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Oral Answers To Questions

Volume 171: debated on Tuesday 1 May 1990

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Health

Out-Patients

1.

To ask the Secretary of State for Health what is the number of out-patients currently being treated by the National Health Service; and how many were treated in 1979.

In the calendar year 1979, some 7·7 million new out-patients attended NHS hospitals in England. In the year ended 31 March 1989 the equivalent figure was 8·4 million.

Do not those figures give the lie to continual talk about cuts and financial difficulties in the Health Service? Can my hon. Friend confirm that in the Norwich health authority area 60,000 more outpatients were treated in 1989 than in 1979—an increase of 25 per cent.? Is that not a good record of which Norwich health authority and the Government can be proud?

I am grateful to my hon. Friend. He is absolutely right, and I confirm his figures. For the country as a whole, real expenditure on out-patient services has increased by 26 per cent. in the past 10 years.

Does my hon. Friend agree that those figures clearly illustrate that the massive sums spent by the Government have reduced waiting lists and, in real terms, have allowed many more patients to be treated? That is surely what the Health Service is about, and we must continue to get better and more efficient use of the vast sums of money that are put in.

I am grateful to my hon. Friend. Most hon. Members would agree that we can do even better in terms of service in out-patient departments, particularly appointment times. In December last year, the Department of Health issued a report recommending how out-patient waiting times can and should be reduced to give a better appointment system.

General Practitioners

2.

To ask the Secretary of State for Health what is the current level of general practitioners' remuneration; and what it was in 1979.

From 1 April 1990, the intended average net remuneration for general practitioners will be £33,280 and the average reimbursement of expenses £42,843. On 1 January 1991, the figure for remuneration will rise to £34,680. The corresponding levels of remuneration and expenses in 1979 were £12,830 and £11,355 respectively.

When my right hon. and learned Friend next meets the British Medical Association, will he suggest that it gives publicity to those figures, which are responsible for the fact that we now have more general practitioners than ever and the average GP patient list is shorter than ever?

I shall put my hon. Friend's excellent suggestion to the BMA when I next meet it. It is certainly the case that the number of GPs in this country has gone up by almost one fifth and lists have become much shorter while the Government have been in power. I expect that the number of GPs will continue to rise because of the attractive figures that I have described, and that lists will continue to fall.

In respect of future remuneration of GPs, is the Secretary of State aware of the anomaly produced by the Jarman indices? Is he aware that in future GPs in the London borough of Newham are scheduled to receive different additional payments in relation to the wards in which their consulting rooms are located? He must surely know that ward boundaries, in his constituency and elsewhere, are arbitrary and that a GP's patients will not necessarily live in an adjacent ward. Will he look at what appears to be an arbitrary and unsatisfactory system for an area which is greatly in need of medical services?

I am keen on the idea of increasing remuneration for those GPs who work in deprived districts, particularly inner city areas. I am glad that I reached agreement with the BMA on that subject. We have agreed that we should apply the Jarman index, but in applying it, it is inevitable that once boundaries are drawn some GPs will be disappointed if they are just the wrong side of them. We have introduced a significant extra incentive to GPs to give the higher levels of service required by people in deprived districts. I shall keep the operation of the arrangements under review, as the hon. Gentleman suggests.

Does my right hon. and learned Friend agree that it would be excellent if more members of the public realised that general practitioners are so well paid? However, will he bear in mind the problem for some GPs with the immunisation bonus payments, which require four separate actions for the child and unless all four are completed the GP will not be deemed to have carried out the treatment?

The public should be aware that GPs are well paid, and I am sure that my hon. Friend agrees that it is right that they should be. No one has ever sought to interfere with that. Our new arrangements carefully spell out, for the first time, what we expect the best practices to deliver and how they will be paid for the best levels of service. It is true that immunisation targets will be met only when full immunisation has been given; otherwise, the child would not be properly protected. I am confident that the targets will be achieved by GPs, although I am the first to acknowledge that it involves considerable hard work and application by a practice to achieve the higher targets that we have laid down.

Residential Homes

3.

To ask the Secretary of State for Health if he will bring forward proposals requiring the disclosure of criminal convictions by persons who are, or intend to become, proprietors, managers or care staff in private residential or nursing homes.

18.

To ask the Secretary of State for Health if he will bring forward proposals requiring the disclosure of criminal convictions by persons who are, or intend to become, proprietors, managers or care staff in private residential or nursing homes.

Registering authorities should ask an applicant for registration to provide details of any previous criminal convictions. We plan to strengthen that by requiring applicants to declare previous criminal convictions when the regulations made under the Registered Homes Act 1984 are next revised.

