To ask the Secretary of State for Health what representations have been made to him by trade unions with members employed in the National Health Service about the pay and conditions of their members.

Recent representations that I have received have been concerned with the implementation of the clinical grading structure for nurses and the grading review for the professions allied to medicine. Pay settlements have now been concluded for 1988 covering more than 90 per cent. of all National Health Service staff.

In view of the most recent leak—about the Autumn Statement—by this leakiest of Governments, will the Secretary of State tell us how he will ensure the full funding of the pay award to the National Health Service ancillary staff? The AHAs say that £2 billion is necessary even now. Will that necessitate the media going to another Spanish beach before the people in the Health Service are told by the Government that they will receive a real reward for the hard efforts that they have put into the service?

The hon. Gentleman will have to contain himself and wait for the Autumn Statement, which I believe he will find contains quite good news. Meanwhile, I can only remind him that 90 per cent. of our staff have reached satisfactory settlements, and these settlements have now been put into effect for the staff concerned.

Will my right hon. and learned Friend accept that his Department's successful achievement in the pay settlement has been received with considerable pleasure? Is he aware that nurses find it difficult to move, especially to the south-east of England, because of the very high cost of housing and living expenses? Does my right hon. and learned Friend agree that the time is fast approaching when we must move to regional pay? What hope can he give that the Government will take that step?

I agree with my hon. Friend, because obviously it is necessary that we recruit and retain people of the required quality in every part of the country. We all know that the costs incurred for staff vary from place to place, as do difficulties in recruitment. We have put in our evidence to the nurses review body the suggestion that we should now move to greater geographical variation and local flexibility, and similar discussions are taking place in the Whitley council about management and administrative staff. I believe that common sense dictates that we should start to reflect local variations in conditions in future pay negotiations for a giant service such as this.

Is the Secretary of State aware of the anger and dismay being expressed by nursing sisters about regrading? I have evidence from Hope hospital and Park hospital in the Greater Manchester area and from many other areas. What will the Secretary of State do to resolve that problem?

When the new G grade posts are created in the new year, about three quarters of all sisters will be on the higher grades. If the right hon. Gentleman has found discontented sisters, he has no doubt looked hard and had the assistance of COHSE, which is trying to make difficulties over the minority of sisters who find themselves on the lower grade. The unions agreed to this grading structure, and it is preposterous now to claim that everyone should have gone on the higher of the grades available to sisters. Sisters have been graded according to their skill and the responsibility of the post.

Will my right hon. and learned Friend make it clear that the fear expressed by a number of health authorities that they could meet the pay award only by reducing services is unjustified? The Government have made extra funds available so that the whole of the award to nurses can be made without any reduction in services within the National Health Service.

Yes, Sir. I am glad that I can give my hon. Friend that assurance. We had to adjust the estimates of the cost as the grading exercise went on and as it became obvious that our first estimate was too low. We have honoured our commitment to fund the cost of the grading exercise in full. We used the regional health authorities' own figures as the basis for doing so, and the authorities have all confirmed that they are satisfied that that funding has been made available in full. That means that there is no reason why patient services should be affected in any way by this desirable improvement in the career structure of nurses.

As this is the Secretary of State's first appearance at the Dispatch Box since his appointment, may I welcome him back to Health and express the hope that he will be with us for rather longer than his predecessor? May I invite the Secretary of State to reconsider his decision of two weeks ago not to meet the trade union side? Is he aware that, in the recollection of the Royal College of Nursing, he is the first Secretary of State who has declined to meet it when requested, which appears all the more odd as his predecessors were doing double the job? Does he agree that most of the 20,000 appeals which are now going through the system could have been avoided if he had agreed to the trade union offer to go to binding arbitration? If he is so confident of his case on regrading, why did he intervene personally to veto arbitration?

First, I thank the hon. Gentleman for his kind words. I look forward to his contribution to our discussions on the Health Service.

To ask the Secretary of State for Health how much in real terms doctors pay has increased since 1978.

Doctors' pay has increased by 36·4 per cent. in real terms since 1978–79.

