The value of an eye test is not disputed. Anyone who read the material provided to us by the British College of Ophthalmic Opticians (Optometrists) will have learned what is involved in an eye test from the, examination of the skin surrounding the eye to the eye surface and the retina. If hon. Members had had the opportunity, as I have, of seeing a detailed examination being carried out by the college, they would have been most impressed, as I was, by its scope and detail and what it can detect. There is ample evidence that a wide range of problems which merit reference to a specialist can be revealed by a test—not only glaucoma and cataract, but symptoms of other problems such as diabetes and hypertension.

As a result of an eye test, it was discovered that a member of my family was suffering from hypertension, which is what you, Mr. Speaker, and I would call high blood pressure. The condition was treated and is under control, but had it not been revealed by the test the consequences might have been serious.

My right hon. Friend the Minister will argue that by withdrawing free tests we are saving money which can be spent elsewhere. I suspect that he will also point out that we are not imposing a charge in the Bill but are simply enabling optometrists to levy one if they wish. Various figures have been suggested; £10 is a popular one. I had my eyes tested only a month or two ago and I spent 30 or 40 minutes with a well-qualified gentleman who used expensive and sophisticated equipment. At the end of the examination I said to him, "Have I had £10-worth?", to which he replied, "You have had about £25-worth," and I believe that he is right.

Whatever the figure, the question is: will such a charge be a deterrent? As I said earlier, any charge, particularly of this sort of magnitude, is bound to deter, especially elderly people on smal incomes—the very people who most need a test.

Would money be saved by this measure? In the short term it would, but in the long term certainly not. The extra cost to the NHS of treating some of the conditions to which I have referred which will have been allowed to develop but which could have been detected earlier by an eye test will be enormous and far greater than for dental matters.

I shall not embarrass the Minister by voicing my assessment of his qualities, but he is wrong on this issue. I shall vote for amendment No. 13 to remove this power from the Bill. It will undoubtedly be said by the media and in the Whips' Office that I have voted against the Government. Perhaps in response I can read a brief quotation:
"Our policies rest on six principles: First, we will give greater emphasis to the prevention of avoidable illness and the promotion of good health—to make the NHS more truly a health service and not merely a sickness service."
My hon. Friends will recognise those words from our party's election manifesto, on which the Minister, I and others fought and won the general election. I supported that policy then, and I shall support it tonight with my vote.

I feel sad about what is happening in this Chamber tonight. The condition of glaucoma appears to be genetically transmitted within my family, so it helps to concentrate my mind on precisely what we are debating here this evening. When my grandmother died it was not from that condition, but it went with her to the grave. I remember well her final years and what it meant in my family, and I cannot understand why the Government wish to press on in this way.

We on the Labour Benches cannot claim any monopoly of compassion and in the context of objectively debating these matters it would be wrong to do so. I cannot understand what thought processes go through Ministers' minds when they conclude that this is in the public interest and, indeed, would safeguard the position of those who may ultimately find that they have this condition.

As my hon. Friend the Member for Linlithgow (Mr. Dalyell) said to me earlier, this goes against everything that he has ever stood for, and I understand exactly what he means. I sense that many Conservative Members who, recognising that none of us can claim a monopoly of compassion, also wish to say that tonight, but they may feel from a sense of loyalty that they are required to vote with the Government. Yet they are not in the Chamber and will not hear this debate. They will walk into the Lobby and support the Government. The Minister knows the antagonism that the measure is creating and the strong feelings that many of us have and must contain.

Some weeks ago I wrote to the Minister responsible, Lord Skelmersdale. Indeed, I wrote to the Secretary of State the other day and added a footnote in my hand, saying that this was wrong and that he misunderstood what the debate was about. My letter to Lord Skelmersdale included a letter from a consultant at the West Cumberland hospital, and the Minister replied, trying to reassure me and the consultant of the merit of the Government's position. I sent the consultant ophthalmic surgeon, Mr. Cubey, the Minister's letter and Mr. Cubey replied:
"I am writing again so soon because I am sure that you will be interested to know that already within three days of having received your letter enclosing Lord Skelmersdale's views, I am able to refute those views categorically by a concrete example.
I have examined for the first time today a 73 year old man who is a constituent of yours. He had not seen an optician for many years but felt that he should perhaps have some reading glasses and therefore consulted an optician just two weeks ago. The optician found in him signs of early glaucoma of which the patient was totally unaware and which were totally unrelated to his reasons for seeking the optician's help. The optician advised the man's General Practitioner that he should be referred to Hospital, and I saw him at the Workington Infirmary this morning. I confirmed that he has early glaucoma and I have started him on treatment aimed at preserving his sight.
I asked the patient whether, if he had thought that he would have to pay a fee of £10 for his sight test by the optician"—
I presume that that is if he were not going in for glasses—
"he would have been deterred from consulting the optician. His reply was unequivocal. He said that in those circumstances he would not have consulted the optician."

That is an admission that someone would not have consulted an optician because of the charge. The assumption made was that the charge would be £10. I have discussed this with my hon. Friends. Indeed, the hon. Member for Chislehurst (Mr. Sims) referred to a completely different figure. We are now talking not about £10 but about £20, £25 or even £30. Does the Minister accept that if such charges are introduced they will act as a disincentive?

The letter continues:
"It is therefore clear that in those circumstances his glaucoma would have gone undetected for a considerable time"—

that is an assumption; it might not be true, but I think that it could be in this context—
"with irretrievable damage to his sight."

That person is a 73-year-old man.

The letter continues:
"I asked the patient if he would agree to me writing to you about the details of his case".

The letter goes on to comment on matters of personal detail and then states:
"I have quoted this case in some detail in order to demonstrate the false assumptions made by Lord Skelmersdale.
It is clear from this case, and this could be multipled many times over in this constituency alone, that Mr. Pitts Crick's fears about the detection of glaucoma are not groundless.
The 'primary purpose of the NHS sight test' may indeed have always been 'to establish if a person needed glasses and if so to what prescription', but an essential purpose of it also is the detection of eye diseases or abnormalities—indeed opticians expose themselves to litigation if they fail to detect these.
It may well be 'that the Government is doing nothing to change the way sight tests are actually conducted', but the proposed restriction of free NHS sight testing will reduce the number of sight tests conducted and hence the number of cases in which for example early glaucoma is detected.
Lord Skelmersdale apparently believes that it 'need not be so' that people would be 'deterred from seeking sight tests on cost grounds'. Here is one clear example of such deterrence. People on low incomes may be deterred by ignorance or by the complexities of having to claim exemption from the sight testing fee.
The recommendations that 'anybody with health worries should in any case consult their family doctor' misses the point altogether, which is that glaucoma, for example, is symptomless until quite advanced, and therefore the sufferer has no cause for concern about it and no indication that he should consult his family doctor until an optician recommends this as a result of his NHS sight test."
A consultant ophthalmic surgeon is telling me that what is being done is wrong and is pointing to the dangers. Surely that must influence ministerial judgment.

I turn to another aspect of the matter. I understand that a court case is going on. I believe that it relates to the British Ophthalmic Lens Manufacturers' and Distributors' Association. I have not done my homework in this area, but I have been informed of it tonight. I understand that it has brought some action, which may be sub judice so I cannot talk about the merits—but perhaps I am wrong—about the right of persons who sell spectacles to sell them without a full eye test. I know that there are shops around the country—I am told that there is one near my constituency in Whitehaven—where a shopkeeper sells spectacles without a formal eye test. It seems that a person enters the shop, looks at a card on the wall and then, based on the identification of certain letters, is able to establish what kind of spectacles are required, and proceeds to purchase them.

7.45 pm

I advise the Minister that persons such as the gentleman to whom Mr. Cubey referred in his letter could enter such a shop—perhaps the Minister could clarify this because I should like to know what the position is—

Perhaps I could finish the point.—and buy his spectacles without having undergone a full eye test, thus slipping through the net for establishing whether glaucoma exists. If that is the case, Ministers must make it clear during tonight's debate.

As the hon. Gentleman will realise, I am not aware at the moment of a court case such as he has described, but as he has suggested that there may be such a case, I must obviously choose my words cautiously. I understand that the provisions in the legislation that introduced the voucher scheme were that spectacles can only be provided against a recent prescription, by which is meant a prescription which would entail an eye examination less than two years old.

Perhaps I can assist the hon. Gentleman. I am not aware of any court case but I have been lobbied and know that many hon. Members of all parties have been lobbied by a company whose name I shall not mention, which wants to sell glasses in shops without a proper eye test. I feel that that is dangerous.

I am sure that the Department's officials will follow up what I am saying tonight to find out whether what I have said has any foundation. I was informed of this just one hour ago by the principal optician in West Cumberland who told me of the existence of this retailer. Perhaps there is a case in the European court—it might not be—but he has referred to an action in some court. I am sure that advice is now being taken from civil servants. The matter should be clarified during tonight's debate.

The second issue that I want to raise is the question of what pensioners will do. As I understand it, the hon. Member for Birmingham, Edgbaston (Dame J. Knight) referred to the fact that three quarters of pensioners would not be entitled to the voucher—

In view of what the hon. Gentleman has said, it would be sensible for me to clear up the matter straight away. What I had asked for from my officials was what I said on precisely this point in Committee. I repeat it:

"The law is that spectacles can be sold against a prescription that is up to two years old. There is scope for argument about whether two years or some other period is right, but there must obviously be some such provision."—[Official Report, Standing Committee A, 11 February 1988; c. 660.]

I then repeated the fact that it is not lawfully possible to sell spectacles other than under those provisions.

The firm that gave me the information this evening is Philip Heal of Workington. I am sure that officials will wish to follow that up.

As I was saying, three quarters of pensioners would not necessarily be supported in the payment of the charges. Pensioners are a group of people particularly susceptible to the condition of glaucoma. I should have thought that detection of the condition is very much dependent on their regular visits to opticians to secure a test. If the charge is not to be £10, if it is to be perhaps £15, £20 or £25 because opticians would know that they are not likely to be selling spectacles, and if a hospital is some distance from where elderly people live—as is the case in parts of my constituency—and with their problems with the resources that they retain, they may well visit opticians less frequently to secure that test.

Unless the Minister can give an absolute guarantee to the House tonight that pensioners will secure tests as regularly as they have done in recent years, he has absolutely no right to press the provision on the House because not to give that guarantee is to accept that pensioners will become a more exposed group of people.

Finally. I am sure that the Secretary of State is listening to what I am saying and I advise him that I am not speaking out of any sense of unreasonable criticism of his position. Yesterday he had a very difficult day in the House. We all understand why, and we do not necessarily blame him. These are collective decisions taken by the Cabinet, and he had to sell a brief to the Commons, a very difficult brief indeed to sell. But there comes a time in life when one must realise that what one is doing is not necessarily correct. He knows that in the event that this is pushed to a Division tonight he will win—and he will win because people will vote who have not heard this debate and who may well not have considered this matter in as great a depth as many of us over the past few months, nor corresponded as much with others as some of us have done.

The Secretary of State is in a position not to press this tonight. He is in a position to accept the tenor of the debate, based on the expression of very strong opinions on this subject. In the light of what happened yesterday, I ask him genuinely to reconsider the position. We have but minutes before the Division. Unless he makes some concession, this amendment will not go through. If so, the damage will be done and it will be he who is held responsible. I am sure that he would not wish to carry that responsibility for the rest of his political life.

My hon. Friends the Members for Birmingham, Edgbaston (Dame J. Knight) and for Chislehurst (Mr. Sims) have made powerful speeches with which I wholly agree. I wish to add only two brief points.

The first relates to road safety. There has recently been much discussion about bringing daylight saving time in this country into line with that in Europe, and the Royal Society for the Prevention of Accidents has argued powefully that the extension of daylight saving, so that we have lighter evenings, will prevent thousands of accidents on the roads, since many drivers with slightly defective eyesight find it particularly difficult to see at dusk and become accident-prone. In the interests of road safety, we ought to encourage more drivers to take eye tests more regularly, and anything that prevents this is a small step in the wrong direction.

Secondly, it is plain that my right hon. Friend the Secretary of State for Social Services, for whom I have the greatest admiration, needs some money and some excuse to get off the hook on which he has impaled himself. I believe that the European Court of Human Rights has provided us with both an excuse and some additional funds. We have argued in the past year in front of the European Court that value added tax should not be charged on opticians' dispensing fees. We lost that case and, as a result, some £25 million of extra money will be flowing into the Treasury from opticians.

We did not want that decision from the European Court. We can, in practice, set it aside by reducing, even by eliminating, the charges proposed. I hope that my right hon. Friend will take this excuse and change his mind.

My first duty is to congratulate the hon. Lady the Member for Birmingham, Edgbaston (Dame J. Knight) on her considered speech, which she delivered with conviction. The House should ponder carefully what she had to say, and the Government should act on her good advice.

In the few brief minutes that I would like to detain the House, I wish to address my remarks to the effect which these changes, particularly the imposition of eye test charges, will have on pensioners. The Federation of Ophthalmic and Dispensing Opticians estimates that over 6 million pensioners will no longer be eligible for free tests under the National Health Service; and, according to its estimates, that is at least two thirds of all pensioners. As the House has already heard, a recent survey of people over 70 in an inner-city area showed that only 50 per cent. had had their sight tested in the previous two years. What we ought to be doing is persuading more pensioners to attend for tests rather than dissuading them because the tests will have to be paid for.

A survey by the British College of Optometrists shows that over half the referrals for treatment or further investigation were in the over-60 age group, particularly for glaucoma, cataracts and certain other conditions. Elderly people are often insufficiently motivated to seek help, and tend to regard deteriorating eyesight as inevitable. So they need particular encouragement and support.

We know that it is the elderly in our society who place the greatest demand on our Health Service. The over-65 age group and particularly now the increasing number of over-75s need more medical treatment proportionately than any other age group. Advances in medicine have enabled people to live longer but we have not really begun to cope with the resulting increase in demand on resources.

Hon. Members on both sides agree that we should treat our elderly people with honour, with respect and with compassion, so that they can enjoy their twilight years without the added burden of worrying about the cost of their health.