That appears to be progress. It is clear that hon. Members and many people outside the House do not understand why there are different criteria—that which applies to children's homes and those who work in them and that which applies to the elderly and the handicapped. They are all vulnerable groups and they need protection. I hope that what the Minister has said will be enacted quickly.

I am most sympathetic to what the hon. Gentleman has said. We are already having discussions with the Home Office. He will be aware that work has started to ensure that criminal records are available for those in the public sector who look after children. There is a new development in voluntary child care, which will be an additional area of activity.

My hon. Friend knows that anxiety about criminal records is felt on both sides of the House. Does she agree that a valuable step in controlling that sort of abuse will come from both the operation of contracts and the work of care managers? Does she further agree that if that is done properly it should make a big difference?

I am grateful to my hon. Friend, who is knowledgeable about these matters. There is no doubt that our community care proposals will enhance the safeguards for individuals who are the subjects of community care—not only the contracts, but making complaints procedures freely available. Those additional safeguards for the frail and the vulnerable, whom we all seek to help, have been written into the Bill.

Is the Minister aware of the case of Olive Wareing, who is in prison for the latest in a string of criminal convictions against elderly people in her care in old people's homes? Does the Minister share my concern that when Olive Wareing leaves prison she can set up an old people's home again and avoid registration provided that there are fewer than three residents in her care? Will the Minister act to plug that dangerous loophole in the law?

The hon. Lady frequently mentions names in her questions. The name in the minds of many Conservative Members is Nye Bevan lodge. Whether in the public or the private sectors, standards must be maintained and protected. As the hon. Lady well knows, during our discussions on the Bill we sought to find a way to introduce controls over smaller homes which did not come within the scope of the Bill. We have made it clear that we are seeking a legislative opportunity to ensure that there is some control over the smaller residential homes.

May I refer my hon. Friend to the report that the Select Committee on Home Affairs published last week about the National Identification Bureau? The report makes a number of recommendations to improve the availability of criminal records, which is rather haphazard at present—there certainly seems to be no uniform policy. No doubt my hon. Friend will wish to discuss with my right hon. and learned Friend the Home Secretary just how those proposals could help to monitor those who have access to individuals, whether through care homes or in any other part of the Health Service, particularly those dealing with children and elderly people? Will she also take care to ensure that, whatever standards are set, the private sector is not discriminated against?

I thank my hon. Friend for his question. I shall certainly study the report to see what further progress can be made. Those responsible for frail and vulnerable people are concerned that such people should be protected. Those responsible for them are in a position of trust. I fully endorse my hon. Friends comments. We seek a mixed economy of care whether in the private, public or voluntary sector. We want high standards of care, with dignity and choice for the elderly.

Nhs Reform

4.

To ask the Secretary of State for Health what are the total estimated costs of the opting-out submissions made for the National Health Service hospitals; and if he will make a statement.

Applications for NHS trust status will not be invited until Parliament has given approval to the necessary legislation. We have made no estimate of the cost of preparing such applications.

Does the Secretary of Health accept that people will regard it as an outrage if a single pound is spent on opting-out submissions, particularly in areas such as Bradford, which has the highest infant mortality rate in the Yorkshire region. If the Minister is so confident about the opting-out process as the first step to towards privatisation, why does he not hold a ballot in Bradford and other areas? Why does he collaborate with serville administrators who are the enemy within the National Health Service led by the Minister as chief saboteur?

I have no doubt that the hon. Gentleman will try to get the public to feel a sense of outrage about almost anything that happens in the Health Service in Bradford, but I do not recognise his description of current events. I am pleased that he has turned his mind to the possible deficiencies and weaknesses in the standard of care provided in Bradford at the moment. I hope that he will give his support to all those local people in Bradford who want to address them and that he will support anybody in Bradford who thinks that being given more local control over how they tackle the problems might improve things.

Does my right hon. and learned Friend agree that none of the real benefits of self-governing trust status will materialise without a clear commitment for regional health authorities to produce speedy and workable plans for weighted capitation? Will he give them a clear message that there must be no room for backsliding or fudging because money travelling with the patient is the essence of those reforms?

We are committed to ensuring that money is placed in the hands of the districts according to the number of their population adjusted for the age and propensity to sickness of that population. We will have to phase in progress to that end to make sure that there is no disruption of the system. However, I can assure my hon. Friend that as from next year, districts such as his own will receive funds on the basis of what they are now spending on their service—which, not surprisingly, is the basis of the present allocation. I am pleased to hear that in Hertfordshire people are now considering how they could use that money to improve the service further. I am sure that GPs, patients and others will be thinking about how to use the funds allocated to them on the new basis.