May I be first on this side of the House to congratulate my right hon. and learned Friend on his first appearance at the Dispatch Box in his new post—[HON. MEMBERS: "Hear, hear".]—and say how warming it is to find such a robust and positive attitude at the Dispatch Box? Given that the average target pay for general practitioners is now about £28,000 and that that represents only one of a number of variable factors, for which it is hard for anyone to budget, is there any hope of a unitary Health Service as long as we have family practitioner committees? Should not family practitioner committees be abolished and brought within the district authority health service?

I am grateful to my hon. Friend for his remarks and for the lively reaction behind me. I suspect that that will not be the only lively reaction behind me before this day is out.

Will the Secretary of State comment also on the pay scales of junior doctors and tell us whether they have had the same increases during the past 10 years as those he has just mentioned? Will the Secretary of State relate that information to the hours of work that junior doctors are now putting in?

Junior doctors also are much better paid than they were—and certainly they deserve to be, because of their heavy commitment to the service. We are looking yet again at the vexed question of the hours of work of junior hospital doctors, which has been tackled by this Government on more than one occasion and to which I am glad we have made some worthwhile improvements. The fact is that getting things improved requires the commitment of the Government, the authorities and the whole profession. Although at every level the representatives of the profession are fully supportive of what we are trying to do, we sometimes encounter local practice where consultants are not as helpful as they might be about the type of cover that they want. I have also encountered some junior doctors who do not really want their hours reduced because they do not like the fall in pay that goes with it. At the moment we are trying to get rid of one-in-two rotas—and so we ought.

To ask the Secretary of State for Health what reduction in hospital waiting lists he expects after removing those patients who have already had treatment or who no longer require it.

Many waiting lists will contain the names of patients who no longer, in fact, require treatment. It is not possible to put a figure on this, although some studies suggest that it could be 10 per cent. or more.

The Minister is correct. Many studies suggest that the figure is at least 10 per cent. and sometimes as high as 30 per cent. I thank the Minister for that answer and welcome him on his first appearance at the Dispatch Box in his new post.

I am grateful to the hon. Gentleman for his welcome. I appreciate his expertise in these matters and the non-partisan way in which he has put a question that goes to the heart of our concern. We are keen that waiting lists should realistically reflect the workload of a district. To that end, we have been sending out questionnaires and requests to districts to ensure that they improve their information systems. The new Körner system is giving us much better statistics than we used to have. We also see an obligation to try to improve the mechanisms, whether in human terms or in terms of the machines needed to ensure that proper records are available. It is crucial to the efficient management of a district that we know exactly the state of a waiting list. It should not be swollen by people who do not want an operation after all.

Will the Minister tell the House the percentage numbers of patients on waiting lists for spare part surgery, where there must obviously be difficulties in moving them from the waiting list?

My hon. Friend is right. One of the major constraints of spare part surgery is the availability of organs to be transplanted. She will have noted the initiative taken by my hon. Friend the Member for Derbyshire, South (Mrs. Currie), the Under-Secretary of State for Health, to encourage more people to carry donor cards, which would assist that process. We are proud of the fact that there has been a marked expansion in spare part surgery. We started heart transplants in 1979 and now have a programme that enables almost 300 a year to be done, and I hope that we shall be able to do more in the near future.

To ask the Secretary of State for Health what representations he has received about the pay of medical physics technicians employed in the National Health Service.

To ask the Secretary of State for Health what representations he has received about the pay of medical physics technicians employed in the National Health Service.

A settlement was reached in the appropriate Whitley council on 19 October. Before that, we had received numerous letters from right hon. and hon. Members and individual technicians.

Is not the truth of the matter that, over the past nine years, the people who work in those backroom capacities, in laboratories, have lost ground in relation to other people? Will the Minister confirm that there are currently recruitment difficulties as a result of that? Is it not a scandal that, when the Government are prattling on about a booming Britain, 46·3 per cent. was handed over in wage increases to business executives last year, while these people are having to potter about on single figure pay increases?