The Government will no doubt ask, as did the hon. Member for Pembroke (Mr. Bennett) in the earlier debate on dental charges, what is a few pounds for a test? Pensioners have fared badly in recent years, and I would like to give an example. A fairly typical pensioner in my constituency will have modest savings; she will be on a state pension; she will have a heart condition; and she will have failing eyesight. If the hon. Member for Pembroke were present for this part of the debate, I would tell him that she would be insulted if anyone were to say that she touched drink or sullied her lips with a cigarette, and she thinks that videos are luxuries for rich people. So we are talking about ordinary pensioners.

In 1987, the local health authority in the county of Gwynedd, because of pressure on the ambulance service, stopped transporting patients to routine hospital clinics. So my constituent, who lives on her own 20 miles from the district hospital, had to cancel her heart test because she could not afford the taxi fares to attend the local hospital, and there is insufficient public transport in our area. Earlier this month that constituent also lost her entitlement to housing benefit, so immediately became worse off to the tune of £7 per week. If this Bill is enacted, she will budget her income and find that she cannot afford the eye test that she desperately needs.

What the Government must consider is the cumulative effect of these changes in health provision and housing benefit. It is not simply a case of a £10 test for eyes or a £3 test for teeth: it is the cumulative effect, the punishing effect, on their budgets. I am sure that right hon. and hon. Members in all parts of the House will support me when I ask the Government to reconsider this cumulative effect of their policies on not only my constituents but the constituents of every hon. Member. I have illustrated the reality of living as a pensioner on a tight budget. That is why I and other hon. Members appeal to the Government for a change of heart on this issue.

8 pm

I have not yet intervened during the debate, although I did so on Second Reading when my right hon. Friend the Secretary of State was speaking.

This matter was eloquently raised by my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight). It has caused me and many Conservative Members considerable concern. The case has been well made about the problems of people being deterred from having their eyes tested. I do not want, therefore, to go over that argument again. I shall do what the Secretary of State asked us to do in the previous debate about charges for dental checks—put the proposal in context. First, I shall put it into its financial context.

In the last debate, my hon. Friend the Member for Great Yarmouth (Mr. Carttiss) asked why charges were necessary. We all know why they are necessary—my right hon. and hon. Friends on the Front Bench could not get money from the Treasury to make the increases that they wanted in the family practitioner service. The only way in which they could obtain an agreement was to introduce charges. We know the realities of power and how they work, but that does not make it right. If every £1 milllion that were spent would endanger the economic well-being of the country, I could understand that argument, but we know that the reverse is the case. There is amply money to provide for what the Government want to do with the family practitioner service without making these charges.

The great danger is that when the Bill is enacted it will be remembered not for the hundreds of millions of pounds that have been put into the family practitioner service but as the Act that introduced charges for eyes tests. That is the wrong king of epitaph for the Bill.

The second matter that I should like to discuss follows the speech of the hon. Member for Ynys Môn (Mr. Jones). There is a danger that the Government have completely misunderstood the problems of many pensioners. I am talking not about pensioners on income support or those who pay income tax, but about the considerable number of pensioners who are in between. That section of our elderly population are being kicked and kicked again at present. They have to pay the extra gas and electricity price increases and the water rates and contribute to their rates. Now they will have to pay £10 to have their eyes tested. That is the context in which this proposal should be judged.

I do not think that my right hon. Friend the Secretary of State is inhumane, and I have the greatest admiration for him. However, he must realise that this proposal, put in the context that I have just outlined, is a dangerous one, which will do great harm and cause much suffering.

Far from furthering the Government's reputation as a Government who care about the nation's health, the Bill will be seen cynically as the one that introduced charges for people who could not afford to pay for eye tests.

As the proposal does not make much financial sense—it has been generally agreed that its long-term costs are likely to be higher than the short-term savings—and as we are seeking to hit again that section of the community that is the most defenceless, and given the political effect of what the Government have done, they should think again. Unless my right hon. Friend the Minister of State can give some heavy assurances, I shall be joining my hon. Friends in the Opposition Lobby.

It is my experience that Governments should always be aware of the long-term consequences of what they are doing when their supporters who know most about a particular subject decide to speak out against their decisions.

For many years, some of us have listened to the hon. Member for Birmingham, Edgbaston (Dame J. Knight), who, if she will forgive me for saying so, has a deep personal interest in this subject and knows much about it. When she makes such a moving and well-informed speech, please let us appeal to Ministers at least to go to the Chief Secretary to the Treasury and say, "This is the collective view of a serious House of Commons; can you not do something about it?" I was glad that the Chief Secretary to the Treasury was in the Chamber earlier.

I shall ask one question, as I did in the last debate, on dental charges. I am conscious that perhaps I asked not so much the wrong question as the right question wrongly worded. The Secretary of State treated me courteously and I have no complaints. I asked whether the chief medical officer had endorsed the Government's view on dental charges. Further, I should like to ask a different question. Have Sir Donald Acheson and Dr. I. S. Macdonald, who is the chief medical officer in Scotland, given medical advice on this subject? If so, what was the precise nature of the medical advice that they gave? I see that the Secretary of State is saying something to his right hon. Friend the Minister of State, but the House is entitled to hear the factual medical evidence. This matter is not the same as an argument with civil servants. The chief medical officer, as a technical, professional and independent representative, is surely entitled to have his advice made known to hon. Members who are interested; it is a different matter whether it is accepted.

I want to know what has changed. I am grateful to my hon. Friend the Member for Livingston (Mr. Cook) for recollecting some assurances that the right hon. Member for Sutton Coldfield (Mr. Fowler), the then Secretary of State for Social Services, gave. He said:
"we also believe that the access to a free sight test is important in detecting serious eye disease."—[Official Report, 20 December 1983; Vol. 51, c. 295.]

I am entitled to ask what has changed. That former Conservative Secretary of State took the same view as every Labour and Conservative Minister has since 1945, and he made those remarks in Parliament, in public. What precisely has changed to make the Government alter their view? What has Sir Donald Acheson, in his capacity as a doctor and medical adviser, said? The House is entitled to know.

The hon. Member for Linlithgow (Mr. Dalyell) is so right. What I, my hon. Friends and my constituents cannot understand is that since 1980 the Government's stated policy from the Dispatch Box has been that it would be completely wrong in principle to abolish or remove exemptions for the free sight test. What has changed? The House should be told.

We all know that all that has changed are the bilateral negotiations between the DHSS and the Treasury. Normally I would not wish to intrude on private grief, but this is not private grief, because 6·5 million pensioners will have to pay. Those pensioners are not on income support, and they will not he assisted. We know that pensioners and elderly people must have their eyes tested regularly, because their eyes are changing all the time.

What about diabetics and people with glaucoma? Diabetes is the largest single cause of blindness in people of working age in the United Kingdom, yet we know that 70 per cent. of that blindness could be prevented if only—this is the key—it is diagnosed early. The same applies to glaucoma sufferers. Glaucoma, as the hon. Member for Workington (Mr. Campbell-Savours) movingly told us, causes blindness and death among many. Sixty per cent. of that blindness and suffering could be prevented. The Health and Medicines Bill is a watershed in primary health care, but what are we doing? The answer is the very thing that will act as a deterrent to primary health care and deter people from going to their optometrists and opticians.

This is not only a stupid decision; it is a wrong one. Will any of my hon. Friends support the Government tonight? Will anyone stand up and say that this is a marvellous idea and endorse it wholeheartedly, going through the Division Lobby with a spring in his step? Of course they will not, because they know in their heart of hearts what the reality is. The electorate forgive the Government quite a bit. They forgive us for messing around with their taxes, their jobs and even their rates, but if we start messing about with their health and their eyesight, there will not be much forgiveness for the Government.

I urge my right hon. Friend to think carefully about this decision. Those of my hon. Friends and I who will vote against the proposal will not defeat the Government tonight, but I sincerely hope that we shall give a clear sign elsewhere.

During my brief time in the House few issues have seemed to transcend political differences. There are ideological differences about the market, but this is not a discussion about the market—it is about the rights and wrongs of a specific proposal and the impact it will have on millions of people throughout the country, regardless of how they vote. More importantly, it will have an impact on their health.

This charge goes to the heart of preventive health care. Many eloquent speeches by Conservative Members this evening have identified the principles at stake and shown clearly that, if there is a necessity to save money, it will be swamped by the needs for health care provision of people who will not receive this excellent service from opticians when they need it and before certain diseases develop to the point at which much greater and costlier health care is required.

Already this week specific cases have been used—especially yesterday in the social security debate—to highlight what are often distressing practical points. Today, my hon. Friend the Member for Livingston (Mr. Cook) referred to a letter that I had received from one of my constituents. When we deal with subjects that are sensitive and emotional, two or three lines from a letter will often more adequately sum up a case than endless speeches from either Government or Opposition Members.

The letter comes from a Mrs. Celia Ralph, who lives in my constituency:
"Dear Mr. McLeish,
I would like my name to be added to those who are opposing charges being made for eye tests.
I count myself very fortunate that I can, in fact, write this letter to you to-day. In mid-July '87 my eyesight changed dramatically. My own doctor could pick up no change in the eye, and he then was going off for a two week holiday. Being quite concerned, and not knowing where to go next, I consulted my optician, who realised that something was terribly wrong. Next day I saw a specialist at the Victoria hospital who diagnosed secondary tumours from breast cancer on both eyes. This is seemingly quite a rare occurrence and all of my doctors at the Western General in Edinburgh had nothing but praise for my optician. I've had radio-therapy and chemo-therapy since, which fortunately has stopped the growth meantime.
The question to be asked is, would I have gone to my optician so quickly, if at all, if I had to find £10 for the examination. My visit to him saved not only my eyesight, but my life."

8.15 pm

Many hon. Members on both sides have said tonight that this is a matter of right and wrong, and few issues come down to that. I earnestly appeal to the Minister to take this matter seriously. It is not an ideological issue that we can kick back and forth. This Chamber is a combative forum, and we use it as such to best advantage, but this is a night for quiet reflection on a serious issue. A consensus has emerged from the debate and I sincerely hope that it will be reflected in the Lobbies.

This is the first occasion in my short time in the House on which I have found myself seriously at odds with the Government. My late father-in-law, who had regular eye checks, either as a result of an accident or of incompetence, did not have glaucoma diagnosed early enough to save the sight of one eye. He was a conscientious man who would probably not have been deterred by the charges from having tests, although he was on a low income, but I fear that, as other hon. Members have said, hundreds or thousands of people in our constituencies would be deterred.

I wish to quote from a letter from a constituent who has been a strong supporter of our party for many years. Many people in our constituencies and elsewhere have worked hard for our party for many years, but are appalled by this measure. She says:
"but for regular eye tests my husband's glaucoma would not have been discovered in its early stages. He had no cause to suspect that anything was wrong."

In previous debates and conversations Ministers have emphasised the need for the revenue from these charges. Whatever concessions my right hon. Friend may produce this evening, he cannot go against that requirement in any significant way. I do not see why new resources for the National Health Service—I am not speaking only of inflation-proofing—must come from this source. The British economy is not now, thank God, in the hands of the IMF. We are not in the position of 1976, or even of 1980, when we were over-spent, over-borrowed and over-taxed.

I am something of an iconoclast about the minutiæ of economic theology, but just assuming—and I do not—that the Treasury needs the money, I suggest two ways of meeting the requirement. I do not believe that my right hon. Friend the Minister can make the concessions this evening, but if, as I suspect, the clause runs into trouble in the Upper House, this will give him time to prepare.

One suggestion is a rather crude solution; nevertheless, I commend it for consideration. If Ministers are convinced that opticians need not pass on these charges, why not prohibit them from doing so? At the very least, will my right hon. Friend give a pledge that he will closely monitor opticians' practice, and if, either generally or in areas such as rural areas in which competition is low, they charge £10 or so, will he take powers to prevent that? That would help to diminish my opposition to this measure.

The second alternative was suggested to me by my hon. Friend the Member for Mid-Kent (Mr. Rowe). It is that all holders of current driving licences should be obliged to have a sight test every three years, for which they would be charged the going rate. That would achieve three things. First, there would probably be more sight-testing among such people than there is now, which would be good for preventive medicine and the Treasury's income. Secondly, it would be good for road safety. Thirdly, people in households who own a car could generally be considered—I appreciate that there will be rough justice for some—able to pay. All others, particularly the elderly whose income, health or eyesight did not permit car driving, would have the eye tests free, as they do now.

The clause is symbolic of two tendencies which I fear and regret in present politics. First, there is the view that new resources—new resources in real terms—for the NHS can or should come from the extension of charges. My hon. Friend the Member for Great Yarmouth (Mr. Carttiss) referred to this, and in the previous debate my hon. Friend the Member for Pembroke (Mr. Bennett) obliged us by saying that he believed that there should be charges for visits to GPs. I would never say never to that, but we need carefully to consider going down that route. There was no consideration of or consultation on this measure before it was announced last autumn.

Secondly, almost without intending it, and indeed almost without expecting it, in the past few weeks my party has drifted into a temporarily regressive fiscal regime. I refer to the combined effect of the Budget and some of the social security measures, especially housing benefit, which came into effect on Monday. The elderly, many of whom out of tradition and loyalty are our supporters, are distressed by this temporary situation. I say "temporary" because I believe that my right hon. Friends the Chancellor and the Secretary of State can put those matters right.

This measure is symbolic of that approach, which is why I cannot support it. I regret having to disregard the advice which, no doubt, my right hon. Friend the Minister will offer, but although the voice at the end of the debate will be the gentle and reasonable voice of my right hon. Friend, the hands which have introduced such a discordant measure into this otherwise excellent Bill—a measure that militates against the preventive medicine which the rest of the Bill promotes—have been the hairy old hands of the Treasury.

We have had an excellent debate, although I have listened in vain for any words from any part of the House in support of the Government's proposals. I make my short contribution from a special and privileged position in that I am a diabetic and, as such, I speak for many thousands of people who can and will be put at risk if this piece of legislation is passed.

The Government have made a mistake. It is a good Government who can recognise that they have made a mistake and withdraw it before it is too late. In the five years in which I have been a Member I have never spoken or voted against the Government, but this evening I shall, because I feel strongly that diabetics are being done a disservice by the Government's proposals.

It is possible, just possible, that my right hon. Friend the Minister will say that he will make a concession to diabetics, but I put it to him that that is rather like closing the stable door after the horse has bolted. More often than not a person discovers that he is a diabetic as a consequence of his eye tests rather than the other way round. If a person is deflected from having an eye test he does not find out that he is a diabetic until perhaps it is a little too far down the road.