Is the Secretary of State aware that in Leeds, West, where the community health council balloted the staff at the Leeds General infirmary on proposals for opting out, nine out of 10 voted against the proposals? Now that the proposals have been widened to include other hospitals and institutions in Leeds, West, and detailed plans have been put forward, will he assure me and the House that there will be a full ballot of staff and people in the area before those proposals are taken a step further?

If the staff are given a description of NHS trust status which makes their blood run cold and their hair stand on end, one tends to find that in a subsequent ballot nine out of 10 say that they are against it. Ballots of that kind remind me of "Beyond the Fringe", many years ago, in which one of those who took part said that when they balloted people on whether they wanted their wives and kiddies fried to a frizzle in a nuclear holocaust 90 per cent. said no, 5 per cent. said yes, and 5 per cent. did not know. Such ballots do not add to public understanding of our Health Service reforms.

Would it not be a helpful if the first task of the newly recruited public relations adviser to my right hon. and learned Friend the Secretary of State were to take steps to persuade the general public and, apparently, some Members of Parliament that the term "opting out" is a misnomer and that in no circumstances will hospitals which choose to take part, be operating outside the National Health Service?

I do not have a public relations adviser and I do not intend to have one. [HON. MEMBERS: "Why not?"] I shall continue to tackle the problem of explaining the NHS reforms to the public myself. The difficulty, which is not encountered in the commercial world is that the public are constantly being given counter-explanations by those who make sensational statements about opting out and what it might mean. When we come to the reality and people can look at local plans put forward by local doctors, nurses and managers, we can have a sensible debate about what NHS trust status might do to improve the Health Service in many areas, including possilbly Bradford and Leeds.

Hospital Closures, Sheffield

5.

To ask the Secretary of State for Health when he next expects to meet the chairman of Trent regional health authority to discuss hospital closures in Sheffield.

Ministers will meet the chairman of all the English regional health authorities, including Trent, at the next regional meeting in May.

When Ministers meet the chairman will they ask him how he defends Sheffield's preferred overall pattern of acute hospital services for the future, which does not take into account bed requirements and will undoubtedly lead to the closure of two support hospitals? Will the Minister also ask the chairman about future demand for beds for the elderly and the possibility of future major accidents?

As my right hon. and learned Friend the Secretary of State has said, from next year we shall begin the process of funding district health authorities on the basis of weighted capitation. Therefore, over a period of years there will be a fair allocation between different parts of the country—for example, between Sheffield and Sevenoaks. As I understand it, there are not yet any formal proposals for Sheffield. There is merely a plan. I assure the hon. Gentleman that if specific proposals are made, to which the community health council has objections, and if those objections are maintained by the regional health authority, the proposals will be brought to Ministers and the hon. Gentleman will have a chance to put his view directly.

Will my hon. Friend confirm that the revenue of Trent regional health authority has once again increased faster than inflation? Would he care to compare that with what happened to the health authority under the Labour Government?

I am grateful to my hon. Friend for reminding the House that the total increase for hospital services in the current year is about 8·5 per cent. in cash terms. In real terms the increase in funding for the National Health Service in the past 10 years is about 40 per cent. Every region in the country has benefited from increased expenditure this year. Every region has benefited from a real terms increase.

Community Care

6.

To ask the Secretary of State for Health what representations he has received regarding the funding arrangements for local authority community care.

We have received many representations about the new arrangements for funding community care outlined in our White Paper "Caring for People".

Is the Minister satisfied that the concept of community care is being implemented in our communities when local government is suffering from the imposition of the poll tax and in many instances bizarre calculations of the standard spending assessment have been made? The SSAs do not take into account local needs in areas with large numbers of elderly people. Elderly people have particular problems in terms of mental illness. Is the Minister aware that in some areas local hospitals have had to turn away people with mental problems who need mental care because the facilities for them are not adequate due to lack of funding? Will the Minister ensure that the necessary funding and commitment is given? We want action and results, not promises.

Many local authorities are making good progress in drawing up their plans for care in the community. We are having discussions with the local authority associations about the precise nature of the funding which will be required when those plans come into effect.

Is my hon. Friend aware that Inward, which does admirable work in my constituency for ex-drug users, is worried about the new funding rate? I have written to my hon. Friend today about that. Can she do something to ensure that the valuable and unglamorous work that that organisation does is not in any way frustrated?

I should like to reassure my hon. Friend that many voluntary organisations which over many years have had a precarious financial base, will have their position safeguarded under the community care plans. Not only will the district health authority have to look to the health needs of the local population, but the local authority, in drawing up its community care plans, will need to see how especially needy groups can have their needs met. If my hon. Friend has any further difficulties, no doubt we can discuss the matter further.