I hope very much that business executives will feel further incentives to generate the wealth which we can tax and from which we can pay the wages of medical physics technicians. There are now 30 per cent. more medical physics technicians than there were in 1979 and, although there may be recruitment difficulties in some areas, our innovative ideas on regional pay will help adjust those. I look forward to the hon. Gentleman's enthusiastic support.

Does the Minister recognise that, while business executives are busy generating wealth, the Parkside health authority has problems, not only with recruitment, but with the retention of suitably qualified staff? What special assistance can be given to such health authorities on that difficult problem, which is beginning to affect patient care?

It is a serious problem. I, too, represent an inner London constituency, and I am aware of recruitment difficulties. I am aware also of the problems that are faced by staff who are not beneficiaries of the review body system. We want to try to address these matters. In the nurses' pay award there was a 9 per cent. additional supplement for inner London, which is the beginning of a move towards regional pay. I believe that that will be the only way in which we can recognise the difficulties that people have in working in the hon. Gentleman's constituency and in mine, as against many areas in the rest of the country where living costs are much lower. I assure the hon. Gentleman that we recognise that there is a problem and that we want to try to do something constructive to resolve it. Any constructive suggestions that he has will be seriously considered.

Does my hon. and learned Friend agree that regional pay is important and that those who do not have the emotional pull of nurses—for example, technicians and others who work in extremely important areas within the Health Service—should not think that the Government ask themselves, "How little can we pay them and get away with it?" We must ensure that market forces are in full play so that we can recruit those who are necessary in technical and other areas. May I have the assurance of my hon. and learned Friend that the Government will work vigorously to introduce reasonable pay differentials so that health authorities in areas such as my constituency in Dorset will be able to recruit staff who are essential for technical departments?

I think that both my right hon. and learned Friend the Secretary of State and I were nodding in assent during my hon. Friend's supplementary question, which made the central point that all those who work within the service are valuable to it. We must ensure that every group is properly considered, and that is more easily said than done. It is plain that there is room in which to examine the issue, and we shall do so.

I welcome the Minister's response to the hon. Member for Brent, South (Mr. Boateng), but I ask him to reconsider his use of percentages to show a decided increase in staffing levels. Does he recognise that over the years there has been. a tremendous advance in the use of science and technology in the service of medicine? That being so, there will be an increase in numbers. Will he recognise also that sometimes some of those who are included in the numbers that are returned are not in post for various reasons? Will he accept that perhaps we are overstraining the commitment of medical staff and technicians to the Health Service and their care of patients?

I am not quite sure what point the hon. Gentleman was making in the first part of his supplementary question. Self-evidently, unless there were a good reason for appointing 30 per cent. more staff in any given grade, the Government would stand condemned for wasteful employment of unnecessary people. It is clear that there has been an increase in high technology medicine. That has required more staff in certain grades and a mass of others in the service with greater qualifications. Our job is to try to ensure that our increased resources touch on the conditions of these people and allow us to recruit the numbers that we need to keep the service going. We must ensure that we look to some of the lesser groups and not only the large groups. We must bear in mind those who do not necessarily have the public emotional clout of some others in the service.

To ask the Secretary of State for Health how he intends to improve value for money in the National Health Service.

We remain committed to ensuring that health authorities continue to improve efficiency in all areas in order to maximise the resources available for patient care. We expect authorities to look critically at all their unit costs, including supplies, energy and, increasingly, clinical costs. Substantial progress has already been made by authorities with over £700 million worth of cost improvement savings expected to have been diverted into providing patient services by the end of this financial year. Health authorities have increased the number of patients they have treated at a faster rate than the increases in their expenditure, and they should continue to do so.

I am sure my right hon. and learned Friend will agree that few reasonable people would quibble with the concept of value for money in the Health Service or anywhere else in the public service. I seek assurances on behalf of the well-run districts which believe in value for money and sensible budgeting, and understand that there are 12 months in a year, and not 10 or 11, as some districts seem to think. I ask for an assurance that sensible, well-run districts will not lose money as a result of the activities of profligate ones, and that their income will be properly protected.

