What proposals he has to promote the benefits of telemedicine in the NHS. [29313]

Telemedicine means harnessing the latest in information technology so as to benefit patients. X-rays and scans can be examined by specialists hundreds of miles away from the patient. Hospitals can send test results to general practitioners and GPs can send patient information to specialists. All this is to provide even higher quality treatment for patients. That is why we are developing telemedicine.

Is the Secretary of State taking Question 15 with Question 1?

I understood, Madam Speaker, that Question 15 had been withdrawn.

No. The hon. Member for Burnley (Mr. Pike) is in his place. We can take the two questions together.

In that case, with the permission of the House, I should like to take Question 15 with Question 1.

My pleasure.

To ask the Secretary of State for Health what proposals he has to promote the benefits of telemedicine in the NHS.

Does my right hon. Friend agree that, for a truly modern and dependable health service, we should make better use of information technology? For instance, would it not be a good idea for general practitioners to have such technology at their fingertips so that patients could then and there be booked into hospital out-patient appointments? Will my right hon. Friend consider such a scheme?

That is certainly something that we aim for. We think that a great deal of people's frustration with the health service is having to go to their general practitioners and then having to wait for an out-patient's appointment to be made. By using information technology, it should in future be possible for people to have an appointment made there and then at the GP's premises. If people then go to an out-patient department, an in-patient appointment could be made in the same way.

I can assure my right hon. Friend that I had no intention of withdrawing Question 15.

That is indeed the case. Information technology in the health service is unsatisfactory at present and needs substantially to be improved. I can say from experience within my constituency at the national hospital for neurology and neurosurgery that, if a patient has something wrong with his brain, the authorities flash the scan over to Paris where a professor, who is the world's expert, can examine the scan at the same time as the staff at Queen square, WC1. That is immensely to the benefit of patients, and we want that sort of idea to spread.

Excited as I am by information technology, I am sure that the Secretary of State will recognise that the key feature is not the technology but what it can do. Will the right hon. Gentleman continue to ensure that technology is used to the fullest extent to devolve the health service to small general practitioner practices in rural areas and, ultimately, even to the home, so that people may get a fairly instant reaction to injuries that they have sustained? The beauty of the internet, combined with the NHS network, is that we can obtain access to expert information rapidly. That can transform the rather bureaucratic and centre-driven aspects of the national health service.

The hon. Gentleman has made a good series of points, which I take on board. We are to introduce NHS direct, and we are running pilot schemes from 1 April. We intend to have a scheme covering the entire country. People will be able to ring in to talk about their condition and receive advice from a nurse-organised help line. We believe that that will be effective and popular.

The right hon. Gentleman will know that the year 2000 problems that his Department is tackling will take up virtually the whole of his IT budget. He has set out in the White Paper details of NHS direct and the other schemes about which he has just told the House, which are all desirable and which the Opposition strongly support. However, will he look carefully at the resources available for information technology within the NHS and talk urgently to the Treasury about additional funds, which will be necessary to do all the things that he wants to do and the whole House wants him to do?

We hope that, over a period of time, the national health service will get all the resources that it needs to do its job properly, including resources for information technology. The present state of information technology in the NHS is deplorable and it will take a long time and a lot of money to put right.

If he will make a statement on dental services in Shropshire. [29314]

Shropshire is an area where we have inherited local difficulties of access to national health service dentistry. Shropshire health authority has submitted eight proposals under the investing in dentistry scheme. One has already been approved at a cost of £45,000.

NHS dentistry is not available to any new patients in Oswestry and, although the new schemes are welcome, they are many miles away. What action will the Minister take this afternoon for the 10,000 to 20,000 people who are estimated by the local heath authority to be on lists for NHS dentistry treatment?

The one thing that I did not bring with me today was my cheque book. I assure the hon. Gentleman that all the proposals received from his area are being considered seriously. In some ways, he wins the award for bare-faced cheek, as it was his Government who ran down NHS dentistry in the first place, not just in Shropshire but throughout the country. This Government will build it up again.

If he will make a statement on progress towards implementing the EC directive on tobacco advertising. [29315]

A common position was agreed on 4 December at the Health Council and was formally adopted on 12 February at the Research Council. The text will now be considered by the European Parliament and the Government will continue to work hard to achieve final adoption of that important and long-awaited legislation.

Is it not the case that that historic agreement would not have been achieved without the British vote? Will my hon. Friend join me in congratulating Birmingham health authority on its public health policy of a smoke-free city, particularly its half a million annual expenditure programme targeting both young and adult smokers? Will she also congratulate Birmingham on achieving a 50 per cent. increase in the number of calls to the national quit smoking line this year alone?

I am happy to congratulate Birmingham on its efforts to reduce smoking. Birmingham sets a clear example and the Government will build on the experience of such cities in taking action across a range of areas to combat smoking. We shall publish our plans in a White Paper later this year. Birmingham is a smoke-free city; it is an extremely good model for combating the harm done by smoking in public places. However, it is clear that a ban on tobacco advertising must be central to all our efforts to protect children from the pernicious effects of tobacco manufacturers' efforts to recruit them to smoking and to get them to take up an addictive habit that will only do them harm.

Is not the high cost of tobacco one of the most effective deterrents to smoking? What discussions has the Minister had with her fellow Ministers in the Health Council about raising the excise duty on tobacco in other European countries so that bootleggers and smugglers can no longer undercut our high taxation policy by selling cheap tobacco to youngsters?

I agree with the hon. Lady that maintaining the high cost of tobacco is an important part of combating consumption, particularly among children. My right hon. Friend the Chancellor is aware of that and has raised the matter with other European Finance Ministers. He has also taken a lead in setting up tough action to combat fraud and smuggling.

While my hon. Friend's statement about a ban on tobacco advertising in Europe is welcome, is it not a serious contradiction, given that the European Union spends some 1 billion European currency units on subsidising tobacco that cannot be sold elsewhere because it is of such a low quality? Will my hon. Friend make every effort in the European Council to end that serious situation? On the one hand, we are trying to reduce smoking but, on the other, taxpayers' money is subsidising tobacco production.