Will the Minister list for the House those organisations which support the Goverments's stance not to ring-fence money for community care?

I am unable to list them at this moment, but I will let the hon. Gentleman have a reply. The key point about ring fencing is that it essentially undermines local accountability. I hope that the hon. Gentleman wants to see that the money set aside for community care is put to good effect. Local authorities have well safeguarded their personal social services spending over the years. It has risen by 38 per cent. I do not believe that one needs to undermine the basic principle of local Government accountability to achieve the end that we both share.

Nurses And Midwives

7.

To ask the Secretary of State for Health how many nurses and midwives there are in the National Health Service now; and how many there were in 1979.

At 30 September 1988, there were 403,900 whole-time equivalent nursing and midwifery staff in the National Health Service in England. The comparable figure for September 1979 was 358,400 whole-time equivalents. That is an increase of 12·7 per cent. The increase in qualified staff over the same period was 26 per cent.

Does my hon. Friend agree that, once again, those figures nail the lie that the Government are making cuts in the National Health Service? Is it not also a fact that since 1979 the average nurse's pay has risen by about 43 per cent. in real terms?

My hon. Friend, as ever, is extremely well informed. I can confirm those figures. Once again, they are a clear indication of the Government's support for the Health Service. I can inform my hon. Friend further that in inner London, for example, a top-grade sister is now earning £17,000—50 per cent. more than she would have done 10 years ago.

Does the Minister recall her own parliamentary answers to me which showed that there was a bigger increase in the number of nurses and doctors in five years of the previous Labour Government than there has been in 10 years of this Government? Is not the achievement on which she is inviting the House to congratulate the Government the achievement of having managed to more than halve the rates of increase in both professions?

I find it surprising that the hon. Gentleman should wish to draw attention to his own record in Government when those very nurses—my hon. Friend the Member for Luton, South (Mr. Bright) referred to their considerable pay increase of 43 per cent.—saw their pay fall by 21 per cent. under the Labour Government.

Day Patients

8.

To ask the Secretary of State for Health what is the number of day patients being treated annually by the National Health Service; and how many were treated in 1979.

Between 1979 and 1988–89 there was an increase in day-case admissions for England—from about 600,000 to just over 1 million, representing a 70 per cent. increase.

I am grateful to my hon. Friend for that answer. Is he aware that in the Kingston and Esher district health authority, which covers part of my constituency, the increase has been getting even better? During the past two years, the surgical day unit has treated 20 per cent. more patients, and last year it dealt with 5,431 patients. Is that not a sign of increasing efficiency in the unit which bodes well for the work of the NHS trust project team?

I am grateful to my hon. Friend. An increase in day surgery is good for patients because they appreciate the chance to have their operations done more quickly and perhaps less invasively, and it is good for the National Health Service because the resources needed to care for the patient coming in for day surgery are clearly fewer. Many hon. Members and their families may have cause to be thankful for day surgery in the coming years—especially, for example, for cataracts, grommets for their children or female sterilisation, three operations now performed by day surgery but which hitherto required a long in-patient stay.

Does my hon. Friend accept that day care represents a cost-effective way of delivering more care to more patients more quickly, provided only—perhaps my hon. Friend can confirm that this is so—that there has been no decrease, but rather an increase, in the number of patients who have been admitted to hospital for operations and other treatment?

I give my hon. Friend that assurance. There has been an improvement in day surgery figures and out-patients and ward attenders—those who go to a ward for minor surgical treatment—have also increased in number, as have in-patients coming in for longer stays. The average length of stay is decreasing, and that is good for patients and for the National Health Service.

Internal Contracts

9.

To ask the Secretary of State for Health whether the National Health Service has any experience of the use of internal contracts.

15.

To ask the Secretary of State for Health what experience there has been of internal contracts within the National Health Service.

The recent document "Contracts for Health Services: Operating Contracts", which is in the Library, contains examples of contracts between NHS bodies. Most come from various district health authority pilot projects supported by my Department to prepare for the implementation of our reforms of the National Health Service. They demonstrate how contracts will benefit patients by specifying the services and quality of care to be provided.

I am grateful to my right hon. and learned Friend for his reply. As most health authorities have experience of internal contracts, is not it nonsense to suggest that the schemes are untested? Will my right hon. and learned Friend assure the House that he will not delay his reforms until all the pilot schemes have been implemented?

A clear majority of authorities have experience of contracting with various bodies; the figure is well over 60 per cent. There are some established and running internal contracts. For example, the contract between Harefield hospital and South Glamorgan, has run without controversy for some time. I agree with my hon. Friend that we must continue to pilot contracting by continuing to finance the work being undertaken at present so that we can be ready by April next year. There is no case for delay because active preparation is well advanced.