I can give my hon. Friend that assurance. The Department allocates all its money each year and does not keep any in reserve centrally. Authorities receive their allocation—allocations are based on the same principles throughout the country—to improve their patient services by a combination of the new money and their efficiency in making use of it. It would be wrong to raid the budgets of better-run districts to help those who get into difficulties. The Health Service sees increasingly that authorities have the remedy in their own hands when they face any short-term financial problems.

Does the Minister agree that the poorest value for money in the Health Service arises from closing acute units for two months at the end of the year? Will he guarantee that that disgraceful situation which occurred in the Health Service last year will not be repeated this year?

I covered that point in reply to my hon. Friend the Member for Nottingham, South (Mr. Brandon-Bravo). We allocate money in England on the same basis to all authorities, using the RAWP formula. The vast majority of health authorities are extremely successful at using that money, increasing their efficiency and increasing the number of patients they treat. Obviously all the authorities face difficult problems and some get into difficulty with their services. I believe that we have provided the funds to enable the service to be expanded and we should see a reduction in local difficulties which crop up from time to time.

Does my right hon. and learned Friend accept that mothers-to-be will not regard it as value for money if the Leicestershire health authority tries to close all rural maternity units? Will he tell the authority that such policies are simply not acceptable in rural areas?

We have a well-tried procedure whereby there is full consultation about proposals of that kind. Eventually the proposal comes to my Department and my hon. and learned Friend the Minister of State would have to approve any closure proposal. There are long-standing arguments all over the country about whether the service is most effectively provided in small maternity units or in the maternity sections of large district general hospitals. If the proposal comes to us, we will look very carefully at the particular situation in Leicestershire and at any representations that my hon. Friend and his constituents wish to make.

Does the Minister agree that the best value for money is to be found in preventive medicine rather than in trying to treat ailments after they have developed? Will he therefore even at this late stage read the document produced by his district health authority's local dental committee and the document from the local optometrists, which demand that the changes in the amounts charged for dental examinations and eye tests should not proceed today? Will he read those documents?

I have read those documents, and obviously it would be most sensible for me to address myself to the arguments that they contain later, when the hon. Gentleman and I will have an opportunity to debate the matter. Of course I agree that preventive medicine is the best value and should be encouraged. I do not agree that the proposed charges will reduce the amount of preventive medicine. I would regard a decision to keep the charges in the pockets of the six out of 10 of the better off who will be liable to them as a very poor use of resources which could be put to much better use elsewhere in the Health Service.

To ask the Secretary of State for Health if he will make a statement on the variations in efficiency between different district health authorities.

The actual cost per in-patient case in 1986–87 varied from £456 to £1,117 in non-teaching districts and from £699 to £1,334 in teaching districts. At least part of those substantial variations remain unaccounted for. We are certain that there is still scope for some authorities to make better use of resources to improve services to patients.

Does not my hon. Friend's answer show the value of performance indicators in assessing relative efficiency and, further to what has just been said, that many health authorities still have a very long way to go to improve their efficiency in spending taxpayers' money?

Oh yes. I am sure that my hon. Friend is aware of the Health Service indicators for the Basingstoke and North Hampshire district health authority, which covers his constituency. The average looks OK, but when we analyse them more clearly it is clear that Basingstoke's throughput is low, the length of stay is too long, the turnover intervals—the length of time that beds are vacant between patients—are too high and the length of time to clear the waiting list is too long. Basingstoke is being reviewed today by the regional chairman and no doubt he will take note of the figures.

Is the Minister aware of the growing bad reputation of the National Health Service as a late payer? As a consequence it is losing discounts on purchasing equipment. Crumpsall hospital in Manchester is so short of equipment that even in the casualty ward there was a shortage of drip equipment. Is that the kind of thing the Minister thinks about when she refers to value for money?

The hon. Gentleman has asked two different questions. I agree with the first part of his question. We do not regard it as a good idea to be late payers. Apart from anything else, that simply pushes up the price of the equipment that we have to purchase. I take note of the second part of his question and will contact him to tell him exactly how the situation stands.