Yes, that is a contradiction. I shall raise the matter with other European Health Ministers, just as my right hon. Friend the Minister of Agriculture, Fisheries and Food has expressed the Government's concern in the Agriculture Council.

Is the Minister aware of the considerable disparity between the revenue raised by the Chancellor through tobacco sales and the low priority given to resources for health promotion? The two figures do not bear comparison. As well as driving forward the agenda to secure an EEC directive, does she recognise the need to promote health among young people? They should not start smoking, but, if they have, they should be encouraged to stop.

My right hon. Friend the Chancellor shares with my right hon. Friend the Secretary of State and Ministers across Government a determination to reduce both the rate at which children take up smoking and tobacco consumption. Smoking costs the national health service £1.4 billion every year. We are determined to reduce that figure by cutting consumption. I remind the House of the previous Government's legacy to the children of this country: in 1992, one in four 15-year-old girls smoked; in 1997, the figure was one in three.

What steps he is taking to promote healthy styles of living among young women. [29316]

The Government's Green Paper "Our Healthier Nation" sets out a strategy for promoting healthy life styles among the whole population, including young women. We are working with the Health Education Authority and the media on initiatives to address issues that are relevant to young women, including smoking rates, alcohol consumption, sexual health and teenage pregnancy.

My hon. Friend will know that, although I welcome what she has said, after 10 months under a Labour Government, many Labour Members are a little impatient for a formidable national advertising campaign to tackle the health of young women. Will she commission the best advertising agencies in this country, which are some of the best in the world, and spend real money on an advertising campaign aimed at young women? There is an epidemic of smoking among young women, and they will later get cancer, so the message should be driven home. We have banned advertising—I fully support that—but advertising money is being shifted into product placement in films and on television. Do we not need an active campaign, sooner rather than later?

I assure my hon. Friend that we shall take action on advertising to make young women aware of the risks of smoking. I shall shortly be meeting editors of teenage magazines to raise that and other issues with them.

The hon. Lady will be aware that one in five women suffer from a mental illness, and that such illnesses cause one in four days off sick among women. I welcome the inclusion of mental health as a key area of the relaunched health strategy, and the proposal of a target similar to that in the previous health strategy. Does she agree, however, that the omission of any mention of mental health in the White Paper "The New NHS" is deplorable? Does she plan to review the Mental Health Act 1983, which would be a great help to young women and others?

I assure the right hon. Lady that we work as one Government and as one team of Health Ministers, and that mental health is indeed referred to in the White Paper. The White Paper and the Green Paper together represent the Government's strategy to improve health, to tackle inequality—that was a glaring gap in the last Government's action in relation to health—and to rebuild a modern and dependable national health service.

What new statutory duties he intends to introduce in the NHS relating to partnership. [29317]

The previous Government's policy set doctor competing against doctor and hospital competing against hospital. We believe that that was wasteful and bad for patients, and so do most of the 1 million people who work in the health service. It is better for patients when all parts of the health service work together instead of working against one another. That is why we intend to make partnership the statutory duty of every part of the national health service.

In a modern and dependable health service, should not everyone work together and learn from each other? Is he aware that, in one hospital, nurses were warned against disclosing information relating to improvements in treatment, because it might jeopardise the hospital's competitive edge? Does that not sum up the gulf between the Government's new agenda for health and the tired old dogma of the Tories?

I can confirm what my hon. Friend has said. When I had the privilege of presenting awards to nurses for nursing innovation, a number of the teams which won the awards told me that their local managements had instructed them not to disclose innovations because that might undermine the competitive edge of their hospital, as against the one down the road. When I informed the former president of the Royal College of Surgeons, he said that people performing cardiac surgery had been given the same message by some stupid managements.

What partnership deal will the Secretary of State offer the additional 54,700 people who joined the waiting lists in the last quarter, and the 1.25 million who are now on waiting lists for NHS treatment? Given that the Government started with a patients charter that still is not honoured—not everyone is receiving treatment within 18 months—and given that the early pledge to reduce waiting lists by 100,000 has turned into an early policy to increase them by 100,000, is not the only way forward to impose a statutory duty on the Secretary of State to reduce waiting lists? That might allow him to go to the Chancellor of the Exchequer to get the money to bring down waiting lists—not just to reduce them by 100,000, which is almost nothing, but to make a radical reduction in the number of people out there who are waiting for treatment in the NHS.

As I have made clear in the House many times since we took office, I told people working in the national health service that their first priority for this winter was to work together to use the extra money that we were finding to cope with the winter pressures. If that had consequences for waiting lists, I should take responsibility for giving the guidance. I do take that responsibility; equally, I am sure that we shall discharge our promise to reduce hospital waiting lists, before the next general election, to a level lower than those that we inherited.

May I draw my right hon. Friend's attention to the excellent bid for health action zone status submitted by the city of Leicester? Will he take this opportunity to congratulate the partnership that has been established by Leicestershire health authority, Leicester city council, community groups and, more recently, private business—not only on the quality of their bid, but on the progress that they have already made towards improving primary health care in very disadvantaged communities?

As my hon. Friend will know, we have received a good many bids for action zone status, and we shall be able to organise only about 10 or a dozen pilot schemes, so I cannot give any promises at the Dispatch Box. I believe that the Minister of State, my hon. Friend the Member for Darlington (Mr. Milburn), is meeting Leicestershire Members later today to discuss various matters. I certainly congratulate people working in the health service in Leicester, both in the hospital sector and in the primary community and mental health services, on the massive contribution that they have been making and on the way in which they have been working together. That should be an example to everyone.