I am lucky; diabetes was detected in good time, so it will not materially affect me during the rest of my life. But many people are not in that lucky position. If they must make—this point has been eloquently put by hon. Members—the choice between buying a pair of shoes for their children and having an eye test, which cannot cost less than £10 and almost certainly will cost a great deal more, they may suffer diabetes with all the attendant consequences.

I am concerned at the principle which the Government have announced and introduced in this way. Yesterday we had another excellent debate on cervical smears. How long will it be before the Government decide that it is a good idea to charge ladies for having cervical smears? When the Government do that, where do we end?

The Government should listen to those who are their most loyal and best supporters on these Back Benches and should not proceed with this piece of nonsense legislation, which will not do the reputation of the Government, the Minister or the Conservative party any good. I urge those Conservative Members who have not heard the whole of the debate not to go slavishly into the Division Lobby to support the Government. I do not regard this as a political issue. It is a conscience issue which should have been given a free vote. I hope that hon. Members will join me in the Opposition Lobby.

I and other Conservative Members expressed our grave concern at this proposal when it came before the House on Second Reading in the hope that my right hon. Friend the Secretary of State would see his way to reconsider his ill-advised proposals, which we all realised did not originate from him or from within his Department.

My right hon. Friend the Secretary of State has admitted in a parliamentary reply to me only this week that he can make no estimate of the number of people who are likely no longer to have eye tests because of the imposition of these charges. He has assured the House that in his judgment it will not be a significant number, but none of us can possibly know what will be the drop in take-up of eye tests.

In a matter as serious as this—many of my hon. Friends have explained this to the House and I touched on it on Second Reading—we are talking not just of people's eyesight but of the many diseases that can be detected in time, allowing positive action to be taken to protect the health and sometimes the lives of individuals. I am not prepared to see my constituents' health and lives gambled with in this way. The way in which the Government have tried to bulldoze this measure through is unacceptable, taking no account, as it does, of the strong representations made to them by their hon. Friends.

The hon. Gentleman said that the proposals did not come from DHSS Ministers. Some of us think that it is unlikely that they came from Treasury Ministers. It is not the Treasury's nature specifically to say, "You shall have such and such measures on eye tests." The Treasury does not operate in that way. From where did the proposals come?

I am afraid that I cannot agree with the hon. Gentleman. I am inclined to think that the Treasury takes a close interest in the budgets of spending Departments. This measure has nothing to do with health but everything to do with the penny-pinching attitude enforced by the Treasury on my right hon. Friend the Secretary of State, and, I regret, accepted by him. It is a mean-spirited measure which is unworthy of the Government. With great regret, because there is so much in the Bill that I applaud, I feel impelled to vote against this measure.

I do not think that in response to the question asked by the hon. Member for Linlithgow (Mr. Dalyell) I can add anything to what my right hon. Friend the Secretary of State said in the previous debate on dental charges.

I want to remind the House of the basic position on the Government's proposal. It is not a matter, as the hon. Member for Peckham (Ms. Harman) sought to imply in a debate yesterday, of seeking to abolish NHS sight tests, any more than we abolished help with spectacles some two years ago. The proposal is to confine that test in much the same way as help with spectacle vouchers, in a scheme which I believe is widely recognised to have been successful, to certain groups, including those on low incomes, and to use that money—I say this without any sense of shame—for other purposes in developing what we believe to be more significant aspects of our primary care services, with an even more important prevention role. I shall return to that later.

No less than one third of the population—one person in three—would remain entitled to NHS tests. They would include all children, all members of families on family credit, all those on income support and all those who are registered blind or partially sighted. One in three of the population would remain entitled.

Can my right hon. Friend explain the distinction between the exemptions in this case and exemptions in the case of prescription? Would it not take a lot of the sting out of the proposals and answer much of the criticism if those exemptions were extended to eyesight tests?

8.30 pm

The distinction goes back a very long way, to the arrangements introduced in relation to spectacles and prescriptions by the Labour Government in 1951 when charges were initially introduced into the Health Service.

It has also been acknowledged—this picks up a point raised by my hon. Friend the Member for Davyhulme (Mr. Churchill) and a number of other hon. Members—that there is no intention to impose a particular charge for tests for those who will no longer be entitled to an NHS test. The hon. Member for Livingston (Mr. Cook) fairly used the figure of £9·30, which is paid to some ophthalmic opticians, although there are others who, for rather curious historical reasons, receive £10. The £10 figure is simply intended to reflect what the DHSS currently pays for a sight test carried out by some of those who do sight tests.

I accept the point made by my hon. Friend the Member for Davyhulme and a number of other hon. Members that we cannot by definition know what, if any, the charge would be for private sight tests in future, because that would be for the market to determine. However, in the light of our experience of the market for spectacles, following the ending of free NHS spectacles and the introduction of vouchers, it seems to me to be overwhelmingly likely that the competition will keep any charge to a modest level.

I am strengthened in that view by the fact that any regular reader of the optical press will find advertisements that offer to pay ophthalmic opticians more for conducting sight tests than the DHSS will pay. One such advertisement offers a fee per capita in excess of £10 per sight test. Another, which relates to Tyne and Wear, Northumberland and County Durham, offers two optometrists a salary package in excess of £35,000, which can include a fully furnished luxury flat, company car, pension and private health insurance,
"coupled with an excellent working environment in modern, well-equipped practices."
A profession that can widely offer such salary packages and offer to pay people for doing sight tests more than they will be reimbursed by the DHSS must contain scope for a considerable amount of downward competitive pressure on some of its activities.

Is my right hon. Friend suggesting that the extravagant salaries and perks to which he has referred are now to be borne largely by pensioners and others who do not qualify for the exemption? Is it not even now possible for the Government to reconsider a blanket exemption for pensioners from the charges, as they are the ones who have to go back again and again for sight tests?

I shall say something more about pensioners in a moment or two.

First, however, I acknowledge that much of the debate has turned on the question whether there will be a significant deterrent effect for that part of the population—I emphasise again that it will not be those on the lowest incomes—who would be expected to pay any charge that might be levied. I accept, as I have throughout our debates on the proposals, that that is not a point that I could, or would, dismiss out of hand.

Apart from anything else, it cannot be a matter of certainty; it has to be a matter of judgment based on experience. However, we have highly relevant experience in the form of what has happened in the market for spectacles. The hon. Member for Livingston pressed me to explain why there had been a change in the Government's position of eight years ago. One of the things that has significantly changed since then is that we have introduced a different policy in respect of the NHS spectacles market which has proved to have had a significantly successful effect on the optical market, and we have sought to build in part on that experience.

May I press the Minister on the point fairly and pertinently raised by my hon. Friend the Member for Linlithgow (Mr. Dalyell)? My hon. Friend reminded the House that a previous Secretary of State said five years ago that the Government

"believe that the access to a free sight test is important in detecting serious eye disease."—[Official Report, 20 December 1983; Vol. 51, c. 295.]
Will the Minister make it clear to the House whether the medical advice from his chief medical officer varied from the advice received five years ago? Has the chief medical officer of health revised his advice on the basis of experience in spectacles?

I cannot add to what my right hon. Friend the Secretary of State said in that respect. In any event, I shall gladly undertake to write to the hon. Gentleman, but I am not in a position, apart from anything else, to be sure of the precise basis on which my right hon. Friend the Secretary of State for Employment, then the Secretary of State for Social Services, made those remarks eight—or was it five?—years ago.

With the greatest reluctance, I must press my right hon. Friend, because this is a matter of supreme importance, to say whether the advice has changed, or whether the situation has changed. Why has the measure been introduced?

I hope and believe that I have already answered that question by reference to the change that was carried through the House which led to the introduction of the NHS spectacle voucher scheme and the ending of the old NHS spectacle regime. That change, which was completed in 1986, has given us significant new experience of the operation of competition in that market and has left us better placed to assess the consequences of the changes that we propose.

My right hon. Friend is replying with his customary courtesy. However, can I press him on this? Is the Government's best and highest medical advice that charging will not be a deterrent and that it will be in everyone's best interests? There should be a simple answer to that question, and my right hon. Friend ought to be able to ascertain that information from a certain quarter during his reply.

My right hon. Friend the Secretary of State made clear the chief medical officer's attitude to the proposals in the White Paper as a whole, which seek to develop our primary care services as a whole and which the Government argue will contribute to a significant improvement to the health of the nation as a whole. It is as a whole that it is right for the policies to be considered.

There is one highly significant piece of evidence from our experience of the scheme that has operated in relation to spectacles and spectacle vouchers since July 1986 which enables us to make a judgment about the possible deterrent effects referred to in the debate. According to a survey conducted by the economists advisory group for one of the optical bodies of those who are entitled to vouchers for their spectacles—by definition broadly the same groups as will continue to be entitled to NHS sight tests, including those on the lowest incomes—some three quarters willingly pay significantly more than £10 on average above the voucher values for their spectacles.

When the survey was conducted, the lowest voucher value was just over £14. At that time, people generally paid more than £15 extra on top of that for their spectacles and the sums ranged as high as £20 and more for some of the higher spectacle voucher values. People have willingly been paying significantly more for their spectacles, in addition to the voucher values, than any sum that has been mentioned as a possible charge for eye testing.

My right hon. Friend relies heavily on the comparison with the situation in relation to spectacles, but if we rely on the forces of competition there will be real dangers. At present, the expression "eye test" is rather vague. Much of the debate has centred on the detection of glaucoma and so on. I understand that at present many eye tests do not cover that aspect, because the opticians involved are not capable of doing so. If we rely on the forces of competition, it is likely that the test will consist purely of the eye test, without the extensive medical coverage that is required. Is there not a danger that, as the price is driven down, the quality of the test will deteriorate?

I hope that I am not doing my right hon. Friend an injustice, but I think that he may have missed my speech yesterday, when the House agreed to insert new clause 15 with the precise purpose of allowing the Government to take powers to determine the content of the eye test to ensure that an eye examination remains part of the test. In fact, somebody has challenged the need for such an examination to be carried out under the present regime, so the validity of the present situation has been called into question. We have made it clear that we intend to ensure by regulation that the test includes the eye examination to which my right hon. Friend the Member for Worthing (Mr. Higgins) attaches importance.

I understand that at present the eye test does not always include that kind of check, because some opticians do not have the necessary equipment.

I shall deal with that point in my comments about diabetics. My right hon. Friend is right in saying that there is a difference of view about what a full examination entails and that at present not all opticians have the necessary equipment to carry out what is known as tonometry, with the result that the necessary pressure tests are not always carried out. That is the present situation. The professional requirements do not necessarily entail carrying out such tests, but I shall return to that point.

I will deal with some of the specific concerns against the background of my judgment that, on the figures that I have given, the alleged deterrent effect is most unlikely to occur. However, I accept that that must be a matter of judgment against the background of experience, and I do not intend to use that judgment as a means of avoiding considerations of the specific concerns expressed in the debate.

With regard to low incomes, I have already said that people on income support or family credit will remain entitled to a free NHS sight test. That group will include, we estimate, a quarter of all pensioners. Indeed, the number will have increased as a result of recent changes in the social security system and in particular the higher pensioner's premium. In low-paid working families, more than 750,000 adults in such families will continue to be entitled to free sight tests. That number is estimated to have grown by nearly 500,000—in other words, it has more that doubled—as a result of the change from family income supplement to family credit. Those are important and significant figures.

In the light of the points made in earlier discussions and in today's debate, we intend to introduce arrangements to provide help for those with incomes just above those qualifying levels. The precise arrangements will need to be worked out, and if necessary we shall seek to amend the Bill in another place to achieve that purpose.

How many more pensioners are likely to be covered by the additional relief that my right hon. Friend has just announced?

It will be some tens of thousands. As we have not yet been able to work out the details, and as the calculation will involve some complexity in the light of the new arrangements, I cannot give more detail than that.

8.45 pm

We share the concern about glaucoma that has been expressed by Members in all parts of the House. Everyone wishes glaucoma to be detected at a stage when it can be effectively treated. At present, when an optician detects signs of glaucoma, the patient is referred to the family doctor. In almost all cases, confirmation of the diagnosis and subsequent mangement and care are provided by the hospital eye service. That will remain the position. As the debate has made clear, however, the process is broadly opportunistic and covers only people who visit an optician, usually because of some problem with their eyes. By definition, therefore, the symptomless glaucomas which have given most cause for concern in the debate are least likely to he picked up by what is an accidental rather than a systematic screening process.

Where the eye examination involves only ophthoalmoscopy, as my right hon. Friend the Member for Worthing pointed out, the condition may not be detected at the earliest possible stage under the present system. Tonometry and visual field tests can provide earlier detection, but are not always undertaken by opticians. One of the ways in which we shall seek to carry things forward in the light of the resource changes proposed in the White Paper and the Bill is to discuss with the profession which tests should be included in the definition of the eye test with the aim of achieving further improvements in the testing process. I believe that that will help the concerns of the House.

We have also been discussing how to tackle the problem of identifying those at higher risk of suffering glaucoma. As there is a strong hereditary element, people over 40 who are children, brothers or sisters of people with glaucoma are at increased risk of themselves developing the condition. We are therefore considering whether and how—I believe that it should be possible to move in this direction, although it will not be as easy as I should like—if necessary by using additional resources, arrangements can be devised to ensure that, whenever glaucoma is identified in a patient, positive steps are taken to ensure that members of the family who may be at risk are identified and their attention drawn to the need for an eye test. I believe that that would do more to improve real screening for glaucoma in good time than anything in the present arrangements.

As I have said, almost all those who already have or are found to have glaucoma are treated by the hospital eye service, although there may be circumstances in which the doctors managing the case will wish to involve an optician. Free sight tests will therefore be available for patients with glaucoma who are referred to an optician by the doctor.

Diabetes has been mentioned as a special area of concern in perhaps more speeches than any other single issue. There are really two separate issues here. Until I heard certain comments in the debate, I thought that it was common ground that sight testing was neither a sensible nor an effective means of screening for diabetes. In Committee, my hon. Friend the Under-Secretary of State quoted the director of a regional retina service as saying:
"it is exceptionally rare for diabetes to be detected by the observation of retinopathy in a person who is otherwise not known to be suffering from the disease."
The hon. Member for Strathkelvin and Bearsden (Mr. Galbraith), with his own particular medical expertise, intervened in my hon. Friend's speech to say:
"We have already accepted that the method for diagnosing diabetes and hypertension is not fundoscopic examination of the eye."—[Official Report, Standing Committee A, 16 February 1988; c. 751–2.]