Will my hon. Friend ensure that districts such as Lancaster, which do well in performance indicators, are not penalised for the benefit of those which do less well, such as some of those represented by Opposition Members?

My hon. Friend is right. The cost per case in Lancaster is £625, which is well below the national average. However, I hope that the Lancaster health authority will not be complacent and will ensure that it obtains the maximum amount of patient care for that money.

To ask the Secretary of State for Health what representations he has received about the pay and conditions of service of ancillary staffs in the National Health Service.

Since the last time this matter was raised during questions on 12 July we have received three letters from right hon. and hon. Members and six from members of the public.

Will the Minister take it from me that should, in the current negotiations, the management side of the Whitley council not recognise the essential part that those overworked and underpaid workers in the NHS play, he will be receiving strong representations from the union side? If the talks end in deadlock, as seems likely, will he give a guarantee now that he will use his best endeavours to ensure that both sides in the pending dispute go to arbitration?

We have enough trouble already without anticipating trouble that may not come. The hon. Gentleman's predictions about what may or may not happen at the end of a pay round that has barely begun do not excite my interest at the moment. The hon. Gentleman does us a disservice. During the course of the previous negotiations the 40-hour week was reduced to 39 hours, which meant that the lowest basic hourly rate for ancillary workers was increased by 9 per cent. That is a much better deal than they obtained under the Labour Government when, he might like to recall, the pay of ancillary workers fell 10 per cent., compared with an increase in spending power during the Conservatives' reign.

Does my hon. and learned Friend agree that the higher that wage settlements in the NHS are in the coming year, the less money will be available for improvements in patient care?

Yes. One thing is absolutely clear. Some people talk about the NHS as though it was merely a basis for increased pay for those who work within it. Already we know that of the substantial resources that go into the NHS, over 70 per cent. goes towards the pay of those who work within it. We recognise that one of the greatest assets of the service is the skills of those who work within it, but a lot more needs to be done and, plainly, improving patient services is something to which we intend to give even greater priority than we have in the past.

To ask the Secretary of State for Health what is his latest estimate of the cost of funding the nurses pay settlement; and what plans he has to fund it in full.

I announced on 13 October additional financial allocations to English regional health authorities to meet in full, the best estimates of the final costs of the nurses' pay settlement, including the clinical regrading exercise. An additional £98 million has been made available, bringing the total cost for England to £731 million.

Is the Secretary of State aware that he has let the nurses down? He has broken a promise to the nurses. The Secretary of State represents a constituency just down the road from mine. I have had nurses from all their organisations coming to have a go at me at my surgery on a Saturday morning when they should have been having a go at him. There is no doubt that, because of what he has said at the Dispatch Box today, he is not holding surgeries to have those nurses come to see him. I want to know whether the Secretary of State will live up to his promise and give the nurses the money to which they are entitled.

I, too, hold my surgeries on Saturday mornings and my constituency is so close to that of the hon. Gentleman that I can almost hear him addressing his constituents. The announcement that we have made honours in full every commitment that we gave to the nursing profession. It represents on average a 17·9 per cent. increase across the country and it is the best deal that the nurses have ever had in the NHS.

Will my right hon. and learned Friend confirm that, following the nurses' pay increase, their salaries will be 45 per cent. higher in real terms than they were in 1979?

That is absolutely correct. It contrasts with a drop of 20 per cent. in real terms that took place during the period of office of the Labour Government.

Will the Minister agree to meet myself, the nurse managers for nurses in hospices and Help The Hospices, which is the umbrella organisation for hospices, to discuss our concern about the effect of the pay award on nurses in hospices? What financial arrangements will he make for pay awards for nurses working in hospices that currently receive no grant from their district authority, such as St. Oswald's in Newcastle, St. Clare's in South Shields, and the Hartlepool hospice?

I can assure the hon. Member that a Minister from my Department will meet her deputation. Obviously it will be left for the most convenient arrangements to be made when she contacts my office. We remembered the hospices in the settlement that we made, although their case was not pressed upon us by anyone in the trade union movement; perhaps the hon. Lady may have done so. We have made a provision of extra money to cover regrading and pay increase costs in those hospices that currently have a relationship with health authorities. We are still discussing how best to distribute it, and we shall listen with interest to whatever the hon. Lady has to say on behalf of individual hospices throughout the country.