Does the Secretary of State not realise that the existing successful partnerships on which the White Paper sought to build—fundholding practices—are successful precisely because they are voluntary? Is that not why the British Medical Association poll of general practitioners showed that less than one third believed that the changes that are outlined in the White Paper would improve the delivery of primary care, while more than half said that they would not be willing to take part in a local primary care group? Unless the right hon. Gentleman believes that shotgun marriages are the way to wedded bliss, what possible sense is there in dragooning MPs into partnerships that they have not been prepared to form voluntarily?

I suspect that the hon. Gentleman is talking about GPs rather than MPs. Frankly, I am not sure that the lot opposite would qualify even as dragoons, but we have made our position clear. We have consulted the various professions and our proposals broadly command their support. Before we implement the changes, we are consulting further on the detail, but it is entirely indicative that the Tory Front-Bench team are harking back to yesteryear. The divisions that they deliberately introduced between fundholding GPs, other GPs and hospital doctors are the way of the past; we propose a way for the future.

Are not community health councils important partners in the NHS? Will my right hon. Friend confirm that they will continue to have a key role in the health service, as mapped out in the White Paper? Is not the great strength of CHCs their ability to relate to the communities that they serve; they do not have to serve vast geographical areas? Will he confirm that that will continue? Does he expect primary care commissioning groups to work closely with CHCs?

I expect everybody to work closely with community health councils. On size, it varies from place to place. For example, Leeds, which will have the biggest health trust in the country when it is amalgamated, is covered by just one CHC. For some strange reason, the Leeds-wide community health council did not want the two trusts to merge so that it had a Leeds-wide trust. I am not quite sure whether I follow its logic, hut we value CHCs' work. As some sign of that, I believe that my visit to their annual conference last year was the first for more than a decade by a Secretary of State for Health.

What steps he is taking to improve public accountability in the NHS. [29321]

As part of our efforts to improve accountability in the NHS, I have required all health boards to meet in public, I have opened up the appointments process, I am placing a duty to co-operate on all parts of the NHS and I require every health authority to prepare a health-improvement programme for its area, in consultation with all interested local organisations.

Will my right hon. Friend take steps to end the practice whereby local health authorities blatantly mislead the public during consultation on closures or changes in the use of health facilities? Will he consider as an example what has happened in Wakefield? A few years ago, Manygates maternity hospital, where I and my children were born, was closed and the health authority gave a clear commitment to build purpose-built maternity provision at Pinderfields general hospital. Not only has that promise never been fulfilled, but there is now a proposal to remove maternity facilities completely from Wakefield. As a Yorkshireman, does he agree that it is inconceivable that people will no longer have the chance to be born in the capital of the West Riding of Yorkshire—my constituency of Wakefield?

I am not sure that I should refer to anything being inconceivable in relation to maternity services, even in Yorkshire. Certainly, one problem facing the national health service when it is trying to re-establish its reputation with local people is that there have been examples of clear promises being made—that if people went along with one closure there would be an opening to compensate, or something of that sort—which were not delivered.

One measure of accountability is the publication of waiting lists. Why does the Secretary of State think those are rising?

At the danger of sounding like the right hon. Member for South-West Surrey (Mrs. Bottomley), which I should hate to do—she has now left the Chamber having asked her question—in the last quarter for which figures were produced, the people working in the health service dealt with more emergency cases than ever before in the history of the NHS. They also dealt with more waiting list cases than in any previous third quarter of the financial year. The only trouble is that the number of people joining the list grew faster than the number being treated. We shall have to see to that, not by reducing the number joining it but by treating more.

Is not the true reason why waiting lists are rising that real increases in spending under this Government of 1.2 per cent this year and 1.5 per cent. for next are running at half the level of the past 18 years? Until the right hon. Gentleman can increase funding levels to what they were for the past 18 years, waiting lists will continue to rise. Far from redeeming his promise to reduce waiting lists by 100,000, he will watch them continue to rise at that rate for the foreseeable future.

I remind the hon. Gentleman that, when the Thatcher Government came to power, about 750,000 people were on the waiting lists. The figure did not go over a million until that Government stupidly introduced the internal market, which contributed to lengthening waiting lists. The money we are spending this year includes £300 million more than the previous Conservative Government had budgeted for this year. That £300 million has been spent to ensure that emergency and urgent cases are properly dealt with. Next year, we intend to spend £1.9 billion, which is £1.2 billion more than the previous Government put in their Budget. If he is not satisfied with spending levels, he should talk to the right hon. and learned Member for Rushcliffe (Mr. Clarke), who was responsible for deciding those things.

What proposals he has to improve working arrangements between health and social services before the report of the royal commission. [29322]

A range of measures have been put in place, including the introduction of health action zones, joint health authority and local authority investment plans and a requirement for better joint arrangements for multi-disciplinary assessments. Partnership and collaboration were also key themes in "The New NHS" White Paper and the "Our Healthier Nation" Green Paper.

I thank my hon. Friend for that answer. The Secretary of State has talked on a number of occasions of the Berlin walls between social services departments and health bodies. We have a particular problem in Gloucestershire because of a rise in the amount of bed blocking. Will my hon. Friend consider having pilot projects in advance of the royal commission to find out whether we can get a better working arrangements between social services departments and health bodies and to scrutinise how the money is being expended?

We are certainly sympathetic to pilot projects and will develop in several ways our initiative to improve working relationships between health authorities and local authorities. We started that work this winter and my hon. Friend's constituency—which has received £200,000 of extra money—is an example of how that work is being cemented. We know that health authorities and local authorities work better together. They want to work together better; we are giving them the means to do so.

Does the Minister accept that the problem of bed blocking was entirely predictable and, therefore, that the most recent round of local authority funding should have reflected the problem? Will he specifically examine the current problems in Shropshire?

The hon. Gentleman really is hoist by his own petard: Conservative Members are responsible for Shropshire's current budget. We are open to representations from any Shropshire Member—indeed, I will soon meet a Shropshire Member and a chief executive. We want—as we have done in our response to winter pressures—to underpin the relationship between local authorities and health authorities. That is a matter not only of resources but of cementing the will to work together and of providing—as we will do—the legal framework to enable them better to do so.