We also accept that it was a useful addition. It was not a primary method of screening or of diagnosis. Secondly, a regular check-up for diabetics is important in order to look for the retinopathy.

I want to say something about that as well. But in relation to retinopathy and hypertension, general practitioners should play a more active role in screening their patients for such conditions, and they should make good arrangements—for example, through regular diabetic or hypertension clinics, which many good general practitioners already do—for their continuing care. That is precisely one of the objectives that we are pursuing in the discussions now taking place with the medical profession about the restructuring of its remuneration and allowances, using the additional resources which the Bill will enable us to make available. I have no doubt that that represents a more effective use of those resources than the maintenance of universal NHS eye tests.

The second issue is the need for regular screening of the eyes of diabetic people, however diagnosed for diabetic retinopathy. The importance of that has already been acknowledged by the Government in the three-year study that is currently being undertaken, and that is due to end next year, to evaluate the most cost-effective way of screening for that condition. We shall, of course, consider what further steps may be appropriate in the light of its results.

Meanwhile, we have listened carefully to what has been said during the discussion on the Bill, including by many of my hon. Friends and others tonight. We recognise that diabetics have a special need for regular eye checks for the detection of retinopathy. Diabetes itself is usually managed by the patient's family doctor or by a clinic if that is desirable. However, some doctors may wish to refer their patients to an optician specifically for those regular eye checks. We wish to support that practice, so we shall make arrangements in the regulations which will provide for free sight tests for diabetics who are referred for an eye check by their GP or clinic. That could potentially benefit some 750,000 people a year.

I hope that those of my right hon. and hon. Friends and others who have spoken in the debate will think that the steps that we have taken in relation to people on low incomes, those with glaucoma and diabetics, constitute a proper and reasonable response to the points that they have raised. They will together reduce the savings which would otherwise have been expected from the measure by some £7 million to £8 million, and, as I have said, extend by at least 750,000 those entitled to NHS sight tests.

I recognise that those steps cannot entirely meet the views of those who argue against the proposals, simply because we are talking about examinations rather than treatment. But to them I have to say that, whether expenditure on health is labelled as prevention, treatment or cure, it is important that we use it to the best effect. Our proposals to redirect some part of the expenditure in this area from its present purpose to others, and in particular to the systematic development of the quality, scope and preventative nature of our family doctor services, will enable us to do more, not less, to promote the heath of the nation.

Eight Conservative Back Benchers have spoken in the course of the debate. As it happens, that is exactly the same number as in the previous debate. Those of my hon. Friends who were present at the end of the previous debate will recall that the scoreboard was five out of eight against the Government's proposals and two out of the eight in support of it.

I have to report that, having kept my scoreboard throughout this debate, of the eight Conservative Back Benchers who have spoken, all eight were against the proposal. There was not a speech in the entire debate, until the Minister for Health rose to speak at the Dispatch Box, in support of the proposal for charging for the eye examination. There has not been an intervention in any speech in the course of the debate in support of charges for the eye examination.

This parliamentary debate has been important because it has exposed the fact that this particular proposal cannot be sustained and is supported only by the Minister who came to the Dispatch Box to defend it. Nobody else came to the Chamber to support the proposal tonight. That demonstrates the importance of the Report stage in the examination of Bills. If parliamentary consideration and examination mean anything, this proposal, after the examination and debate that it has received tonight, should be thrown out.

I want to say a few words about what the Minister said in reply to the debate. The intervention in the Minister's speech by his right hon. Friend the Member for Worthing (Mr. Higgins) was well-merited, in that the first half of the Minister's speech based the Government's proposal on their experience with the charges and competition which they have introduced in the spectacles market. That was wholly at variance with the gravamen of the debate that preceded the Minister's reply. The gravamen of that debate was about people who had suffered from serious systematic diseases such as glaucoma, cataracts and diabetes, which is almost irrelevant to whether they require eye tests to determine whether they need spectacles.

To the suggestion that competition may bring down charges, I have to say that it is possible. It is possible that as a result of competition not every optometrist will charge £9·30. It is also possible that, as a result of competition, prices will go up. In America there is competition for this type of eye examination and the prices are very high indeed. Indeed, a Conservative Back Bencher spelt out what remarkably good value the eye examination is for £9·30, with half an hour's time of a highly-qualified technician using extremely expensive equipment. If they were to put a charge on their service that represented the full market cost of that half hour, they would be charging well above £9·30.

Yes, it is possible that competition could bring down charges. Let us suppose that competition is so intense and successful that it halves the charge. We would still be talking about an eye examination charge of £5. Who in this Chamber is prepared to say that that will not be a deterrent to some people who are on the margins? Moreover, it will only halve the charge at the expense of lower income to optometrists from eye examinations. That will have two consequences.

The first consequence is that the optometrist service will contract. It will be centralised in the areas of urban population. I warn Conservative Members that it is their constituents rather than ours who will be likely to suffer most from that withdrawal of services from centres of urban populations.

Secondly, it will inevitably drive optometrists—indeed, the Minister came near to saying that this was the intention of the competition—to look more and more for their income and profit to the sale of spectacles rather than to eye examiniations and the provision of a full examination of the inner eye.

Do hon. Members believe that in that competitive environment in which optometrists are more and more obliged to look for commercial sale of their spectacles that we shall have optometrists who are prepared to take the time, and with the experience and qualifications, to detect the kind of rare case referred to by my hon. Friend the Member for Fife, Central (Mr. McLeish), in which a woman with secondary cancer was diagnosed because she presented herself for an eye examination and whose life was therefore saved?

I am well aware that the House wishes to move to a Division, but I want to return to the telling intervention of my hon. Friend the Member for Linlithgow (Mr. Dalyell). He asked what had been the medical advice offered to the Government by the chief medical officer. We can certainly hear what the advice has been from the House tonight. Every hon. Member who has spoken in the debate has expressed concern about the medical consequences of the charge; the medical consequences of the deterrent effect of that fee being introduced. I find it very difficult indeed to credit that the medical advice that the Government may have received from the chief medical officer could have varied from the advice that the Minister has heard in the House tonight. The Minister said that he relied upon what the Secretary of State said in response to the earlier debate. In response to the earlier debate the Secretary of State said that the chief medical officer had endorsed the White Paper as a whole.

All Opposition Members, at any rate, have experience of putting our names to composite resolutions. We know what that means. Inevitably on every occasion one swallows something that one would dearly have liked to leave out. The question remains: what was the chief medical officer's advice in respect of the charges for eye examinations? What advice did he tender to Ministers on whether such a charge would deter people from turning up? What advice did he offer them on the one screening method which currently produces three times as many diagnoses of glaucoma as any other screening arrangement? The Minister said that he would write to me telling me what that advice was. Unfortunately, that letter will arrive after the Division tonight.

There is a way round that predicament. Frankly, if the Minister was listening to the debate tonight, and if Treasury Ministers were interested in taking the temper of the House of Commons, the response of the Minister would be clear. He would accept the amendment and withdraw the proposal. If the Minister can justify the proposal in a way in which he has been unable to justify it tonight, he can always reintroduce it in the other place. If he is going to say that we must wait until another day to find out what was the medical advice on which the proposal was based, I have to say to him that no self-respecting House of Commons can tolerate that offer. We shall, therefore, press the amendment to a Division and we hope that all hon. Members who have heard the debate and who share our deep trouble and concern about the consequences of the proposal will join us in the Lobby tonight.

Question put, That the amendment be made:—

The House divided: Ayes 206, Noes 280.

Division No. 259]

[9.00 pm

AYES

Abbott, Ms DianeChurchill, Mr
Adams, Allen (Paisley N)Clarke, Tom (Monklands W)
Allen, GrahamClay, Bob
Archer, Rt Hon PeterClelland, David
Armstrong, HilaryClwyd, Mrs Ann
Ashley, Rt Hon JackCohen, Harry
Banks, Tony (Newham NW)Cook, Frank (Stockton N)
Barnes, Mrs Rosie (Greenwich)Cook, Robin (Livingston)
Barron, KevinCoombs, Simon (Swindon)
Battle, JohnCorbett, Robin
Beckett, MargaretCorbyn, Jeremy
Bell, StuartCormack, Patrick
Benn, Rt Hon TonyCox, Tom
Bennett, A. F. (D'nt'n & R'dish)Cummings, John
Bermingham, GeraldDalyell, Tam
Bidwell, SydneyDarling, Alistair
Blair, TonyDavies, Rt Hon Denzil (Llanelli)
Boyes, RolandDavies, Ron (Caerphilly)
Bradley, KeithDavis, David (Boothferry)
Bray, Dr JeremyDavis, Terry (B'ham Hodge H'l)
Brown, Gordon (D'mline E)Day, Stephen
Brown, Nicholas (Newcastle E)Dewar, Donald
Brown, Ron (Edinburgh Leith)Dixon, Don
Bruce, Malcolm (Gordon)Dobson, Frank
Buchan, NormanDoran, Frank
Buckley, George J.Duffy, A. E. P.
Caborn, RichardDunnachie, Jimmy
Campbell, Menzies (Fife NE)Dunwoody, Hon Mrs Gwyneth
Campbell-Savours, D. N.Eadie, Alexander
Canavan, DennisEastham, Ken
Carttiss, MichaelEwing, Mrs Margaret (Moray)
Cartwright, JohnFatchett, Derek
Chapman, SydneyFearn, Ronald

Field, Frank (Birkenhead)Marek, Dr John
Fields, Terry (L'pool B G'n)Marshall, David (Shettleston)
Fisher, MarkMarshall, Jim (Leicester S)
Flannery, MartinMartin, Michael J. (Springburn)
Flynn, PaulMartlew, Eric
Foot, Rt Hon MichaelMaxwell-Hyslop, Robin
Foster, DerekMeacher, Michael
Fraser, JohnMichie, Bill (Sheffield Heeley)
Fry, PeterMillan, Rt Hon Bruce
Fyfe, MariaMitchell, Austin (G't Grimsby)
Galbraith, SamMolyneaux, Rt Hon James
Galloway, GeorgeMoonie, Dr Lewis
Garrett, John (Norwich South)Morgan, Rhodri
George, BruceMorley, Elliott
Godman, Dr Norman A.Morris, Rt Hon J. (Aberavon)
Golding, Mrs LlinMowlam, Marjorie
Goodhart, Sir PhilipMullin, Chris
Graham, ThomasMurphy, Paul
Grant, Bernie (Tottenham)Oakes, Rt Hon Gordon
Griffiths, Nigel (Edinburgh S)O'Brien, William
Griffiths, Win (Bridgend)O'Neill, Martin
Grocott, BruceParry, Robert
Hardy, PeterPatchett, Terry
Harman, Ms HarrietPeacock, Mrs Elizabeth
Hawkins, ChristopherPendry, Tom
Hayes, JerryPike, Peter L.
Hayhoe, Rt Hon Sir BarneyPowell, Ray (Ogmore)
Heffer, Eric S.Prescott, John
Henderson, DougQuin, Ms Joyce
Hicks, Robert (Cornwall SE)Radice, Giles
Hinchliffe, DavidRandall, Stuart
Hogg, N. (C'nauld & Kilsyth)Redmond, Martin
Holt, RichardRees, Rt Hon Merlyn
Home Robertson, JohnReid, Dr John
Hood, JimmyRichardson, Jo
Howarth, George (Knowsley N)Roberts, Allan (Bootle)
Howells, GeraintRobertson, George
Hoyle, DougRobinson, Geoffrey
Hughes, John (Coventry NE)Rogers, Allan
Hughes, Robert (Aberdeen N)Rooker, Jeff
Hughes, Simon (Southwark)Ross, Ernie (Dundee W)
Hunt, John (Ravensbourne)Rowlands, Ted
Illsley, EricRuddock, Joan
John, BrynmorSedgemore, Brian
Jones, Barry (Alyn & Deeside)Sheerman, Barry
Jones, Ieuan (Ynys Môn)Sheldon, Rt Hon Robert
Jones, Martyn (Clwyd S W)Shore, Rt Hon Peter
Kennedy, CharlesSims, Roger
Kilfedder, JamesSkinner, Dennis
Kirkwood, ArchySmith, Andrew (Oxford E)
Knight, Dame Jill (Edgbaston)Smith, C. (Isl'ton & F'bury)
Knox, DavidSoley, Clive
Latham, MichaelSpearing, Nigel
Leadbitter, TedSteinberg, Gerry
Leighton, RonStott, Roger
Lewis, TerryTaylor, Matthew (Truro)
Litherland, RobertTurner, Dennis
Livsey, RichardVaz, Keith
Lloyd, Tony (Stretford)Wall, Pat
Lofthouse, GeoffreyWalley, Joan
Loyden, EddieWardell, Gareth (Gower)
McAllion, JohnWareing, Robert N.
McAvoy, ThomasWelsh, Andrew (Angus E)
McCusker, HaroldWilliams, Rt Hon Alan
McFall, JohnWilliams, Alan W. (Carm'then)
McKelvey, WilliamWinnick, David
McLeish, HenryWorthington, Tony
McNamara, KevinYoung, David (Bolton SE)
McTaggart, Bob
Madden, MaxTellers for the Ayes:
Madel, DavidMr. Frank Haynes and
Mahon, Mrs AliceMr. Allen McKay.