But does my right hon. and learned Friend accept that the National Health Service is not necessarily the swiftest organisation to take on board new ideas and bring them into practice? A number of authorities are slightly concerned that a blockbuster approach may be used. Does my right hon. and learned Friend agree that a simple and more evolutionary approach would be better in the introduction of this method, and would benefit patients?

I agree with my hon. Friend, and I reassure him that we have been urging a simple and evolutionary approach on health authorities since last summer. We expect the majority of health authorities to begin with block contracts with straightforward specifications of what they want. We envisage that health authorities, hospitals and GPs will begin by getting their existing pattern of referral of patients in place within the contract system. Thereafter, they will know what they will spend on each part of the service and what quality they are getting and they can work together to make the system more sophisticated and improve the quality of care that they give to patients.

Does the Secretary of State accept that the National Health Service is far too important for the same mess to be made of it as the Government have made with the poll tax? Before he spends one penny on training staff, will he ensure that the public have the chance to have their say through the ballot box, or is he frightened of democracy?

I certainly agree that the National Health Service is far too important for us to make a mess of reforms intended to improve it, although I do not accept the hon. Gentleman's comparison. We certainly do riot intend to make a mess of the National Health Service reforms. The answer lies in the supplementary question asked by my hon. Friend the Member for Hertfordshire, South-West (Mr. Page). There will not be a sudden transformation of the world next April or a blockbuster change to the system. We shall have improvements for which everyone has worked and prepared. Thereafter, we shall see steady improvements throughout the 1990s, as the benefits of better management work their way into the service and we concentrate on quality.

I am all in favour of consulting at every stage—for example, over the National Health Service trusts—but I do not think that the rather foolish local ballots being organised by the trade unions and the Labour party are helping to explain the issues or allay public concern.

Does the Secretary of State agree that if he is to push ahead with the contracts, everybody will want to judge how well they are operating, and that a key factor in making that judgment will be the flow of information available which will depend heavily on the ability of hospitals and health authorities to introduce proper and full computerisation? Will the right hon. and learned Gentleman therefore pay heed to the point that I have raised with him before—that many people in the National Health Service are saying that the money and time required to computerise to the level of sophistication necessary to monitor the system and make it work as the Government want it to are not available?

I hope that the hon. Gentleman will agree that the Health Service needs to be computerised and that it needs information systems to enable everyone concerned to run it better. That would have been needed whether or not we reformed the Health Service and it will take some years to achieve a good up-to-date level of information systems.

However, I do not accept that we cannot start the process of reform until we have completed that investment. The experience of contracting was not based on modern information systems. We are allocating a lot of money to update those systems, but we can begin with the basic contracting system next year on the basis of the information that we already have. We can start it simple and then sophisticate it afterwards as the information systems come along.

Royal Colleges Of Medicine

10.

To ask the Secretary of State for Health when he last met representatives of the royal colleges of medicine; and what matters were discussed.

On 4 April, I met representatives of the medical royal colleges along with representatives from the dental, midwifery and nursing royal colleges to discuss ways of safeguarding and securing improvements in clinical standards for National Health Service patients after the introduction of our NHS reforms in April next year.

Does my right hon. and learned Friend recall that he dug the first turf at the new general hospital in Bury a few years ago, thereby demonstrating his and the Government's commitment to high quality and good service in the NHS? When does he think that the royal colleges will finally realise that that same determination for quality and service runs through the health reforms that my right hon. and learned Friend is pursuing? When does he think that they will finally welcome some of the quality initiatives that we have taken instead of being so keen to criticise?

I well remember turning the first sod in my hon. Friend's constituency and I still have the spade in my study to remind me of that happy event. I am delighted that that new hospital is now operational.

With regard to quality, I accept that the royal colleges still have some concerns about the impact on clinical standards although I do not believe that those concerns are well founded. For that reason, I have been having a dialogue with all the royal colleges and I want them to make a positive contribution by helping to monitor clinical standards in the improved NHS in the 1990s. I detect a preparedness on the part of the royal colleges to contemplate that and a willingness to reach agreement if we can.

As the royal colleges have expressed some concern about opting out, should not they be told by the Secretary of State that a referendum was organised in my borough by the local council with questions that were approved by the local health authority and that more than 78 per cent. said that they were against opting out? If there were referendums in other parts of the country, is not it clear that the results would be the same? That is why the Secretary of State is so hostile to balloting and why he is so fearful of people being able to express their views. All the public relations advisors in the world will not be able to sell that idea to the British public.

The Labour party is quite bereft of any contribution to the debate on National Health Service reforms. Labour prefers to publicise ill-founded fears about what might occur and then carry out ballots afterwards like a lot of demented amateur Gallup pollsters. That is not a sensible approach to NHS reforms.