Does my hon. Friend share my concern that, of 38 questions on today's Order Paper, this is the only one that even obliquely refers to the work of the social work profession? Does he agree that, despite the Health Committee's recent excellent scrutiny of the subject of children in care, the crucial work of social services requires more scrutiny? Will he consult other Ministers to determine whether there are other ways in which that work can be done?

I hear what my hon. Friend says, but questions are a matter for the House and for hon. Members. I am heartened by the work of the all-party Committees, which have shown that hon. Members are very interested in social care and are determined—as Ministers are—not only to give it a higher profile but, importantly, to create the circumstances in which health care and social care work ever more closely together.

What plans he has to recruit more medical staff for the NHS. [29323]

We are recruiting more medical staff. We have also introduced a range of initiatives to improve not only retention but recruitment. We are currently considering the medical work force standing advisory committee's recommendation to increase the annual intake to United Kingdom medical schools by 20 per cent.

Is the Minister aware that there is a shortage of 120 hospital doctors in the South and West health authority, which directly affects my constituents in Eastleigh? Is he aware that a recent parliamentary answer revealed a shortage of 1,600 hospital doctors, 8,000 nurses and 1,000 general practitioners across the NHS? Does he agree that that must have a direct impact on this winter's record cancellation of operations and on the fact that waiting lists for hospital places are climbing out of control? Is it not about time that the Government took the matter seriously and took some firm action to provide an NHS that is properly funded and properly resourced?

That is precisely what we are doing: we are putting in extra money this year. Next year, we will put in an extra £50 million to aid education and training of future doctors. However, it is not only a question money. The best recruiting sergeant for attracting more doctors into the NHS will be to restore doctors' sense that, rather than being sidelined, they are at the heart of the NHS. Our White Paper proposals will do precisely that, not only in primary care—where family doctors and community nurses will be in the driving seat in shaping the future of local health services—but in local health services, where we will explicitly bring hospital consultants in from the cold so that they will have an opportunity to help shape the local health service as they have been unable to do under the internal market.

In view of the general shortage of dentists, particularly in the south-west—about which, as the Minister will know, I have been in consultation with his Department—will he consider setting a capital allowance for dentists who wish to start a new dental clinic in areas where it is acknowledged that a clinic is required and allow that capital to be repaid over a 10-year period from the fees earned? The difficulty with starting a new clinic is often the capital cost. An allowance would surely be a way of easing the problem and would be preferable to introducing mobile dental clinics—which we have in my constituency and which must be nonsense in this modern age.

Perhaps I can reassure the right hon. Gentleman that, in part, that is precisely what investing in dentistry does; it makes available to dentists and health authorities that want to work in collaboration grants for improvements to premises and, in some cases, for construction. The deal we offer dentists is that they can come back into the NHS and get a grant for doing so, provided they give a three or five-year commitment to continue in NHS dentistry. I assure the right hon. Gentleman that, of the 200 applications we have received under investing in dentistry, 73 have come from the South and West health authority area, and they will be considered seriously.

What progress has been made in the PFI hospital building programme since 1 May. [29324]

Before the general election, the tired old Tory Government spent more than £30 million on legal and other fees for the private finance initiative programme but did not make a start on one hospital. Since May last year, I have authorised progress on 17 new hospitals. Building work has already started at Dartford and Gravesham; Carlisle; Norfolk and Norwich; and the two hospitals in South Buckinghamshire.

Does my right hon. Friend agree that the centrepiece of this Government's legislation is to start, through the private finance initiative, to build the hospitals that the previous Conservative Government only promised? Does he further agree that whereas, if I can use this phrase, the previous Government were all mouth and no trousers, he is mouth and trousers?

I am not sure whether that is a compliment or an insult, but I shall assume that it is a compliment as it comes from our side of the House.

As the previous Government gave the go-ahead for the development of phase 1b at Barnet general hospital and the new Government have decided not to reopen the accident and emergency department at Edgware, and understanding that the new Government wanted time to review all the hospital building programmes, will the Secretary of State tell the House when construction work will start on phase 1b at Barnet general hospital?

I cannot, but I will write to the hon. Gentleman with that information.

What changes he intends to make to the current role of NHS trusts in shaping local health care. [29325]

National health service trusts will be brought in from the cold and given back their place in the shaping of local health services. In place of competition, NHS trusts will work with the rest of the local health service to plan and deliver the best possible services.

My hon. Friend will be aware that, under the old Tory NHS, trusts often slashed their costs on an unsustainable short-term basis to drive the so-called competition—other hospitals—out of business. Will he confirm that, under Labour's new NHS, that approach will not be acceptable and that co-operation rather than competition will be the way forward? Co-operation was one of the founding principles of the NHS, and that is what the Labour Government are bringing back to the NHS.

My hon. Friend is absolutely right. We start from a simple premise: one cannot treat hospitals as if they were supermarkets. The old internal market that the Tories unleashed on the NHS set not only doctor against doctor but hospital against hospital. All that is being swept away; in its place there will be partnership and co-operation, which will truly benefit patients.

The new primary care commissioning groups will have a major role in shaping local health care in the future. The only area over which community health councils have no powers is general practice. Will the Minister consider imposing some obligation on primary care commissioning units to consult CHCs in the management of the provision of care?

That is an extremely important question. We want the new primary care groups and trusts to be representative of, and properly to engage with, their local communities. That is why we determined that the boards of the groups and the trusts should include representatives from the public they serve—that will be a helpful step forward. The hon. Gentleman is right; no part of the national health service can be exempt from public scrutiny or from the need to drive up standards and quality.

Will my hon. Friend consider the actions of hospital trusts? The Government are doing excellent work in opening up the partnerships, but will he examine the management costs that trusts are still incurring on administration and premises, as there has been no decrease, particularly in areas such as Bradford?