NOES

Aitken, JonathanAmos, Alan
Alexander, RichardArbuthnot, James
Alison, Rt Hon MichaelArnold, Jacques (Gravesham)
Allason, RupertArnold, Tom (Hazel Grove)
Amery, Rt Hon JulianAshby, David
Amess, DavidAspinwall, Jack

Atkinson, DavidGower, Sir Raymond
Baker, Nicholas (Dorset N)Grant, Sir Anthony (CambsSW)
Baldry, TonyGreenway, John (Ryedale)
Banks, Robert (Harrogate)Griffiths, Sir Eldon (Bury St E')
Batiste, SpencerGriffiths, Peter (Portsmouth N)
Bellingham, HenryGrist, Ian
Bennett, Nicholas (Pembroke)Ground, Patrick
Biggs-Davison, Sir JohnGrylls, Michael
Blackburn, Dr John G.Gummer, Rt Hon John Selwyn
Blaker, Rt Hon Sir PeterHamilton, Hon Archie (Epsom)
Body, Sir RichardHamilton, Neil (Tatton)
Bonsor, Sir NicholasHampson, Dr Keith
Boswell, TimHanley, Jeremy
Bottomley, PeterHargreaves, A. (B'ham H'll Gr')
Bowden, A (Brighton K'pto'n)Hargreaves, Ken (Hyndburn)
Bowden, Gerald (Dulwich)Harris, David
Bowis, JohnHayward, Robert
Boyson, Rt Hon Dr Sir RhodesHeathcoat-Amory, David
Braine, Rt Hon Sir BernardHeddle, John
Brandon-Bravo, MartinHeseltine, Rt Hon Michael
Brazier, JulianHind, Kenneth
Bright, GrahamHogg, Hon Douglas (Gr'th'm)
Brittan, Rt Hon LeonHordern, Sir Peter
Brooke, Rt Hon PeterHoward, Michael
Brown, Michael (Brigg & Cl't's)Howarth, Alan (Strat'd-on-A)
Bruce, Ian (Dorset South)Howarth, G. (Cannock & B'wd)
Buck, Sir AntonyHowell, Ralph (North Norfolk)
Burns, SimonHughes, Robert G. (Harrow W)
Burt, AlistairHunt, David (Wirral W)
Butcher, JohnIrvine, Michael
Butler, ChrisIrving, Charles
Carlisle, John, (Luton N)Jack, Michael
Carlisle, Kenneth (Lincoln)Jackson, Robert
Carrington, MatthewJanman, Tim
Cash, WilliamJessel, Toby
Chalker, Rt Hon Mrs LyndaJohnson Smith, Sir Geoffrey
Channon, Rt Hon PaulJones, Gwilym (Cardiff N)
Chope, ChristopherJones, Robert B (Herts W)
Clark, Dr Michael (Rochford)Key, Robert
Clark, Sir W. (Croydon S)King, Roger (B'ham N'thfield)
Clarke, Rt Hon K. (Rushcliffe)King, Rt Hon Tom (Bridgwater)
Colvin, MichaelKirkhope, Timothy
Conway, DerekKnapman, Roger
Coombs, Anthony (Wyre F'rest)Knight, Greg (Derby North)
Cope, JohnKnowles, Michael
Couchman, JamesLamont, Rt Hon Norman
Cran, JamesLang, Ian
Currie, Mrs EdwinaLawrence, Ivan
Curry, DavidLee, John (Pendle)
Davies, Q. (Stamf'd & Spald'g)Lightbown, David
Devlin, TimLilley, Peter
Dickens, GeoffreyLloyd, Sir Ian (Havant)
Dorrell, StephenLloyd, Peter (Fareham)
Douglas-Hamilton, Lord JamesLord, Michael
Dover, DenLuce, Rt Hon Richard
Dunn, BobLyell, Sir Nicholas
Durant, TonyMcCrindle, Robert
Eggar, TimMacfarlane, Sir Neil
Evans, David (Welwyn Hatf'd)MacGregor, Rt Hon John
Evennett, DavidMacKay, Andrew (E Berkshire)
Fallon, MichaelMaclean, David
Farr, Sir JohnMcLoughlin, Patrick
Favell, TonyMcNair-Wilson, M. (Newbury)
Fookes, Miss JanetMcNair-Wilson, P. (New Forest)
Forman, NigelMajor, Rt Hon John
Forsyth, Michael (Stirling)Malins, Humfrey
Forth, EricMans, Keith
Fowler, Rt Hon NormanMaples, John
Fox, Sir MarcusMarlow, Tony
Franks, CecilMarshall, John (Hendon S)
Freeman, RogerMartin, David (Portsmouth S)
Gale, RogerMates, Michael
Garel-Jones, TristanMaude, Hon Francis
Gill, ChristopherMawhinney, Dr Brian
Glyn, Dr AlanMayhew, Rt Hon Sir Patrick
Goodlad, AlastairMellor, David
Goodson-Wickes, Dr CharlesMeyer, Sir Anthony
Gorman, Mrs TeresaMiller, Hal
Gorst, JohnMills, Iain
Gow, IanMitchell, Andrew (Gedling)

Mitchell, David (Hants NW)Soames, Hon Nicholas
Moate, RogerSpicer, Sir Jim (Dorset W)
Monro, Sir HectorSpicer, Michael (S Worcs)
Moore, Rt Hon JohnSquire, Robin
Morris, M (N'hampton S)Stanbrook, Ivor
Morrison, Hon Sir CharlesStanley, Rt Hon John
Morrison, Hon P (Chester)Stern, Michael
Moss, MalcolmStevens, Lewis
Moynihan, Hon ColinStewart, Allan (Eastwood)
Neale, GerrardStewart, Ian (Hertfordshire N)
Needham, RichardStokes, John
Nelson, AnthonySumberg, David
Neubert, MichaelSummerson, Hugo
Newton, Rt Hon TonyTapsell, Sir Peter
Nicholls, PatrickTaylor, Ian (Esher)
Nicholson, Emma (Devon West)Taylor, John M (Solihull)
Onslow, Rt Hon CranleyTaylor, Teddy (S'end E)
Oppenheim, PhillipTebbit, Rt Hon Norman
Page, RichardTemple-Morris, Peter
Paice, JamesThompson, D. (Calder Valley)
Parkinson, Rt Hon CecilThompson, Patrick (Norwich N)
Patnick, IrvineThornton, Malcolm
Patten, Chris (Bath)Thurnham, Peter
Patten, John (Oxford W)Townsend, Cyril D. (B'heath)
Pattie, Rt Hon Sir GeoffreyTracey, Richard
Pawsey, JamesTredinnick, David
Porter, David (Waveney)Trippier, David
Portillo, MichaelTrotter, Neville
Price, Sir DavidTwinn, Dr Ian
Raffan, KeithVaughan, Sir Gerard
Raison, Rt Hon TimothyViggers, Peter
Redwood, JohnWaddington, Rt Hon David
Renton, TimWakeham, Rt Hon John
Rhodes James, RobertWaldegrave, Hon William
Riddick, GrahamWalden, George
Ridley, Rt Hon NicholasWalker, Bill (T'side North)
Rifkind, Rt Hon MalcolmWalker, Rt Hon P. (W'cester)
Roberts, Wyn (Conwy)Walters, Dennis
Roe, Mrs MarionWard, John
Rossi, Sir HughWardle, Charles (Bexhill)
Rost, PeterWells, Bowen
Rowe, AndrewWheeler, John
Rumbold, Mrs AngelaWhitney, Ray
Ryder, RichardWiddecombe, Ann
Sackville, Hon TomWiggin, Jerry
Sainsbury, Hon TimWilshire, David
Sayeed, JonathanWolfson, Mark
Scott, NicholasWood, Timothy
Shaw, David (Dover)Woodcock, Mike
Shaw, Sir Giles (Pudsey)Yeo, Tim
Shaw, Sir Michael (Scarb')Young, Sir George (Acton)
Shephard, Mrs G. (Norfolk SW)Younger, Rt Hon George
Shepherd, Richard (Aldridge)
Skeet, Sir TrevorTellers for the Noes:
Smith, Sir Dudley (Warwick)Mr. Robert Boscawen and
Smith, Tim (Beaconsfield)Mr. Mark Lennox-Boyd.

Question accordingly negatived.

I beg to move amendment No. 66, in page 11, line 37, at end insert—

'( ) Subsection (4)(b) shall apply, in the case of a person suffering from a prescribed medical condition, both to the inspection or course of treatment during which the condition is diagnosed and to subsequent inspections and courses of treatment while the condition continues to be diagnosed or suspected'.

With this it will be convenient to take amendment No. 76, in page 14, line 6, at end insert—

'( ) Subsection (1C)(b) shall apply, in the case of a person suffering from a prescribed medical condition, both to the inspection or course of treatment during which the condition is diagnosed and to subsequent inspections and courses of treatment while the condition continues to be diagnosed or suspected'.

These amendments are designed to ensure that patients with prescribed medical conditions are not charged for examinations for the entire period during which they suffer from those conditions. Thus, the whole procedure, or series of procedures, when the condition is first diagnosed is exempted from any charge and this exemption continues until the end of the episode of care during which the patient is finally cleared of any suspicion of still suffering from the condition. Unless this interpretation is made clear and is entrenched, the promotion of good health will be put at risk.

Again, as with dental charges, we take particular exception to the proposal to charge for eye examinations and we have voted against it, but, as the Opposition amendment failed a few moments ago, we shall expect support for the view that our interpretation of the period of exemption from charges as set out in amendments Nos. 66 and 76 is the correct one.

9.15 pm

Our understanding of the effect of the amendment is that a prescribed medical condition is one of the criteria which may be used to define eligibility for NHS sight tests. The amendment would ensure that the sight test at which the prescribed condition was found and subsequent tests were NHS tests.

The only comment that I can make on this slightly arcane point is that there is already power to extend NHS tests to those suffering from prescribed medical conditions. In my previous speech I said something about diabetics. The amendment would simply provide that the test at which the condition was found could also be an NHS test. However, if the person is having a test, it seems likely that he has not been deterred by the private fee.

I said earlier that we would make changes in the arrangements for diabetics and those at risk from glaucoma. I shall examine what the hon. Gentleman has said against what is on the Amendment Paper. If it turns out that we need a provision of the kind proposed in the amendment, I shall be prepared to consider it later. I am not at present persuaded, partly because I think that there is confusion about the purpose and purport of the amendment.

It would appear from what I hear that the Minister accepts the general theme that I have put forward. Therefore, I beg to ask leave to withdraw the amendment.

Amendment, by leave, withdrawn.

Amendments made: No. 31, in page 12, line 12, leave out

'The services provided under this section'

and insert

'Regulations shall define the services for the provision of which arrangements under this section are to be made and the services so defined'.

No. 32, in page 14, line 29, leave out

'The services provided under this section'

and insert

'Regulations shall define the services for the provision of which arrangements under this section are to be made and the services so defined'.

No. 33, in page 12, line 35, leave out 'subsection' and insert 'section'.

No. 34, in page 14, line 41. leave out 'subsection' and insert 'section'.— [Mr. Newton.]

Clause 11

Sight-Testing

Amendment made: No. 35, in page 15, line 1, leave out clause 11.— [Mr. Newton.]

Clause 13

Limits On Reimbursement Of Expenses

I beg to move amendment No. 85, in page 16, line 25, leave out clause 13.

With this, we will take the following amendments: No, 77, in page 16, line 36, at end insert—

'( ) It shall be the duty of a Family Practitioner Committee to report to the Secretary of State any instance when. it considers that the amount allotted under subsection (97)(1)(b)(ii) above is insufficient for the purposes prescribed, and to make known to the public in its locality the content of such report'.
No. 78, in page 17, line 2, at end insert—
'( ) It shall be the duty of a Health Board to report to the Secretary of State any instance when it considers that the amount allotted under subsection (85)(2)(a) above is insufficient for the purposes prescribed, and to make known to the public in its locality the content of such report'.
No. 79, in page 17, line 7, at end insert—
'(5) Each Family Practitioner Committee and each Health Board shall have the duty to satisfy itself, after consulting such bodies as appears to it to represent the interests of the public in its locality within the National Health Service, that the payments made pursuant to this section are available without discrimination in all parts of its locality and to all practitioners in contract with it and covered by any such allotment'.

In view of the time, I intend to be brief. I was not a member of the Standing Committee which considered the Bill but I have read the debate in Committee on clause 13. Many of the details were well aired in the debate. However, it is right at this stage that hon. Members who did not have the opportunity to participate in that debate should search further to find out whether the Government have advanced their thinking on these issues.

I want to refer to statements by the Parliamentary Under-Secretary of State. She referred to doctors who
"were worried that the new system has not been explained sufficiently to allay their fears. This is partly because some of the details…are still to be worked out."
I wonder whether the Government have worked out further details. She also said:
"My first and most important reassurance is that we firmly anticipate spending a great deal more on the services than currently."—[Official Report, Standing Committee A, 23 February 1988; c. 870.]
Can a specific figure be offered by the Government now, particularly in view of the fact that later in that debate the Parliamentary Under-Secretary said that she was hoping that funds would be raised from the implementation of clauses 8 and 10? We have had a concession from the Minister for Health that there will be a reduction of £7 million to £8 million as a result of his statement. Will that affect in any way the money which comes in?

The Parliamentary Under-Secretary of State also indicated that it was not the Government's expectation that the clause would come into effect immediately. It seems strange to include in the Bill a clause which is not to be implemented until negotiations are complete. Surely we must be given a final date which will be applied to the negotiations.

We put our general practitioners in the front line of medicine. We turn to them in times of crisis and indeed of health. How can we expect them to expand and improve primary care and preventive medicine, yet put cash limitations on their ability to do so? If we expect our GPs to take a pro-active role, we must take account of their financial needs. It is wrong to place cash limits on GPs in the clause, rather than look at the service and the needs of patients.

It is clear that general practitioners have been very cost-effective in their application of the funding available to them. I will quote from a letter that I received from Grampian local medical committee, because that is my local medical authority. The committee is deeply concerned about the implications of the clause. The letter says:
"We would emphasise that such cash-limiting is not necessary, as the service we provide is widely recognised as being extraordinarily cost-effective—the cost of the availability and services of the General Practitioner being around £28 per patient per year, which includes all the expenses of running a practice."
For a Government who talk of cost-effectiveness, I do not think that I could find a better example of a cost-effective service than that provided in Grampian at a cost of £28 per patient per year.

Because of other financial pressures being exercised on the National Health Service, and presssure on the Grampian health board budget, several practices, mainly in health centres, are already withdrawing treatment room nurse provision. Arrangements are being negotiated so that the GPs will meet part of the cost, the whole cost previously having been borne by the health board. Against that sort of background, I ask the Government to withdraw the clause until we have sorted things out and know in our own minds exactly what to do. They should give our general practitioners the vote of confidence that they so obviously deserve.

I am anxious not to protract the proceedings, but I am sure that I am not the only hon. Member who has had letters from GPs within his constituency. They are concerned that the effect of the clause will be to restrict the extent to which patients consult them. I am sure that that is not intended, and it would be helpful if the Minister could give appropriate assurances when replying to the debate. Indeed, perhaps at some stage what is known as a "Dear Doctor" letter can be sent clarifying the situation so that these misunderstandings can be removed.