Will my right hon. and learned Friend confirm what was said by his predecessor, that under the award, nurses will receive equal pay for equal work and responsibility, but that it will be made clear that some nurses have more responsibility than others in the work that they have to do, and that that is a crucial factor in deciding whether they are graded G or F?

My hon. Friend is right, and seeking to ensure that such is done on the right basis throughout the country has been a complicated process. I think that that exercise has been extremely successful. In some cases a new G-grade post will have to be created. My hon. Friend is right to say that there will have to be some competition, so that the health authority may choose the best candidate for the extra skill and responsibility involved. We have ensured that once that skill and responsibility is being carried, it will be properly paid for under the new arrangement.

To ask the Secretary of State for Health what representations he has received on the implication of the nurses pay award.

To ask the Secretary of State for Health what representations he has received from trade unions and professional bodies with members in the nursing profession about the recent pay award.

The Government's decision to provide substantial additional funding to meet in full the estimated final costs of the nurses' pay settlement has been welcomed by health authority chairmen and managers and by responsible representatives of the trade unions and professional bodies.

Does the Secretary of State agree that his cavalier refusal to meet the nurses' organisations at an earlier point in the disagreement arising out of the current pay dispute has resulted in poor morale in the Health Service? Although the Minister has so far committed himself to paying the estimated cost of the award, it could yet be that the award will be still higher than the level of money currently being discussed. In those circumstances, will the Secretary of State guarantee that further money will be made available?

The morale of all Health Service staff would be raised if the Government, management and trade unions all took part in responsible discussions on these matters. At certain stages in the negotiations over the detail of the grades and structure, I believe that people were seeking meetings with me more for the benefit of securing publicity for themselves than for the purpose of furthering the nurses' pay settlement.

If the Minister believes that he has treated the nurses very generously, can he explain to the House why so many nurses and midwives are angry and have seen through his outrageous regrading swindle?

Certainly one of the trade unions involved is having remarkably little success in its continued attempts to find nurses with a sense of grievance about the settlement. I regret the fact that some trade union leaders continue trying to find opportunities for dispute. I particularly deplore the fact that they are trying to organise industrial action in one or two places up and down the country. I am sure that they will not succeed, and I am sure also that the public recognise that the great bulk of the nursing profession is very satisfied with such a very generous award.

In 1985 my right hon. and learned Friend's Department was unable to tell the Public Accounts Committee whether we were employing too many or too few nurses. Can he tell us now whether there are too many or too few?

We certainly have much better information than we had a few years ago about the number of staff whom we employ, and we are improving the quality of nurse management. Now that we have given them a new career structure, it is extremely important that those responsible for the management of the skilled professional staff make the best possible use of their trained manpower. We are looking for the best deployment of nurses in all grades to ensure the maximum quality of service for patients.

I am sure that the Secretary of State will have read in yesterday's Western Mail that nurses in Wales are not to be paid their new rates or be regraded at the same time as their colleagues in England, because the Treasury has intervened. Will he now consult urgently with the Secretary of State for Wales so that they can go back to the Treasury and say that nurses in Wales are entitled to the same pay rates as their counterparts at the same time?

I regret to say that I have not read the Western Mail, and this is plainly a matter for my right hon. Friend the Secretary of State for Wales. However, the regrading exercise was carried out on exactly the same basis in Wales as it was in England, and should produce the same satisfactory conclusion for nurses and midwives in both countries.

To ask the Secretary of State for Health when he expects to publish the results of his review of the National Health Service.

To ask the Secretary of State for Health when he expects to publish the results of his review of the National Health Service.

We shall bring forward a White Paper in the new year.

Does the Secretary of State expect the review to confirm the principle of a tax-funded National Health Service, or does he expect it to follow his charges for preventive tests, with charges for accommodation and food in hospitals? Or is he waiting for the Prime Minister to make up his mind for him?