The Government have instituted two important policy developments. The first is to cut the money spent on bureaucracy and to ensure that front-line patient services receive the savings from cutting red tape. As my hon. Friend will realise, the White Paper proposes that we shall save £1 billion as a result of moving away from the discredited and expensive internal market and reintroducing to the NHS a partnership approach. Secondly, we shall consider favourably any trust mergers that are proposed, provided that they are in the interests of patients and that they release at least £500,000 from bureaucracy to front-line patient care. That is what patients deserve and staff want.

If he will make a statement regarding the regional availability of Aricept in the NHS. [29326]

Information about the prescribing of Aricept in the national health service is available only for prescriptions dispensed in the community in England; in many health authorities, these will have been issued in hospitals. Available data show that prescriptions have been dispensed in 99 of the 100 health authorities in England. However, I understand that many health authorities are reluctant to commit resources to the drug because of the perceived lack of evidence about its clinical and cost-effectiveness.

Will the Minister say what a patient should do when the general practitioner advises him—or, more likely, one of his relatives—that the condition would benefit from the prescription of Aricept but that, under the local regime, that is not possible? Should the patient move house?

The hon. Gentleman raises an extremely important issue, with which I think the whole House will sympathise. Alzheimer's disease is among the most distressing of medical conditions, not only for the sufferers, but perhaps particularly for the carers and close family. However, there is no instant, miracle cure and there is certainly no wonder drug either on the market or about to come on the market. Published data show that Aricept has a limited beneficial effect on the symptoms of the disease. It is important that hon. Members, from whatever party, do not raise unrealistic expectations about the ability of this or any other drug to deal with this severe, debilitating and ultimately fatal condition.

The hon. Member for New Forest, West (Mr. Swayne) raises a wider question—the availability of treatments apparently by postcode rather than by cost-effectiveness. The Liberal Democrats and the Minister disagree about funding, but will he at least accept that the people who make decisions on funding should take some democratic responsibility? Decisions to ration treatment because of cost are taken locally, but there is no local mechanism to vote people out if they are not prescribing certain drugs or treatments.

The hon. Gentleman is right—there is a disagreement between my party and his on the funding of the national health service: his party wanted to put in less money. On rationing by postcode, it is important that we put the issue into perspective. For most patients in most places for most of the time, most services and treatments are available on the national health service. We should say that loudly and clearly, and we should celebrate it, because it is a success story for the NHS. However, we want to build on that and, as the hon. Gentleman is aware, our proposals in the White Paper for a national institute of clinical excellence and for national service frameworks are intent upon bearing down on unacceptable and unjustifiable variations in performance and availability of service. We want a genuinely national health service to be available to people.

What steps he plans to take to improve the monitoring of outcomes and the quality of patient care after the abolition of the NHS internal market. [29327]

"The New NHS" White Paper set out our new approach to assessing and monitoring performance, focusing on the quality, effectiveness and outcomes of care. It incorporates a range of indicators that encompass health outcomes of NHS care and effective health care delivery. We are currently consulting on the detail of this approach.

Can my hon. Friend assure the House that, in the initiatives that he has announced, quality of care will now take precedence and we will get away from the old days when number crunching and making the tables look right was more important than quality? Can he also assure the House that quality of care will also take precedence in the NHS complaints procedure?

I can certainly give my hon. Friend the latter assurance. Under this Government, standards are as important in health as they are in education. There have recently been recurring problems with standards and quality in the NHS, particularly the difficulties with hip joints and the dreadful problems affecting screening services in Kent and Canterbury Hospitals NHS trust. If we are genuine about wanting a one-class, first-class service, we should no longer be willing to tolerate what is, frankly, second best.

While the Minister is considering outcomes, will he acknowledge that unless people can get off the waiting lists and into treatment there is no question of outcomes? Given the sensitivity of the issue, will he give the House an assurance that there is no question whatever of manipulating the figures by allowing patients off the waiting list either because they have died or because it is unrealistic for them to be treated? In particular, will he consider introducing a robust measurement of overall unmet patient need in order to satisfy us that the NHS is genuinely tackling the problems?

I have to say to the hon. Gentleman, for whom I have a great deal of respect on this and other issues, that if patients have died I do not see why they should remain on NHS waiting lists. As for manipulating the figures, I remind him that it was his party, not mine, that was most adept at manipulating figures—certainly the unemployment figures.

Does my hon. Friend agree that the crisis affecting hip replacements was entirely predictable and inevitable and resulted from the market free-for-all that was extremely profitable for the 60 companies that produced new hip prostheses when two very reliable ones—the Stanmore and the Charnley—were already on the market? Will one of the Government's major reforms be to change the health service so that the emphasis is not on making money or on the quantity of the service, but on the quality of the service?

My hon. Friend is absolutely right that in future the emphasis will be on quality, quality and quality. It is quality that counts, quality that patients experience, and when quality goes wrong it is the patients who suffer.

What action he is taking to promote the development of primary care. [29330]

The White Paper "The New NHS" sets out our approach to modernising the national health service and providing integrated primary and community health care services. It will be done through the establishment of primary care groups and ultimately primary care trusts. The establishment of the primary care groups will build on other policies that we have already implemented, such as the National Health Service (Primary Care) Act 1997, personal medical services pilots, the salaried doctors scheme and other local pilots. We shall introduce schemes only when they have been tried and tested.

Is my right hon. Friend aware that his policies are warmly welcomed by the doctors and nurses in my constituency, but that they also seek reassurances? In particular, they want a package of incentives to reward them adequately for the extra work that they will be asked to undertake.

There will be such incentives. Knowing the professionalism of the doctors, nurses and other staff involved, the greatest incentive will be that the policies will lead to a better health service, for which they have all been hoping and working for years.

The Secretary of State will have heard the concerns that have been expressed about social care. Is he happy with the links between health professionals and social care workers in dealing with the scourge of child abuse? Are there enough social workers to deal with the problem?