In my constituency, people are very fortunate in the high quality and standards offered to them by the general practitioner service throughout Angus. I have had the opportunity to visit practices in Montrose, and I was very impressed by their use of technology, and modernisation assisting in patient care, to ensure an efficient and caring service.

My purpose in speaking is to draw to the Government's attention the views of such working general practitioners. These practical and qualified men and women are concerned about the Government's proposals. I shall be using their words, and I hope that the Minister will respond to them.

The substance of clause 13 implies a concept of cash limiting the funding of primary care services, and it is that to which these general practitioners are opposed. Montrose practices are typical of those in Angus, and elsewhere in Scotland, in that forward-looking practices are extending their functions in preventive medicine to include cervical and other screening procedures and the care of the sick at home in the community. In national terms these services are cost effective because they relieve hospitals of additional burdens. If cash limits are imposed on primary care, such initiatives will be abandoned. My doctors believe that it will revert to a "national sickness" service.

The unique contractual relationship within the NHS means that general practitioners have a direct incentive to extend and improve services, retaining, in their own interests, the need to be very cost effective. There is an entrepreneurial attitude in Montrose, which its GPs believe should be supported by the Government rather than be hamstrung by cash limiting.

General practice in the United Kingdom is experiencing a renaissance of technological development, an extension of function and an improvement in services for patients. Notwithstanding that, the cost to the state is lower than in any other country in the Western developed world. The profession is willing and has the capacity to do much more in primary care, but that attitude will be to no avail if cash limits are imposed.

The doctors in another Montrose practice state:
"Primary care is cost-effective at present, with patients entitled to open access to Primary Health Care services, with no limits on the number of consultations."
Despite that open-endedness, the primary health care system is cost effective, making this unlimited access available at the cost of about £28 per patient per year in total for expenses and paying for the general practitioner. Those doctors believe that cash limiting is an attempt to bring the hospital cuts into the sphere of general practice, and there will be cuts if the clause is passed.

Hospital cuts have led to longer waiting lists which have increased the work load on GPs; for example, because patients require attention for pain relief and drugs while waiting for admission. Earlier discharge from hospital means that GPs treat more people with drugs which otherwise would have been provided from hospital, thus adding to the work load and costs of general practice.

Rationing primary health care is not a desirable option and any attempt at rationing in this sphere would impose limitations on patient access to primary health care. My doctors believe that cash limits are not necessary. In general, practice costs are largely reimbursed on the basis of national average cost levels and GPs control their costs tightly to maintain their practice income. This in turn ensures that average cost levels are maintained in future years. Therefore, doctors have a personal incentive in controlling costs, resulting in national saving.

The Government want GPs to develop their service to patients, but to do that they must have sufficient quality staff. Doctors state that it is obvious from their surgeries that ancillary staff offer great benefits to patients, for example, in easing the arrangements between patients and hospitals, ambulances, social work departments, the DHSS, employers, the district nurse and the health visitor, and by making available in the surgery treatments which would normally mean a patient having to travel to hospital. The benefits cover the whole spectrum of staff, from practising nurses to administrators, secretaries and receptionists. The direct reimbursement scheme pays only part of those salaries and GPs shoulder the remainder, so they have a powerful incentive to be cost effective.

The doctors of Montrose have attractive premises in the town, but they state that with cash limitations even planned projects will now be made more doubtful, let alone new projects. Limitations on the existing cost-rent scheme threaten them, but further cash limiting would torpedo them altogether.
"This direct reimbursement scheme also has powerful incentives to cost-effective development, for although the scheme yields a return on capital invested in practice premises, the GP still has to put up the capital and bear the burden of increased running costs of new or improved premises."
Those are the words of working GPs who deal not only with the theory, but with the practice, of medicine. The Government's proposals will threaten directly their work and efficiency. I support my hon. Friend in opposing clause 13 and I hope that the Minister will listen and respond to the genuine voice of the medical profession.

I support amendment No. 85. We do not believe that the case for imposing cash limits has been made by the Government. There is no evidence that across the country GPs plan to be unreasonable in their demands to take advantage of what the Government clearly see as a potential loophole in the Bill. On the contrary, GPs will be reasonable and will not employ more staff than they need to look after their patients. However, it is certain that the Government will not concede this point. Accordingly, amendments Nos. 77 and 78 place a duty on a general practitioner committee or a health board to make a public report to the relevant Secretary of State if they believe that their allocation for these purposes is insufficient.

The amendment assumes that family practitioner committees will be responsible. If they need to report they will reflect the inadequacy of Government provision. Any responsible Government would welcome such a report and take action to remedy the unsatisfactory state of affairs. We cannot see any justification for the Government refusing to accept the amendment.

Amendment No. 79 places a duty upon FPCs to ensure that, if a limited sum is available, it is distributed in a non-discriminatory manner. It would be entirely inappropriate if an FPC benefited part of its area at the expense of other parts. The amendment also strengthens the hands of FPCs in their planning functions. It will help FPCs to strengthen services in deprived parts of their areas. The fact that they can plead that statutory duty is likely to overcome the resistance that they might encounter. That can only benefit the service. In other words, FPCs can become more active in aiding the development of services. It will no longer be sufficient for FPCs simply to react to events. I hope that the amendments, like some of my others, are not too clever for the Minister.

9.30 pm

I rise briefly to support amendment No. 85. There is universal opposition to cash-limiting the family doctor service. Representations have been made to Members of Parliament, including no doubt to members of the Government, from worried general practitioners around the country. I challenge the Government to name one single independent reputable organisation that supports the cash-limiting of GP services. I am talking about anybody the Under-Secretary of State can mention who supports clause 13, not about people who have made statements of general support for the White Paper. Nobody supports clause 13 and its cash limits.

General practitioners are absolutely right to be fearful. It is clear that the Government now intend to wield the axe over GP services in exactly the same way as they have chopped hospital services.

I hope that the Government will not insult our intelligence tonight by saying that they are introducing cash limits so that they can spend more than they currently spend. We were not born yesterday. It is unbelievable to think that in introducing a clause entitled,
"Limits on reimbursement of expenses"
the Government are introducing the clause to enable them to spend more. It is nonsense to say that a cash limit will improve and develop services. A cash limit is there simply to limit cash. It will stifle the development of services.

GP services do need developing. We want to see the benefits of new technology harnessed for the benefit of patients. New technology in communication and in diagnostic equipment should be available to GPs. We want to see GPs work as part of an enhanced team with nurses, health visitors, midwives, chiropodists, physiotherapists and other health professionals. We want to see GPs' premises improved so that they provide pleasant waiting and treatment areas with easy access for parents with small children and for disabled people. We want to see GPs develop their work on screening and prevention and provide, at local level, diabetic clinics, ante-natal services and counselling on diet and smoking. There is no chance of those developments taking place if, instead of saying to family doctors, "Let us discuss how we can improve services", the Government say, "Go away and cut costs."

It is not as if at any time in Committee the Government pointed out that there has been an inefficient use of resources. Family practitioner committees are already obliged to, and do, take into account value for money. If anything, we would criticise them for having erred on the side of caution and for not pressing hard enough or fast enough to develop and improve GP services. It is clear that the Government intend to squeeze GP services. They want to use the dissatisfaction that that creates in patients as an excuse to bring in commercial, American-style health maintenance organisations. That would be a catastrophic mistake.

The family doctor service is not perfect, but it is a good base and provides a good framework on which to build. The problem is that the Government do not want universal public provision of primary care services. This is the first step on the road to undermining those services.

The Parliamentary Under-Secretary has been kind enough to inform me that she issued a press release earlier today, announcing an initiative on practice nurse training. I welcome the fact that the Government are taking this initiative but I feel that it is not a serious measure because of the sum of money and the number of nurses involved. The training initiative has, we are told in the press statement, attracted only £150,000 of Government money. That addition to nurse training must be looked at against a background of a cut of £40 million in nurse training provision between 1979 and today. The figure of £40 million comes from a parliamentary answer from the Minister. We are told that the training initiative is to cover 500 nurses; but that must be looked at against a background of a cut in the intake of student and pupil nurses of 12,550 between 1979 and now. That figure again comes from a parliamentary answer from the Minister.

I hope that the Parliamentary Under-Secretary will acknowledge that, although the Government now say that they are promoting practice nurse training, this is a very measly start from a Government with a shameful record on nurse training. I hear the Parliamentary Under-Secretary muttering that I do not understand the figures. I understand only too well that what the Government have done, in practice, in nurse training is cut programmes to ribbons. Yet they are trying to give themselves a bit of a public relations puff by announcing £150,000 to cover 500 nurses. The wool will not be pulled over our eyes in that respect.

The system for paying general practitioners is, like that of the other family practitioner professions, based on the cost-plus principle which was established at the inception of the National Health Service. That is, the payments that they receive are intended to cover expenses and to provide on top a net income for every GP. Based on the return to the Inland Revenue, expenses incurred in providing general medical services are paid back to the profession in full. That is, if the tax man accepts it as a legitimate expense, we accept it.

Some of these expenses are paid back to the individual GP, and that is known as direct reimbursement. The remainder is reimbursed on an average basis through standard rate fees and allowances—that is, indirectly reimbursed—and general practitioners' net income is also delivered through fees and allowances. I am sure that the hon. Member for Southport (Mr. Fearn), who was an assistant bank manager, has understood all that.

Clause 13 will enable directly reimbursed expenses to be subject to a cash limit, but expenses not directly reimbursed in full will nonetheless be reimbursed indirectly through fees and allowances.

The total spend on family practitioner services in Britain is over £5,000 million, and by 1990–91 we hope to have increased it by some £600 million. I cannot tell the hon. Member for Moray (Mrs. Ewing) exactly how much will come under clause 13 because at least part of it will be the subject of discussions with the profession, but that is the sort of sum of money that we are talking about; and the directly reimbursed element of that sum amounts to £455 million in 1987–88. These are Great Britain figures.

Our proposals, as set out in the White Paper, would involve cash-limiting barely half of that. In other words, the proposals would cover less than 5 per cent. of the total spend on these important family practitioner services, and over 95 per cent. would continue to be run in exactly the same way as they are now.

Our intent, as was recognised in Committee, is to give family practitioner committees and health boards a chunk of money to help them concentrate premises improvement funds where they are most needed, particularly, for example, in the inner cities, and we also want them to help doctors everywhere to improve their practice teams, with a far wider range of staff than is currently possible. We are very concerned to improve the practice team. I share that view with the hon. Member for Angus, East (Mr. Welsh).

As the hon. Lady the Member for Peckham (Ms. Harman) said, I was very glad to announce earlier today that we are making an extra £150,000 available immediately to increase sharply the number of training opportunities for practice nurses. The detailed arrangements are a matter for discussion with the profession, but I expect to see rapid action as the money is available now. We hope that £50,000 will be used to create distance learning materials, including videos, which will help practice nurses all over the country, particularly those in rural areas such as the constituences of the hon. Member for Moray and Angus, East and my own, the sort of nurses in rural areas who cannot always get to meetings or training courses.

In addition, the bulk of the money will be used, I hope, to pay the course fee. If the hon. Lady the Member for Peckham wants to understand the figures and the amounts, perhaps she would like to listen to this. I hope that the bulk of the money will be used to pay the course fee for practice nurse training courses. Indeed, we expect more such courses to be set up as a result of that money. We foresee 500 nurses being able to take advantage of the extra money this year. If those courses are satisfactory, we hope to do the same next year. After that, clause 12, which has gone through all its stages without comment, will come into operation and will enable those fees to be paid.

The difference between that money and the money about which the hon. Member for Peckham was speaking is that it is used simply to pay course fees. The money about which the hon. Lady was speaking includes salaries.

I have told the officials concerned that I am particularly keen to improve training for practice nurses to take cervical smears, and I hope that the hon. Member for Peckham will at least say thank you for that.

We have been asked why we should not continue with the current set-up. The present ancillary staff scheme was introduced in the mid-1960s. Some 20 years on 24,000 family doctors in Great Britain are employing over 36,000 practice staff. Of that figuree, 16,000 are receptionists and 11,000 are secretaries, but the number of practice nurses is only 3,000. In Scotland, 3,000 family doctors have only 170 practice nurses for a population of 5 million, which is completely unsatisfactory.

We consider the present system to be far too restrictive because it does not encourage the recruitment of other health professionals such as chiropodists, counsellors and physiotherapists, and it prevents the payment of people such as doctors' wives, which I regard as iniquitous. We shall change that.

With regard to practice premises, we feel that the present system is unsatisfactory. Many examples of bad surgery premises were given in Committee. That system is used at present simply because there is a strong incentive for the doctor to do nothing, which answers the question of the hon. Member for Angus, East.

The present system is old-fashioned because it does not link spending with health needs and we shall do something about that in the near future. We think that cash limits will be useful as they will concentrate minds and enable priorities to be sorted out. I therefore reject the amendments.

If the Minister was seeking to reassure me, she has singularly failed to do so. I believe that there are various principles at stake in the amendment.

The Minister spoke of cash-limiting the total amount given. That would be detrimental to general practices throughout the United Kingdom. A principle is involved, because if half of the total amount is to be cash limited, as time goes on the amount cash limited will increase more and more.

I refer the Minister to what the British Medical Association said about clause 13. It said:
"Indeed it carries the potential to threaten patients' equality of access to services in the future."
Nothing that the Minister said showed that she will guarantee equality of access or protect the rights of general practitioners. Therefore, I feel that I have no option but to press the amendment to a vote.

Question put, That the amendment be made:—

The House divided: Ayes 182, Noes 304.