The hon. Gentleman will have to wait for the review, but I can assure him that it will be consistent with our policy of seeking to improve and develop the NHS. As for the charges, it was a Labour Government who, in 1951, introduced the principle of payment for dental, optical and pharmaceutical services by those who could afford it. The Labour party has never gone back on that, except for a very short period. Labour raised charges when it was in office, and it is obvious that this is a sensible way of raising revenue to finance the considerable expansion of the NHS that we are implementing.

Is not creeping privatisation the cup of poison that the Government have planned for the NHS? Are they not planning a further rundown in the NHS to help the rise of the private sector, although that sector does not train nurses but only steals them from the NHS? Will not this pernicious privatisation mean more personal bankruptcies from bad health and the shrinking of available treatment on the NHS?

The answer to all three questions is no. The hon. Gentleman should not base questions on such a parody of our policies after a period when we have plainly improved the NHS greatly, compared with its performance under the preceding Labour Government.

If, as my right hon. and learned Friend seems to suggest, there is a certain slowing in the pace of the NHS review, will he take the opportunity to focus particularly on treatment of the elderly? Although I do not exclude the advantages that the elderly can gain from private health insurance, will my right hon. and learned Friend try to appreciate even more than he does now that the elderly rely perhaps more heavily than any other section of the community on provision by the NHS?

We welcome all contributions to our discussions while they continue, and I certainly welcome any from my hon. Friend. One reason why demands on the NHS continue to rise so inexorably is that an ever higher proportion of the population are living into old age and need to have more recourse to the service. We have so far managed to keep ahead of that rising demand, and we must continue to do so.

When my right hon. and learned Friend publishes his White Paper, will he address the question of AIDS? Bearing in mind the lack of accurate information about the rate at which the virus is spreading, will he introduce at the earliest opportunity a system of anonymous blood tests so that future policy can be formed on the basis of accurate information?

As my hon. Friend knows, we are making available considerable resources to deal with the advance of this pandemic. We must continue to do so on the best estimates we have of the continued increase in patients. We are actively considering anonymous testing as a contribution to studies of the epidemic, but it raises a number of difficult ethical and legal problems.

In reaching his conclusions on the review of the NHS, will the Secretary of State bear in mind the warning provided by the experience of Mrs. Veronica Barnes, who, despite paying 40 years' subscriptions to Private Patients Plan, has had her cover for treatment for cancer withdrawn. Will he give weight to her observation:

"Private insurers seem keen enough to get you when there is nothing wrong with you, but as soon as you are really ill, they don't want to know."

It is ridiculous to say that the Government are running down the National Health Service, when one compares our nine-year record with that of our predecessors. I only hope that the hon. Gentleman's random question, with a letter from one person, is not part of his support to his junior spokesman, who is still conducting attacks on private medicine more suitable to the politics of the 1960s than today. It is obvious that in a more prosperous society an ever-higher proportion of the population will look to private insurance for part of their health treatment. That is a good thing, because it relieves pressure on the National Health Service.

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

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

When the take-up of family credit is as low as one in three, how can the Prime Minister justify the sacking of 4,400 civil servants? Does she agree that those people would be best employed increasing the take-up of benefit in places such as my constituency of Stoke-on-Trent, North?

No. The work of the social security officers in dealing with the unemployed has reduced substantially. I am sure that the hon. Lady is very pleased about that. That also applies to social security offices. There is no point in keeping on people who have no work to do. Where we need extra efficiency, we are trying to get it by improved use of all the latest office equipment. Where we need people to do specialist work we shall take them on, but we shall take on only a particular kind of person.

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

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

Does my right hon. Friend agree that those who have benefited most from the substantial reductions in income tax, particularly those on high incomes, should be prepared to accept the personal responsibility of paying for their own eye tests and dental examinations? Will she make it clear that it is not Government policy, it never has been and it never will be, to levy charges on children, the low-paid and the partially blind? Will she confirm that 20 million people will be exempt from such charges?