The Utting committee reported to me before Christmas with proposals to deal with the abuse of children living away from home. The record is disgraceful. We intend to change the arrangements to ensure that the situation improves. It is staggering that, although the number of young people in care—as it is fondly called—represents only a small proportion of the population, 22 per cent. of the prison population was previously in care. That does not say a lot for the care.

When the Secretary of State comes to designate primary care commissioning pilots, will he ensure variety—not just geographical variety, but a variety of approaches to primary care commissioning? Will he also ensure that larger fundholding practices that feel capable of being primary care commissioning groups are offered opportunities to bid for pilot schemes? When will the Secretary of State seek a debate in the House on the NHS White Paper?

The hon. Gentleman makes a reasonable point. The idea of the pilot schemes is to test different approaches. There is no point in having 30 identical pilot schemes. We want a variety of approaches, some of which include the enthusiastic involvement of fundholding doctors. We shall see what works and what does not. I shall say now so that no one can accuse me of not saying it in advance that some of the pilot schemes will almost certainly prove not to be successful. That is why we are having pilot schemes—to find out what works and what does not.

What proposals he has for community hospitals. [29331]

As we said in our White Paper, we see an important role for community hospitals providing intermediate care close to where people live. The new arrangements that we are introducing will make it easier for hospital and primary care to work together to achieve that aim.

Is the Minister aware that hundreds of thousands of people, particularly in rural areas, regard their local community hospital as the most important part of the national health service? Will he give as much support and encouragement as he can to local health authorities that are doing their best to maintain as many such hospitals as possible?

We recognise the vital role that many community hospitals play as a local resource. We want the best balance between them, acute hospitals and other community facilities to ensure the delivery of emergency, elective and rehabilitative care. Those three objectives, and a range of ways of delivering them, are at the heart of the new NHS.

Will my hon. Friend join me in welcoming the announcement that building of the new community hospital for Chepstow will finally begin later this year? It will be the first hospital built in Wales under the private finance initiative.

I am delighted to do so. That is another gain for new Labour.

Will not the quality of care depend on the number of people who can be employed in hospitals? Given that only a limited amount of money is available—albeit the Government claim that there will be an extra £1 billion—what representations has the Minister made to the Low Pay Commission on the minimum amount of money an hour that staff in hospitals should be paid?

The hon. Gentleman is notoriously Whiggish on this and other points. Let us be very clear. We put our faith in NHS staff. NHS staff will be paid a proper wage. NHS staff deserve the very best. This new Labour Government will give it to them.

What recent representations he has made to the World Health Organisation in relation to Iraq. [29332]

We have made no representations recently to the World Health Organisation about Iraq. We welcome and support the humanitarian work that the World Health Organisation is carrying out in Iraq. It is worth noting that, since 1991, the United Kingdom has contributed more than £94 million in humanitarian and medical aid through bilateral and multilateral sources to Iraq, especially northern Iraq, where Saddam Hussein deployed chemical weapons against his own people.

Is not now the time to help the children of Iraq, particularly in relation to waterborne diseases?

The British Government have taken the lead in trying to double the amount of oil that the Iraqis can sell to raise money to provide medicine and medical treatment for their people. It is worth remembering that, although the first United Nations resolution went through in 1995, it was December 1996 before the present Government of Iraq were even willing to go ahead with that resolution, which was intended to make food, medical equipment and pharmaceuticals available to the people of Iraq. If anyone is to blame for those materials and that food not getting through, it is the Government of Iraq, not the Government of Britain or the World Health Organisation.

I beg to move amendment No. 46, in page 1, line 8, after 'Kingdom', insert 'and Gibraltar'.

With this, it will be convenient to discuss the following amendments: No. 7, in page 1, line 9, at end insert—

'1A. For the purposes of this Act, the United Kingdom includes Gibraltar.'.

'1A. Wherever the words United Kingdom appear in this Act they shall be deemed to include Gibraltar.'.

'(e) the register of electors in Gibraltar.'.

Gibraltar has been a subject of debate, interest and importance to this country for at least 300 years. British possession took place in 1704 and was ratified by the treaty of Utrecht in 1713. Ever since, Spain has wanted it back.

"The noble Lord, Lord Bethell, and the noble Baroness, Lady Hooper, raised questions about voting rights in Gibraltar in the European Parliament elections. Gibraltar's lack of representation in the European Parliament results from Annex II of the 1976 EC Act on direct elections. The affect of Annex II on the 1976 Act is to restrict the application of the Act to the UK itself, to the exclusion of other UK territories such as Gibraltar, the Channel Islands and the Isle of Man, to which the EC treaty apply in part. Amending Annex II would require the unanimous agreement of all EU member states. However, the Government are aware of the strength of feeling in Gibraltar on that issue."—[Official Report, House of Lords, 26 November 1997; Vol. 583, c. 1058.]

With the greatest respect to the shadow Home Secretary, the issue is much narrower. The provision should relate exclusively to Gibraltar for one reason: Gibraltar is in the European Union, and the Channel Islands and the Isle of Man are not. I would ask the Committee to concentrate exclusively on Gibraltar as it is a stand-alone case. The other two jurisdictions are not in the European Union and are not seeking that facility.

I entirely agree. The rest of my case concerns the uniqueness of Gibraltar. I was quoting a Foreign Office Minister in another place. It was she, not I, who widened the issue to include the Channel Islands and the Isle of Man.

The two categories in France are known as the DOM and the TOM.

We are deeply grateful to the Home Secretary for that penetrating insight. I guess that that is his bid to be associated with the DOM, not having been invited to the celebrations this morning.