Division No. 260]

[9.42 pm

AYES

Abbott, Ms DianeFisher, Mark
Adams, Allen (Paisley N)Flannery, Martin
Allen, GrahamFlynn, Paul
Archer, Rt Hon PeterFoot, Rt Hon Michael
Armstrong, HilaryFoster, Derek
Ashdown, PaddyFraser, John
Ashley, Rt Hon JackFyfe, Maria
Banks, Tony (Newham NW)Galbraith, Sam
Barron, KevinGalloway, George
Battle, JohnGarrett, John (Norwich South)
Beckett, MargaretGeorge, Bruce
Benn, Rt Hon TonyGodman, Dr Norman A.
Bennett, A. F. (D'nt'n & R'dish)Golding, Mrs Llin
Bermingham, GeraldGraham, Thomas
Bidwell, SydneyGrant, Bernie (Tottenham)
Blair, TonyGriffiths, Nigel (Edinburgh S)
Boyes, RolandGriffiths, Win (Bridgend)
Bradley, KeithGrocott, Bruce
Bray, Dr JeremyHardy, Peter
Brown, Gordon (D'mline E)Harman, Ms Harriet
Brown, Nicholas (Newcastle E)Haynes, Frank
Brown, Ron (Edinburgh Leith)Heffer, Eric S.
Bruce, Malcolm (Gordon)Henderson, Doug
Buchan, NormanHinchliffe, David
Buckley, George J.Hogg, N. (C'nauld & Kilsyth)
Caborn, RichardHome Robertson, John
Campbell, Menzies (Fife NE)Hood, Jimmy
Campbell-Savours, D. N.Howarth, George (Knowsley N)
Canavan, DennisHowell, Rt Hon D. (S'heath)
Clarke, Tom (Monklands W)Howells, Geraint
Clay, BobHoyle, Doug
Clelland, DavidHughes, John (Coventry NE)
Clwyd, Mrs AnnHughes, Robert (Aberdeen N)
Cohen, HarryHughes, Simon (Southwark)
Cook, Frank (Stockton N)Illsley, Eric
Cook, Robin (Livingston)John, Brynmor
Corbett, RobinJones, Barry (Alyn & Deeside)
Corbyn, JeremyJones, Ieuan (Ynys Môn)
Cox, TomJones, Martyn (Clwyd S W)
Cummings, JohnKennedy, Charles
Dalyell, TamKilfedder, James
Darling, AlistairLeadbitter, Ted
Davies, Rt Hon Denzil (Llanelli)Leighton, Ron
Davies, Ron (Caerphilly)Lewis, Terry
Davis, Terry (B'ham Hodge H'I)Litherland, Robert
Dewar, DonaldLivsey, Richard
Dixon, DonLloyd, Tony (Stretford)
Doran, FrankLofthouse, Geoffrey
Duffy, A. E. P.Loyden, Eddie
Dunnachie, JimmyMcAllion, John
Dunwoody, Hon Mrs GwynethMcAvoy, Thomas
Eadie, AlexanderMcCusker, Harold
Eastham, KenMcFall, John
Ewing, Mrs Margaret (Moray)McKay, Allen (Barnsley West)
Fatchett, DerekMcKelvey, William
Fearn, RonaldMcLeish, Henry
Field, Frank (Birkenhead)McNamara, Kevin
Fields, Terry (L'pool B G'n)McTaggart, Bob

Madden, MaxRobertson, George
Mahon, Mrs AliceRobinson, Geoffrey
Marek, Dr JohnRogers, Allan
Marshall, David (Shettleston)Rooker, Jeff
Marshall, Jim (Leicester S)Ross, Ernie (Dundee W)
Martin, Michael J. (Springburn)Rowlands, Ted
Martlew, EricRuddock, Joan
Meacher, MichaelSedgemore, Brian
Michie, Bill (Sheffield Heeley)Sheerman, Barry
Millan, Rt Hon BruceSheldon, Rt Hon Robert
Mitchell, Austin (G't Grimsby)Shore, Rt Hon Peter
Molyneaux, Rt Hon JamesShort, Clare
Moonie, Dr LewisSkinner, Dennis
Morgan, RhodriSmith, Andrew (Oxford E)
Morley, ElliottSmith, C. (Isl'ton & F'bury)
Morris, Rt Hon J. (Aberavon)Soley, Clive
Mowlam, MarjorieSpearing, Nigel
Mullin, ChrisSteinberg, Gerry
Murphy, PaulStott, Roger
Oakes, Rt Hon GordonTaylor, Matthew (Truro)
O'Brien, WilliamTurner, Dennis
O'Neill, MartinVaz, Keith
Parry, RobertWall, Pat
Patchett, TerryWalley, Joan
Pendry, TomWardell, Gareth (Gower)
Pike, Peter L.Wareing, Robert N.
Powell, Ray (Ogmore)Williams, Rt Hon Alan
Prescott, JohnWilliams, Alan W. (Carm'then)
Quin, Ms JoyceWinnick, David
Radice, GilesWorthington, Tony
Randall, StuartYoung, David (Bolton SE)
Rees, Rt Hon Merlyn
Reid, Dr JohnTellers for the Ayes:
Richardson, JoMr. Andrew Welsh and
Roberts, Allan (Bootle)Mr. Archy Kirkwood.

NOES

Adley, RobertCarlisle, John, (Luton N)
Aitken, JonathanCarlisle, Kenneth (Lincoln)
Alexander, RichardCarrington, Matthew
Alison, Rt Hon MichaelCarttiss, Michael
Allason, RupertCash, William
Amery, Rt Hon JulianChalker, Rt Hon Mrs Lynda
Amess, DavidChapman, Sydney
Amos, AlanChope, Christopher
Arbuthnot, JamesChurchill, Mr
Ashby, DavidClark, Dr Michael (Rochford)
Aspinwall, JackClark, Sir W. (Croydon S)
Atkinson, DavidClarke, Rt Hon K. (Rushcliffe)
Baker, Rt Hon K. (Mole Valley)Colvin, Michael
Baker, Nicholas (Dorset N)Conway, Derek
Baldry, TonyCoombs, Anthony (Wyre F'rest)
Banks, Robert (Harrogate)Coombs, Simon (Swindon)
Batiste, SpencerCope, John
Bellingham, HenryCormack, Patrick
Bennett, Nicholas (Pembroke)Couchman, James
Biggs-Davison, Sir JohnCran, James
Blackburn, Dr John G.Currie, Mrs Edwina
Blaker, Rt Hon Sir PeterCurry, David
Body, Sir RichardDavies, Q. (Stamf'd & Spald'g)
Bonsor, Sir NicholasDavis, David (Boothferry)
Boswell, TimDay, Stephen
Bottomley, PeterDevlin, Tim
Bowden, A (Brighton K'pto'n)Dickens, Geoffrey
Bowden, Gerald (Dulwich)Dorrell, Stephen
Bowls, JohnDouglas-Hamilton, Lord James
Boyson, Rt Hon Dr Sir RhodesDover, Den
Braine, Rt Hon Sir BernardDunn, Bob
Brandon-Bravo, MartinDurant, Tony
Brazier, JulianEggar, Tim
Bright, GrahamEmery, Sir Peter
Brittan, Rt Hon LeonEvans, David (Welwyn Hatf'd)
Brooke, Rt Hon PeterEvennett, David
Brown, Michael (Brigg & Cl't's)Fallon, Michael
Bruce, Ian (Dorset South)Farr, Sir John
Buck, Sir AntonyFavell, Tony
Burns, SimonFookes, Miss Janet
Burt, AlistairForman, Nigel
Butcher, JohnForsyth, Michael (Stirling)
Butler, ChrisForth, Eric

Fowler, Rt Hon NormanLloyd, Peter (Fareham)
Fox, Sir MarcusLord, Michael
Franks, CecilLyell, Sir Nicholas
Freeman, RogerMcCrindle, Robert
Fry, PeterMacfarlane, Sir Neil
Gale, RogerMacGregor, Rt Hon John
Gill, ChristopherMacKay, Andrew (E Berkshire)
Glyn, Dr AlanMaclean, David
Goodhart, Sir PhilipMcLoughlin, Patrick
Goodlad, AlastairMcNair-Wilson, M. (Newbury)
Goodson-Wickes, Dr CharlesMcNair-Wilson, P. (New Forest)
Gorman, Mrs TeresaMadel, David
Gorst, JohnMajor, Rt Hon John
Gow, IanMalins, Humfrey
Gower, Sir RaymondMans, Keith
Grant, Sir Anthony (CambsSW)Maples, John
Greenway, Harry (Ealing N)Marlow, Tony
Greenway, John (Ryedale)Marshall, John (Hendon S)
Griffiths, Sir Eldon (Bury St E')Martin, David (Portsmouth S)
Griffiths, Peter (Portsmouth N)Mates, Michael
Grist, IanMaude, Hon Francis
Ground, PatrickMawhinney, Dr Brian
Grylls, MichaelMayhew, Rt Hon Sir Patrick
Gummer, Rt Hon John SelwynMellor, David
Hamilton, Hon Archie (Epsom)Meyer, Sir Anthony
Hamilton, Neil (Tatton)Miller, Hal
Hampson, Dr KeithMills, Iain
Hanley, JeremyMitchell, Andrew (Gedling)
Hargreaves, A. (B'ham H'll Gr')Moate, Roger
Hargreaves, Ken (Hyndburn)Monro, Sir Hector
Harris, DavidMoore, Rt Hon John
Hawkins, ChristopherMorris, M (N'hampton S)
Hayes, JerryMorrison, Hon Sir Charles
Hayhoe, Rt Hon Sir BarneyMorrison, Hon P (Chester)
Hayward, RobertMoss, Malcolm
Heathcoat-Amory, DavidMoynihan, Hon Colin
Heddle, JohnNeale, Gerrard
Heseltine, Rt Hon MichaelNeedham, Richard
Hicks, Robert (Cornwall SE)Nelson, Anthony
Higgins, Rt Hon Terence L.Neubert, Michael
Hind, KennethNewton, Rt Hon Tony
Hogg, Hon Douglas (Gr'th'm)Nicholls, Patrick
Holt, RichardNicholson, David (Taunton)
Hordern, Sir PeterNicholson, Emma (Devon West)
Howard, MichaelOnslow, Rt Hon Cranley
Howarth, Alan (Strat'd-on-A)Oppenheim, Phillip
Howarth, G. (Cannock & B'wd)Page, Richard
Howell, Rt Hon David (G'dford)Paice, James
Howell, Ralph (North Norfolk)Parkinson, Rt Hon Cecil
Hughes, Robert G. (Harrow W)Patnick, Irvine
Hunt, David (Wirral W)Patten, Chris (Bath)
Hunt, John (Ravensbourne)Patten, John (Oxford W)
Irvine, MichaelPattie, Rt Hon Sir Geoffrey
Irving, CharlesPawsey, James
Jack, MichaelPeacock, Mrs Elizabeth
Jackson, RobertPorter, David (Waveney)
Janman, TimPortillo, Michael
Jessel, TobyPowell, William (Corby)
Johnson Smith, Sir GeoffreyPrice, Sir David
Jones, Gwilym (Cardiff N)Raffan, Keith
Jones, Robert B (Herts W)Raison, Rt Hon Timothy
Kellett-Bowman, Dame ElaineRedwood, John
Key, RobertRenton, Tim
King, Roger (B'ham N'thfield)Rhodes James, Robert
Kirkhope, TimothyRiddick, Graham
Knapman, RogerRifkind, Rt Hon Malcolm
Knight, Greg (Derby North)Roberts, Wyn (Conwy)
Knight, Dame Jill (Edgbaston)Roe, Mrs Marion
Knowles, MichaelRossi, Sir Hugh
Knox, DavidRost, Peter
Lamont, Rt Hon NormanRowe, Andrew
Lang, IanRumbold, Mrs Angela
Latham, MichaelRyder, Richard
Lawrence, IvanSackville, Hon Tom
Lee, John (Pendle)Sainsbury, Hon Tim
Lennox-Boyd, Hon MarkSayeed, Jonathan
Lester, Jim (Broxtowe)Scott, Nicholas
Lightbown, DavidShaw, David (Dover)
Lilley, PeterShaw, Sir Giles (Pudsey)
Lloyd, Sir Ian (Havant)Shaw, Sir Michael (Scarb')

Shephard, Mrs G. (Norfolk SW)Tredinnick, David
Shepherd, Richard (Aldridge)Trippier, David
Sims, RogerTrotter, Neville
Skeet, Sir TrevorTwinn, Dr Ian
Smith, Sir Dudley (Warwick)Vaughan, Sir Gerard
Smith, Tim (Beaconsfield)Viggers, Peter
Soames, Hon NicholasWaddington, Rt Hon David
Spicer, Sir Jim (Dorset W)Wakeham, Rt Hon John
Spicer, Michael (S Worcs)Waldegrave, Hon William
Squire, RobinWalden, George
Stanbrook, IvorWalker, Bill (T'side North)
Stanley, Rt Hon JohnWalker, Rt Hon P. (W'cester)
Stern, MichaelWaller, Gary
Stevens, LewisWalters, Dennis
Stewart, Allan (Eastwood)Ward, John
Stewart, Ian (Hertfordshire N)Wardle, Charles (Bexhill)
Stokes, JohnWells, Bowen
Sumberg, DavidWheeler, John
Summerson, HugoWhitney, Ray
Tapsell, Sir PeterWiddecombe, Ann
Taylor, Ian (Esher)Wiggin, Jerry
Taylor, John M (Solihull)Wilshire, David
Taylor, Teddy (S'end E)Wolfson, Mark
Tebbit, Rt Hon NormanWood, Timothy
Temple-Morris, PeterWoodcock, Mike
Thompson, D. (Calder Valley)Young, Sir George (Acton)
Thompson, Patrick (Norwich N)Younger, Rt Hon George
Thornton, Malcolm
Thurnham, PeterTellers for the Noes:
Townsend, Cyril D. (B'heath)Mr. Robert Boscawen and
Tracey, RichardMr. Tristan Garel-Jones.

Question accordingly negatived.

Clause 20

Commencement And Transitional

Amendment made: No. 36, in page 19, line 40, leave out '11' and insert '[Sight-testing];'.— [Mr. Newton.]

Clause 21

Northern Ireland

Amendment made: No. 37, in page 21, line 5, leave out '11' and insert '[Sight-testing]'.[Mr. Newton.]

Schedule 2

Repeals

Amendments made: No. 19, in page 24, line 8, at end insert—

'1968 c. 46.Health Public 1968.Service Healthand ActSection 63(3).'

No. 30, in page 25, line 14, leave out from beginning to '11' in line 15 and insert 'sections 10 and'.— [Mr. Newton.]

Order for Third Reading read.

Motion made, and Question proposed, That the Bill be now read the Third time.— [Mr. Newton.]

The issue that arises is whether the House of Commons is entitled to know the technical, professional, medical advice of the chief medical officer. Understandably, hon. Members want to vote quickly so I shall leave it at that, but surely the House of Commons has a right to know what Sir Donald Acheson, and Dr. Macdonald—or whoever occupies their positions—have to say on contentious issues such as eye testing and dental charges.