How does my right hon. and learned Friend equate his remarks in respect of the National Health Service and Community Care Bill with remarks made yesterday by my hon. Friend the Under-Secretary of State for Health to people from MIND when he said that hundreds of mentally ill patients have been dumped on the streets and that he is determined to give those people a new deal? Will my right hon. and learned Friend the Secretary of State tell us how the Government are going to give a new deal to those hundreds of mentally ill people who have been dumped on the streets because of a lack of places in appropriate hospitals?

My hon. Friend the Under-Secretary of State for Health used slightly different language and a slightly more analytical approach to a serious problem about which I know my hon. Friend the Member for Macclesfield (Mr. Winterton) feels strongly. As my hon. Friend the Under-Secretary said yesterday, he has put a great deal of work into preparing an initiative on that subject because we all know that mentally ill patients have fallen through the net and become homeless in London. When my hon. Friend the Under-Secretary is ready with the details, he will announce what I believe will be an extremely valuable new initiative to tackle that serious problem.

I congratulate the Secretary of State on having achieved unity among the royal colleges for the first time in the 40-year history of the NHS. Did he see their joint statement in the week he met them in which they concluded that there was no evidence that his changes will improve the standard of care, access to care, choice of care or even the cost-effectiveness of care? Why do Ministers persist in thinking that more than 20 colleges have got it wrong and that only they have got it right?

The hon. Gentleman should stop taking questions from my Parliamentary Private Secretary and answering them. The hon. Gentleman knows perfectly well that the royal colleges support the vast bulk of what we are doing, including the introduction of the resource management initiative and the introduction of clinical audit, in which the royal colleges are playing a leading role. I have already recognised that they still have some concerns about the consequences of the reforms, but at my meeting it was clear that the royal colleges wish to reach agreement with the Government on how standards can be monitored and supervised after we introduce the reforms next year.

Clinical Standards

11.

To ask the Secretary of State for Health if he will make a statement on his Department's proposals for future monitoring of clinical standards in the National Health Service and the terms of reference of any monitoring agency.

On 4 April, I invited the presidents of the dental, medical, midwifery and nursing royal colleges for talks on the assessment of clinical standards for National Health Service patients after the proposals in the National Health Service and Community Care Bill are implemented. I put forward ideas for setting up a national multi-professional clinical standards advisory group. That was broadly welcomed by the professions, but further discussions will be needed on the way in which such a group might operate.

I thank my right hon. and learned Friend for that answer. Will he confirm that he and the Department are most enthusiastic about the new proposal and getting the system right? Will he say a little more about the composition of the advisory group? It will be of critical importance in reassuring all opinion—lay and medical—that the standards will e properly monitored.

I am grateful to my hon. Friend because, in broad terms, his reaction is the same as that of the presidents of the medical, nursing and dental colleges. We all agreed that we need more talks about how such a system might work, be financed and so on. On the whole, the composition of any group would need to be determined by the medical, nursing and dental royal colleges, and comprise representatives from all the professions to work on a multi-disciplinary basis.

Is my right hon. and learned Friend aware that perhaps we could learn a lesson from the United States, where peer review organisations examine about one in four operations and determine whether it was necessary in the first place, at what cost it was done and how successful it was? Such detail is more likely to result in patient satisfaction than some overall national body.

I do not envisage a national body taking over the detailed operation of local services. I envisage a national body that will be available as a source of advice if people encounter local difficulties. I agree with my hon. Friend that we require what I call systematic quality control, which is usually described as audit control. We are drawing on American experience, but the royal colleges and the Government would like an even better system introduced in all branches of the National Health Service.

On the monitoring of the health of any community, will not the Secretary of State admit that family practitioner committees are extremely worried about the lack of morbidity statistics in terms of their ability to play a constructive role—if that is not a contradiction in terms—in how the NHS reforms are now being applied?

We have morbidity statistics. I have not had representations from English medical practitioner committees about the inadequacy of the statistics, but I shall certainly make inquiries to see whether the federation believes that it is a problem or whether there is a particular problem in Wales.

General Practitioners

12.

To ask the Secretary of State for Health what is the number of general practitioners in the National Health Service now; and what it was in 1979.

At 1 October 1988 there were 25,322 GPs in England. That compares with 21,357 at 1 October 1979, an increase of 18·6 per cent.

Bearing in mind the substantial increase in the number of GPs and the fact that our population is static, will my hon. Friend explain why some doctors believe that service to patients will reduce because list sizes will increase?