"The Spanish delegation blocked three decisions which were ripe for agreement, over the status of Gibraltar. One decision concerned a proposed joint action for the creation of a European legal contact network. Spain, which does not recognise the independence or the autonomy of Gibraltar, did not want the British Government to appoint a magistrate or prosecutor to Gibraltar. To mollify the Spaniards, the Presidency asked all the Member States to notify their contact points—judiciary authorities and magistrates specialising in the fight against large-scale crime—to the Secretary General of the Council, so that this joint action could be implemented immediately once adopted at a future session. The UK delegation announced that it did not plan to create a contact point on Gibraltar."

I am grateful to the right hon. Gentleman for allowing me to intervene, because it stops a flood of tears springing to my eyes about the situation in Gibraltar. Did the outgoing Conservative Government intend to include Gibraltar in this Bill on the European elections?

I have two things to say to the hon. Gentleman, whom, as he knows, I hold in the highest possible regard. First, had he been able to organise his timetable to join us a little earlier than he did, he would have already heard me deal with that point at considerable length and to the general approval of the Chamber. Secondly, had we won the election last year, we would not have dreamed of bringing in such a rotten Bill.

I support the amendments. I formally apologise to the shadow Home Secretary for interrupting and misunderstanding him. We were at one on the point that he was making. The amendments relate exclusively to Gibraltar. They relate to a self-standing case. It needs to be borne in mind that no other territory is relevant to the issue. The word "territories" is in all European legislation and treaties, and it is an accident. The treaties should specifically refer to Gibraltar since there is simply no other "territory" falling into that category.

I am sorry if I made it more difficult for the hon. Gentleman on a partisan basis. I was not trying to do that. He has just made an important and realistic point—that, if the Bill were amended to include Gibraltar, it is conceivable that, between it receiving Royal Assent and the 1999 elections, the Government might not get the agreement of Spain. That might take a little longer. In which case, were the Government to indicate a willingness in principle to incorporate something along the lines of the amendments, I would be very happy to withdraw our amendment, as I am sure he would withdraw his, to give the Government the opportunity on Report to table a more enabling amendment.

I agree. I hope that Ministers are listening to the suggestion that there should be further reflection on the matter at least to enable the UK Government to extend the franchise. That is fair and sensible. If they do not accept that, the onus is on them to advance the reasons why they are unable to. I use the word "unable" deliberately, because, if they cannot advance such reasons, we must conclude that they are unwilling and we are entitled to ask why. I think that the smoking gun goes back to the Foreign Office, which has significantly failed the people of Gibraltar for a decade or more. I ask the Home Secretary to consider re-examining the matter.

This is an important debate. Extending the franchise to people who should have a way of representing themselves democratically is very important. I listened carefully to the points made by the right hon. Member for South-East Cambridgeshire.

North-West Cambridgeshire

I apologise; I was misinformed. The right hon. Member for North-West Cambridgeshire (Sir B. Mawhinney) had five or six minutes of good points and it was good to hear them extended to 28 minutes. He is right to say that it is an old question. Arguably, it goes back to the treaty of Utrecht, which was in some ways an imperfect document, but it was of its time. Nevertheless, it creates anomalies that have yet to be rectified.

I did not quite understand the hon. Gentleman's last point. My understanding, which was reinforced by the quotation from Baroness Symons that I read out earlier, is that such action is not outwith the law, and that the difficulty was the need for unanimity. Knowing Spain's attitude to Gibraltar, that would be a difficult task. Is he saying that there is a genuine legal impediment, as opposed to what I might call a handling problem?

Test it.

I am grateful to the right hon. Gentleman. The hon. Member for Thurrock says that we should test it. It may need to be tested. I understand that the current advice of the Foreign Office—

It is wrong.

It may well be wrong, but it is borne out by my reading of the annexe and the treaty. The treaty would have to be amended, and it is that, rather than the treaty's interpretation, which would require unanimity among member states. That advice is not cast solid. A letter from the Foreign and Commonwealth Office to the Foreign Affairs Committee on behalf of Baroness Symons offers to ask legal experts to look again at ways of getting around that apparent difficulty. That is right, but we cannot simply wish it away and say that there is no impediment.

I support the three amendments in my name, and those tabled by my right hon. Friend the Member for North-West Cambridgeshire (Sir B. Mawhinney) and others.

"30,000 British Gibraltarians, and other EU Nationals resident in Gibraltar, are the only EU Nationals who have no right to vote at Euro-Elections. This is in stark contrast to citizens of Spanish territories in North Africa, and some French territories even further away, who do vote. The people of Gibraltar have long felt aggrieved by this serious democratic deficit. The position is now even more anomalous following extension of the co-decision procedure, which gives the European Parliament a far more extensive role in the process of legislation which Gibraltar is subsequently required to transpose into our own laws and to implement."

"The provisions of this Treaty shall apply to the European territories for whose external relations a Member State is responsible."

"The United Kingdom can unilaterally extend the right of franchise to the European Parliament to Gibraltar if such an extension can be put into effect without the need to amend Annex II."

"the United Kingdom can unilaterally extend the right of franchise to the European Parliament to Gibraltar because:

(a) the Act on Direct Elections is applicable to Gibraltar by virtue of the operation of Article 227(4) EC Treaty;

(b) for EC purposes, Gibraltar is considered to be an integral part of the Member State, the United Kingdom."

"by the integration of the Gibraltarian vote in the vote of European Parliamentary constituency in the United Kingdom"—

"by the grant of a European Parliamentary seat to the territory of Gibraltar."

"in the former case, the United Kingdom can … act unilaterally whereas in the latter case it cannot do so."

"it is possible for the Gibraltarian vote to be integrated into the vote of a European Parliamentary constituency in the United Kingdom. This solution would maintain the exclusion of the territory of Gibraltar from the Act on Direct Elections, as interpreted by the United Kingdom, but would allow the citizens of the European Union who reside in Gibraltar to exercise the rights protected under Article 3 of Protocol No. 1. Since this vote would be expressed in the context of a European Parliamentary constituency in the United Kingdom there is no need to amend Annex II. The problem would be solved internally and unilaterally by the United Kingdom."