Question put, That the Bill be now read the Third time:—

The House divided: Ayes 305, Noes 185.

Division No. 261]

[9.55 pm

AYES

Adley, RobertDurant, Tony
Aitken, JonathanEggar, Tim
Alexander, RichardEmery, Sir Peter
Alison, Rt Hon MichaelEvans, David (Welwyn Hatf'd)
Allason, RupertEvennett, David
Amery, Rt Hon JulianFallon, Michael
Amess, DavidFarr, Sir John
Amos, AlanFavell, Tony
Arbuthnot, JamesFookes, Miss Janet
Arnold, Tom (Hazel Grove)Forman, Nigel
Ashby, DavidForsyth, Michael (Stirling)
Aspinwall, JackForth, Eric
Atkinson, DavidFowler, Rt Hon Norman
Baker, Rt Hon K. (Mole Valley)Fox, Sir Marcus
Baker, Nicholas (Dorset N)Franks, Cecil
Baldry, TonyFreeman, Roger
Banks, Robert (Harrogate)Gale, Roger
Batiste, SpencerGarel-Jones, Tristan
Bellingham, HenryGill, Christopher
Bennett, Nicholas (Pembroke)Glyn, Dr Alan
Biggs-Davison, Sir JohnGoodhart, Sir Philip
Blackburn, Dr John G.Goodlad, Alastair
Blaker, Rt Hon Sir PeterGoodson-Wickes, Dr Charles
Body, Sir RichardGorman, Mrs Teresa
Bonsor, Sir NicholasGorst, John
Boswell, TimGow, Ian
Bottomley, PeterGower, Sir Raymond
Bowden, A (Brighton K'pto'n)Grant, Sir Anthony (CambsSW)
Bowden, Gerald (Dulwich)Greenway, Harry (Ealing N)
Bowis, JohnGreenway, John (Ryedale)
Boyson, Rt Hon Dr Sir RhodesGriffiths, Sir Eldon (Bury St E')
Braine, Rt Hon Sir BernardGriffiths, Peter (Portsmouth N)
Brandon-Bravo, MartinGrist, Ian
Brazier, JulianGround, Patrick
Bright, GrahamGrylls, Michael
Brittan, Rt Hon LeonGummer, Rt Hon John Selwyn
Brooke, Rt Hon PeterHamilton, Hon Archie (Epsom)
Brown, Michael (Brigg & Cl't's)Hamilton, Neil (Tatton)
Bruce, Ian (Dorset South)Hampson, Dr Keith
Buck, Sir AntonyHanley, Jeremy
Burns, SimonHargreaves, A. (B'ham H'll Gr')
Burt, AlistairHargreaves, Ken (Hyndburn)
Butcher, JohnHarris, David
Butler, ChrisHawkins, Christopher
Carlisle, John, (Luton N)Hayes, Jerry
Carlisle, Kenneth (Lincoln)Hayhoe, Rt Hon Sir Barney
Carrington, MatthewHayward, Robert
Carttiss, MichaelHeathcoat-Amory, David
Cash, WilliamHeddle, John
Chalker, Rt Hon Mrs LyndaHeseltine, Rt Hon Michael
Channon, Rt Hon PaulHicks, Robert (Cornwall SE)
Chapman, SydneyHiggins, Rt Hon Terence L.
Chope, ChristopherHind, Kenneth
Churchill, MrHogg, Hon Douglas (Gr'th'm)
Clark, Dr Michael (Rochford)Hordern, Sir Peter
Clark, Sir W. (Croydon S)Howard, Michael
Clarke, Rt Hon K. (Rushcliffe)Howarth, Alan (Strat'd-on-A)
Colvin, MichaelHowarth, G. (Cannock & B'wd)
Conway, DerekHowell, Rt Hon David (G'dford)
Coombs, Anthony (Wyre F'rest)Howell, Ralph (North Norfolk)
Coombs, Simon (Swindon)Hughes, Robert G. (Harrow W)
Cope, JohnHunt, David (Wirral W)
Couchman, JamesHunt, John (Ravensbourne)
Cran, JamesIrvine, Michael
Currie, Mrs EdwinaIrving, Charles
Curry, DavidJack, Michael
Davies, Q. (Stamf'd & Spald'g)Jackson, Robert
Davis, David (Boothferry)Janman, Tim
Day, StephenJessel, Toby
Devlin, TimJohnson Smith, Sir Geoffrey
Dickens, GeoffreyJones, Gwilym (Cardiff N)
Dorrell, StephenJones, Robert B (Herts W)
Douglas-Hamilton, Lord JamesKellett-Bowman, Dame Elaine
Dover, DenKey, Robert
Dunn, BobKing, Roger (B'ham N'thfield)

King, Rt Hon Tom (Bridgwater)Rifkind, Rt Hon Malcolm
Kirkhope, TimothyRoberts, Wyn (Conwy)
Knapman, RogerRoe, Mrs Marion
Knight, Greg (Derby North)Rossi, Sir Hugh
Knowles, MichaelRost, Peter
Knox, DavidRowe, Andrew
Lamont, Rt Hon NormanRumbold, Mrs Angela
Lang, IanRyder, Richard
Latham, MichaelSackville, Hon Tom
Lawrence, IvanSainsbury, Hon Tim
Lee, John (Pendle)Sayeed, Jonathan
Lennox-Boyd, Hon MarkScott, Nicholas
Lester, Jim (Broxtowe)Shaw, David (Dover)
Lilley, PeterShaw, Sir Giles (Pudsey)
Lloyd, Sir Ian (Havant)Shaw, Sir Michael (Scarb')
Lloyd, Peter (Fareham)Shephard, Mrs G. (Norfolk SW)
Lord, MichaelShepherd, Richard (Aldridge)
Lyell, Sir NicholasSims, Roger
McCrindle, RobertSkeet, Sir Trevor
Macfarlane, Sir NeilSmith, Sir Dudley (Warwick)
MacGregor, Rt Hon JohnSmith, Tim (Beaconsfield)
MacKay, Andrew (E Berkshire)Soames, Hon Nicholas
Maclean, DavidSpicer, Sir Jim (Dorset W)
McLoughlin, PatrickSpicer, Michael (S Worcs)
McNair-Wilson, M. (Newbury)Squire, Robin
McNair-Wilson, P. (New Forest)Stanbrook, Ivor
Madel, DavidStanley, Rt Hon John
Major, Rt Hon JohnStern, Michael
Malins, HumfreyStevens, Lewis
Mans, KeithStewart, Allan (Eastwood)
Maples, JohnStewart, Ian (Hertfordshire N)
Marlow, TonyStokes, John
Marshall, John (Hendon S)Sumberg, David
Martin, David (Portsmouth S)Summerson, Hugo
Mates, MichaelTapsell, Sir Peter
Maude, Hon FrancisTaylor, Ian (Esher)
Mawhinney, Dr BrianTaylor, John M (Solihull)
Mayhew, Rt Hon Sir PatrickTaylor, Teddy (S'end E)
Mellor, DavidTebbit, Rt Hon Norman
Meyer, Sir AnthonyTemple-Morris, Peter
Miller, HalThompson, D. (Calder Valley)
Mills, IainThompson, Patrick (Norwich N)
Mitchell, Andrew (Gedling)Thornton, Malcolm
Moate, RogerThurnham, Peter
Monro, Sir HectorTownsend, Cyril D. (B'heath)
Moore, Rt Hon JohnTracey, Richard
Morris, M (N'hampton S)Tredinnick, David
Morrison, Hon Sir CharlesTrippier, David
Morrison, Hon P (Chester)Trotter, Neville
Moss, MalcolmTwinn, Dr Ian
Moynihan, Hon ColinVaughan, Sir Gerard
Neale, GerrardViggers, Peter
Needham, RichardWaddington, Rt Hon David
Nelson, AnthonyWakeham, Rt Hon John
Neubert, MichaelWaldegrave, Hon William
Newton, Rt Hon TonyWalden, George
Nicholls, PatrickWalker, Bill (T'side North)
Nicholson, David (Taunton)Waller, Gary
Nicholson, Emma (Devon West)Walters, Dennis
Onslow, Rt Hon CranleyWard, John
Oppenheim, PhillipWardle, Charles (Bexhill)
Page, RichardWarren, Kenneth
Paice, JamesWells, Bowen
Parkinson, Rt Hon CecilWheeler, John
Patnick, IrvineWhitney, Ray
Patten, Chris (Bath)Widdecombe, Ann
Patten, John (Oxford W)Wiggin, Jerry
Pattie, Rt Hon Sir GeoffreyWilshire, David
Pawsey, JamesWinterton, Mrs Ann
Peacock, Mrs ElizabethWinterton, Nicholas
Porter, David (Waveney)Wolfson, Mark
Portillo, MichaelWood, Timothy
Powell, William (Corby)Woodcock, Mike
Price, Sir DavidYoung, Sir George (Acton)
Raffan, KeithYounger, Rt Hon George
Raison, Rt Hon Timothy
Redwood, JohnTellers for the Ayes:
Renton, TimMr. Robert Boscawen and
Rhodes James, RobertMr. David Lightbown.
Riddick, Graham

NOES

Abbott, Ms DianeDoran, Frank
Adams, Allen (Paisley N)Duffy, A. E. P.
Allen, GrahamDunnachie, Jimmy
Archer, Rt Hon PeterDunwoody, Hon Mrs Gwyneth
Armstrong, HilaryEadie, Alexander
Ashdown, PaddyEastham, Ken
Ashley, Rt Hon JackEwing, Mrs Margaret (Moray)
Banks, Tony (Newham NW)Fatchett, Derek
Barnes, Mrs Rosie (Greenwich)Fearn, Ronald
Barron, KevinField, Frank (Birkenhead)
Battle, JohnFields, Terry (L'pool B G'n)
Beckett, MargaretFisher, Mark
Benn, Rt Hon TonyFlannery, Martin
Bennett, A. F. (D'nt'n & R'dish)Flynn, Paul
Bermingham, GeraldFoot, Rt Hon Michael
Bidwell, SydneyFoster, Derek
Blair, TonyFraser, John
Boyes, RolandFyfe, Maria
Bradley, KeithGalbraith, Sam
Bray, Dr JeremyGalloway, George
Brown, Gordon (D'mline E)Garrett, John (Norwich South)
Brown, Nicholas (Newcastle E)George, Bruce
Brown, Ron (Edinburgh Leith)Godman, Dr Norman A.
Bruce, Malcolm (Gordon)Golding, Mrs Llin
Buchan, NormanGraham, Thomas
Buckley, George J.Grant, Bernie (Tottenham)
Caborn, RichardGriffiths, Nigel (Edinburgh S)
Campbell, Menzies (Fife NE)Griffiths, Win (Bridgend)
Campbell-Savours, D. N.Grocott, Bruce
Canavan, DennisHardy, Peter
Cartwright, JohnHarman, Ms Harriet
Clarke, Tom (Monklands W)Heffer, Eric S.
Clay, BobHenderson, Doug
Clelland, DavidHinchliffe, David
Clwyd, Mrs AnnHogg, N. (C'nauld & Kilsyth)
Cohen, HarryHome Robertson, John
Cook, Frank (Stockton N)Hood, Jimmy
Cook, Robin (Livingston)Howarth, George (Knowsley N)
Corbett, RobinHowell, Rt Hon D. (S'heath)
Corbyn, JeremyHowells, Geraint
Cox, TomHoyle, Doug
Cummings, JohnHughes, John (Coventry NE)
Dalyell, TamHughes, Robert (Aberdeen N)
Darling, AlistairHughes, Simon (Southwark)
Davies, Rt Hon Denzil (Llanelli)Illsley, Eric
Davies, Ron (Caerphilly)John, Brynmor
Davis, Terry (B'ham Hodge H'I)Jones, Barry (Alyn & Deeside)
Dewar, DonaldJones, Martyn (Clwyd S W)
Dixon, DonKennedy, Charles

Kilfedder, JamesQuin, Ms Joyce
Kirkwood, ArchyRandall, Stuart
Leadbitter, TedRedmond, Martin
Leighton, RonRees, Rt Hon Merlyn
Lewis, TerryReid, Dr John
Litherland, RobertRichardson, Jo
Livsey, RichardRoberts, Allan (Bootle)
Lloyd, Tony (Stretford)Robertson, George
Lofthouse, GeoffreyRobinson, Geoffrey
Loyden, EddieRogers, Allan
McAllion, JohnRooker, Jeff
McAvoy, ThomasRoss, Ernie (Dundee W)
McCusker, HaroldRowlands, Ted
McFall, JohnRuddock, Joan
McKelvey, WilliamSedgemore, Brian
McLeish, HenrySheerman, Barry
McNamara, KevinSheldon, Rt Hon Robert
McTaggart, BobShore, Rt Hon Peter
Madden, MaxShort, Clare
Mahon, Mrs AliceSkinner, Dennis
Marek, Dr JohnSmith, Andrew (Oxford E)
Marshall, David (Shettleston)Smith, C. (Isl'ton & F'bury)
Marshall, Jim (Leicester S)Soley, Clive
Martin, Michael J. (Springburn)Spearing, Nigel
Martlew, EricSteinberg, Gerry
Meacher, MichaelStott, Roger
Michie, Bill (Sheffield Heeley)Straw, Jack
Millan, Rt Hon BruceTaylor, Mrs Ann (Dewsbury)
Mitchell, Austin (G't Grimsby)Taylor, Matthew (Truro)
Molyneaux, Rt Hon JamesTurner, Dennis
Moonie, Dr LewisVaz, Keith
Morgan, RhodriWall, Pat
Morley, ElliottWalley, Joan
Morris, Rt Hon J. (Aberavon)Wardell, Gareth (Gower)
Mowlam, MarjorieWareing, Robert N.
Mullin, ChrisWelsh, Andrew (Angus E)
Murphy, PaulWilliams, Rt Hon Alan
Oakes, Rt Hon GordonWilliams, Alan W. (Carm'then)
O'Brien, WilliamWinnick, David
O'Neill, MartinWorthington, Tony
Parry, RobertYoung, David (Bolton SE)
Patchett, Terry
Pendry, TomTellers for the Noes:
Pike, Peter L.Mr. Frank Haynes and
Powell, Ray (Ogmore)Mr. Allen McKay.
Prescott, John