I am quite unable to explain it. As my hon. Friend rightly says, the population remains static. There are more GPs joining the lists each year and we have seen lists come below 2,000 for the first time. That is a major achievement and it leads to better patient care.

Mental Handicap

13.

To ask the Secretary of State for Health if he will bring forward proposals to improve the availability and quality of day care services for the mentally handicapped.

Local authorities are primarily responsible for providing day services for mentally handicapped people. The recent social services inspectorate report, "Inspection of Day Services for People with a Mental Handicap", suggested a number of ways in which day services could be improved within existing resources.

Because of the haste to close mental handicap hospitals and discharge mentally handicapped people, because of the problems facing local authorities—with restrictions on financing and the fact that the money allowed to them is not ring-fenced and there is no guarantee that there will be a sufficient increase to allow for inflation—and because every pound spent above the level of assessment set by the Government under the poll tax arrangements for services for the mentally handicapped means a £4 increase in the poll tax, when does the Minister intend to do something to provide real services for the mentally handicapped?

There is no rush to close mental handicap hospitals. The closure programme and the discharge of patients back into the community from mental handicap hospitals is relatively slow. As for the transfer of resources from the Health Service to local authorities for patients discharged, we are looking at the future of joint finance—of finance passing from the Department of Health to the Department of the Environment—and we shall bring to the House in due course our proposals for ensuring adequate funding for such patients.

Prime Minister

Engagements

Q1.

To ask the Prime Minister if she will list her official engagements for Tuesday 1 May.

This morning I had meetings with ministerial colleagues and others. In addition to my duties in the House, I shall be having further meetings later today.

Does the Prime Minister accept responsibility for the chaos and confusion at the heart of Government over the poll tax? Does not she owe it to the House and the people before they vote on Thursday to give a straight answer to a straight question? What, precisely, is she going to do about the poll tax?

Had the hon. Gentleman read he Official Report of the debate we had on that subject last week, he would have known the answer. We are looking to see whether any adjustments need to be made to the community charge for next year. Some of those were indicated in the debate, and there is no surprise about it. When one goes from a rate tax to a community charge, adjustments will, of course, need to be made, and we are looking to see which ones need to be made for next year—[Interruption.] If there is any confusion or any high rates, that is in the minds of Labour local authorities. High community charges are due to local Labour councils. Most councils have got out their charges with the rebates and the traditional relief included in them.

Q2.

To ask the Prime Minister if she will list her official engagements for Tuesday 1 May.

I refer my hon. Friend to the reply that I gave some moments ago.

Does my right hon. Friend agree that it would be wrong for a local authority to cave in to threats of a politically motivated strike, particularly to secure the reinstatement of a leading member of Class War who hailed the Trafalgar square rioters as heroes?

Yes, I agree with my hon. Friend. I understand that Hackney suspended a person who hailed the Trafalgar square rioters as heroes, that the National and Local Government Officers Association threatened to go on strike and that Hackney then caved in. That tells us a lot about the people whom Hackney employs, a lot about NALGO and a lot about what life would be like under Labour.

Will the Prime Minister tell us now, is she or is she not going to introduce legislation to change the poll tax in this Session of Parliament?

When we have a statement to make we shall make it—[Interruption.]—and it will be far more detailed and thorough than any statement we hear from the right hon. Gentleman about roof tax.

Does the Prime Minister recall telling me just a few short weeks ago that she thought:

"The community charge will he very popular?"—[Official Report, 22 March 1990; Vol. 169, c. 1231.]
Does she still believe that, and if she does, why is she sending her Ministers off in every direction, desperately searching for an escape route from the poll tax?

The community charge is a much fairer charge than rates—[Interruption.]

—and a far fairer charge than the alternative roof tax. I notice that when the right hon. Gentleman gave an interview to The Independent on 21 April, it stated that Mr. Kinnock—[Interruption.]

Order. The Prime Minister was asked a question. She must be given a chance to answer.

It stated:

"Mr. Kinnock then gave a strong indication of his own thinking. He said 'the tax base for rates was imputed rents and that's one thing we can take into account now and bung into the computer.'"
Does not he know the old computer saying, "Garbage in, garbage out"?

Cannot the Prime Minister understand what just about everybody in the country now understands —that the poll tax will never be fair? It cannot be amended; it must be got rid of, even if that means that the Prime Minister goes down with her own flagship.

Cannot the right hon. Gentleman understand that domestic rates have been abolished; that they were a most unfair tax; and that the enemy is not the community charge, but the high-spending Labour councils?

Does my right hon. Friend agree that as only 19 million people paid the rates and 36 million people will now pay towards community services, the community charge is already infinitely fairer for over half the adult population?