"Persons who are citizens of the United Kingdom and Colonies by birth or by registration or naturalisation in Gibraltar, or whose father was so born."

I support the hon. Member for Ludlow (Mr. Gill) and my right hon. Friend the Member for Strangford (Mr. Taylor), who have tabled amendment No. 7, for various reasons. I remember my first visit to Gibraltar, when the Chief Minister and Members of the Council were socialists. We are dealing with the full spectrum of political opinion in Gibraltar when we discuss this matter.

I wish to put in an historical context the case for giving Gibraltar the rights that the amendments enshrine. It is significant that, in this short discussion, hon. Members representing four political parties have spoken in support of the amendments. That shows that this is one of the least divisive issues that Parliament has addressed in recent weeks. The Government would not lose face by accepting the amendments; there is widespread consensus in support of them, and I would welcome the Minister's acceptance of them when she winds up the debate.

My hon. Friend suggests that the Government might take note of what the French would do in such circumstances. I am sure that, like me, he has read the interesting debate on Gibraltar in another place on 26 November last year. Does he agree that the Government should also take careful note of the views expressed in that debate by their former colleague in this House, now Lord Janner of Braunstone? Does my hon. Friend agree also that the Government would be wise always to take note of their former senior Back Benchers?

And existing Back Benchers, please.

My hon. Friend makes an excellent point, as does the hon. Member for Thurrock (Mr. Mackinlay). Senior Back Benchers, both those who have gone to another place and those still in this place before elevation to another place, can make great sense on the issue.

My hon. Friend made an interesting and important point about the French. Is it not the case that Martinique, Guadeloupe, Réunion and so on are already départements of France? They are seen to be part of France. From 1713, and later in the treaty of Paris, they were turned into colonies.

My hon. Friend is right. There is an exact equivalence, which is why the Committee should accept the amendments.

This has been an interesting debate, and I recognise the strength of feeling that has been evident in the speeches of many hon. Members, particularly the hon. Member for Ludlow (Mr. Gill), who raised this issue on Second Reading, and my hon. Friend the Member for Thurrock (Mr. Mackinlay), who has referred to the matter on various occasions.

May I help the hon. Lady by reminding her that I said that we recognised, as did her party, before the first direct elections and subsequently, that the form of direct elections that we had adopted—European constituencies based on parliamentary constituencies—made it difficult to accommodate the matter. That was the view of her party in opposition, which never sought to persuade us to take action on it. Having decided to change the system, the Government have now provided an opportunity to redress a wrong that should be put right.

I find that even less convincing than when the right hon. Gentleman said it the first time round. The previous Government were in power for 18 years. At various points during that time, European constituency boundaries were changed. They never raised the matter.

"We—

"recognise the formidable practical difficulties in resolving this issue, in that any alteration to the status quo would require the agreement of all member states, including Spain."—[Official Report, House of Lords, 26 November 1997; Vol. 583, c. 1052.]

The Minister says that she will not say that Spain will not like it. What does she think Spain's reaction would be if the Government accepted the amendment?

I said that I am not going to say that Spain would not like it as a reason for not accepting the amendments.

I accept that that is the argument that the Minister is advancing, but what is the answer to my question? What does she think Spain's attitude would be if the Government accepted the amendment?

As that is not the argument that I am advancing, the hon. Gentleman's argument is hypothetical. It would seem that his question has been answered by his colleague in another place, Lord Moynihan.

Will the Minister give way?

I shall not keep on giving way to the right hon. Gentleman, but I shall do so on this occasion.

I am grateful to the Minister. My noble Friend is not a Minister and I am not advancing any particular point of policy. I am merely asking the Minister a question, and a simple question. It may not be part of her argument but she is a Minister and it is a legitimate question for me to ask her. What is the Government's assessment of Spain's reaction if the Government accepted the amendment and tried to move things forward?

As that is not central to my argument, it is not appropriate for me to make such an assessment. The issue that the right hon. Gentleman has raised is not a stumbling block when it comes to the proposed legislation before us.

In the Minister's opinion, is there any legal bar to the people of Gibraltar being included in the electoral roll of an English region at the next European elections?

I am coming to that point. The legal arguments are central to the point of view that the Government are taking.

The Minister is now addressing the nub of the question. The hon. Member for Thurrock (Mr. Mackinlay) and I maintain that there is no bar to Gibraltarians' being put on the electoral roll of one of the new regions in the United Kingdom. Does the hon. Lady accept that much of the new European law that is applied in Gibraltar has to be put on the statute book in Gibraltar and that that is done because of Gibraltar's relationship to the United Kingdom? However, it is not stated in directives that they apply to the United Kingdom and Gibraltar. It is assumed that Gibraltar is part of the United Kingdom for such purposes. What is sauce for the goose is sauce for the gander. It is—

Order. The hon. Gentleman must not make a second speech in an intervention.

Our understanding of the legal situation is that Gibraltar cannot be included in the way that is suggested. That view seems to be shared by the Opposition spokesman in another place. We are not making a judgment hastily; we closely examined the evidence. It seems that it is not possible to include Gibraltar in the way the hon. Gentleman describes.

My hon. Friend has referred to the inclusion of Gibraltar along with the Channel Islands and the Isle of Man. There is a substantive difference in law. The Isle of Man and the Channel Islands are not in the European Union. The treaties apply in part to those territories but they are not in the EU. People who live in the Channel Islands or the Isle of Man do not have EU citizenship, whereas the people of Gibraltar do. Gibraltarians are in the EU, although in a special category.

As I have said, there are differences between the status of Gibraltar in the European Union and, for example, the status of the Channel Islands and the Isle of Man. However, for the purposes of the EU parliamentary elections, it is clear that they have the same status. That is the legal position. If that position were to be changed, it would require a proposal from the European Parliament, and a unanimous decision in Council followed by ratification by all member states. I am sure that the formidable political obstacles that would be encountered by that course of action are more than evident to the Committee.

rose—