Yes, my hon. Friend is correct. I noticed that in a recent poll over 70 per cent. of people thought that everyone should make some contribution to local authority spending. That is precisely what the community charge does, with more generous rebates than have ever been given before and with generous rebates for transitional relief. It is a much fairer tax than either the rates or the roof tax.

Is banding of the poll tax one of the adjustments that the Prime Minister has in mind, so that people can pay on the basis of their ability to pay, or is the Prime Minister opposed to that in principle? Or are there practical arguments, in which case perhaps she will enumerate them to us?

Those who cannot afford to pay get generous community charge rebates—far more generous than ever before. Some 9 million people will benefit from them. Those who have a sharp difference between the old rates and the community charge are eligible for transitional relief. That applies to some 7 million people. The people who do not get sufficient transitional relief live in the areas of high-spending labour councils, which care nought for their citizens but are more anxious to dig their hands deeply into their citizens' pockets. People who are better off pay far more to local services because the taxpayer is the greatest contributor to local authority spending. The top 10 per cent. of income earners pay 40 per cent. of the income tax yield and therefore pay more for local services than the people in the bottom 10 per cent.

Q3.

To ask the Prime Minister if she will list her official engagements for Tuesday 1 May.

During her busy day, will my right hon. Friend spare a moment to commend Medway city council on setting the lowest community charge in Kent? Will she list the five local authorities that have the worst education record, the largest number of empty council houses and the highest rent arrears?

I gladly pay tribute to the eficient Conservative authority in Medway.

With regard to my hon. Friend's question about the five worst education authorities and so on, I am sure that the House is avidly waiting to hear my reply. The five councils with the worst education results are Knowsley—[HON. MEMBERS: "Labour."]; Waltham Forest—[HON. MEMBERS: "Labour."]; Barking—[HON. MEMBERS: "Labour."]; Newham—[HON. MEMBERS: "Labour."]; and Sandwell—[HON. MEMBERS: "Labour."].

The five authorities which have most empty council houses are Manchester—[HON. MEMBERS: "Labour."]; Liverpool—[HON. MEMBERS: "Labour."]; Sheffield—[HON. MEMBERS: "Labour."]; Salford—[HON. MEMBERS: "Labour."]; and Birmingham—[HON. MEMBERS: "Labour."]. Between them, those Labour-controlled authorities have more than 20,000 empty houses.

The five authorities with the highest rent arrears are Southwark—[HON. MEMBERS: "Labour."]; Lambeth—[HON. MEMBERS: "Labour."]; Liverpool—[HON. MEMBERS: "Labour."]; Brent—[HON. MEMBERS: "Labour."]; and Islington—[HON. MEMBERS: "Labour."]. Between them, those authorities are owed £86 million in uncollected rents.

Q4.

To ask the Prime Minister if she will list her official engagements for Tuesday 1 May.

I refer the hon. Gentleman to the reply that I gave some moments ago.

Is the Prime Minister aware of the many thousands of people in the United Kingdom who have been discriminated against because of a hostile interpretation of rules governing concessionary television licences for the elderly and the disabled? Although they live in identical circumstances, because of the regulations they are being denied what is rightfully theirs. In the twilight of the Prime Minister's premiership, will she now find it within her heart to instruct her Ministers to give to retired people that which is equal and just?

I am not aware of any discrimination in interpreting the regulations. Interpreting the regulations is a matter for the Department concerned and I am sure that if people are entitled to receive a concessionary licence they will do so.

Is my right hon. Friend aware that 6,000 people in Ealing have been sent bills for the full community charge, regardless of their rebate applications? Some of those people are pensioners and students who are entitled to pay only one fifth—£87—but instead are being required to pay £435 by Ealing's Labour council, which will not process their rebate applications until after the local elections next Thursday. Is not that another wicked Labour con trick?

I agree with my hon. Friend. Most local authorities have been thoughtful enough of their residents to deduct the community charge relief and the transitional relief from the bills, so that they do not raise needless fears. That is naturally good administration. If there are any who have not done it, it is bad administration and demonstrates sheer lack of consideration for their own citizens.

Q5.

To ask the Prime Minister if she will list her official engagements for Tuesday 1 May.

I refer the hon. Gentleman to the reply that I gave some moments ago.

Does the Prime Minister recall those heady days when she described the poll tax as her flagship? Now that Thursday's election torpedo is fast approaching, despite the captain's apparent order to change course, does she recall the fate of another flagship, the Belgrano?

The hon. Gentleman could have done rather better than that.

As regards the community charge in Scotland, where it has operated for a considerable time, far more councils are now either holding the charge or reducing it. Accountability in Scotland is at last beginning to work, as this year councils know that they cannot blame increases on anyone but themselves.