My hon. Friend is correct in saying that some 20 million people—more than one third of the population—will be exempt from charges on sight tests and dental examinations. Most people can pay small charges for dental and eye examinations. They are very willing to pay small charges. They cannot pay the big charges for operations for cataracts, hip replacements and so on. [Interruption.] Small charges amount to a very considerable sum which enables us to have reductions in waiting lists, such as the initiatives we have had in the past. If we are deprived of those small sums, people will not be able to get the operations they really need as soon as they otherwise would. Many people would be quite put out if they were not allowed to pay—[interruption.]

Order. The Prime Minister has not finished answering the question.

Many people would feel that it was quite wrong if they were not allowed to pay the small sums which they can well afford, to enable substantial developments in the Health Service to take place.

There is now conclusive proof that family credit reaches only 30 per cent. of eligible families. When a targeted benefit misses 70 per cent. of the people it is supposed to help, had the Prime Minister not better do something about her aim?

My right hon. Friend the Secretary of State for Social Security has said that we shall have a major effort to get more people who are entitled to family credit to receive it. That will mean, among other things, a major programme of television advertising. I hope that the right hon. Gentleman will not then object to that expenditure.

Is the Prime Minister not aware that, at the outset of family credit, the Government budgeted for only 60 per cent. take-up? Actual take-up has been half that. Does that cause the Government and the Prime Minister any regret, or is it yet another attempt to ensure that money can be saved at the expense of the poor?

More money is being spent on the poor and not on better-off people. The right hon. Gentleman is aware that people can claim family credit with a family of two up to an income of £9,300 a year. I would have hoped that the right hon. Gentleman would join in trying to get people who are entitled to family credit to go along and claim it. If he will not, why not?

I am rather more in favour of the poor getting money than is the Prime Minister, on the basis of her record. Last week the Government again froze child benefit. They spent £70 million on family credit. If the Prime Minister is so keen to provide money for the poor, why did she not spend the whole £206 million previously earmarked for child benefit on providing family benefit for people who are most greviously in need of it as a result of the means tests that the Government have applied to them?

Never has more been spent on social security payments and the Health Service, because the wealth created by enterprise under this Government has enabled us to do that. Family income supplement, as it used to be, was introduced by a Conservative Government. Family credit—an enormous improvement which helps people on low wages—was also introduced by a Conservative Government. There have been no such things under Labour.

I welcome my right hon. Friend's continued support for the Channel tunnel project. Is she aware that there appears to be no co-ordination between the British Government through British Rail and the French Government through Societé Nationale des Chemins de fer Francais of the investment criteria governing the construction and development of rail services at each end of the line? Does my right hon. Friend think that this is necessary? If so, will she please arrange for the two Departments of Transport to meet soon to discuss the matter?

I would not necessarily accept that. I think that there is co-ordination. I think that my hon. Friend is probably referring to the fact that the French need the high-speed train in any event, whereas we do not have the same need for it on this side of the tunnel for services to London. I will, however, look further into the matter.

Is the Prime Minister aware that those of us who struggle with tobacco addiction—it is some struggle, as I am sure the Leader of the Opposition agrees—are interested to read speculation that she is contemplating some legislation in this area? Is she aware that in West Germany for example, tobacco companies are compelled by law to print on cigarette packets the nicotine and carbon content of cigarettes, thus at least enabling people to choose the least injurious? Will she consider leaning on tobacco companies to do that voluntarily in the United Kingdom?

I am not aware of any further legislation. The health warning on the packet does not seem to have had very much effect. Persuasion is a far better weapon than legislation on this issue.

To ask the Prime Minister if she will raise at the next meeting of the European Council the question of the use by the Commission of the powers given it in the Single European Act.

No, Sir. The Single European Act did not confer additional powers on the Commission and the power of final decision remains with the Council of Ministers. The Commission has used its existing powers to bring forward proposals for the completion of the internal market, as required by the Single European Act. I do not see a need for any increase in its powers.

Does not the message of my right hon. Friend's splendid speech at Bruges point out the real danger that the much publicised free trade in 1992 will be a major disappointment and let-down for Britain so long as the Commission, under Mr. Delors, uses the powers of the Single Act to promote pointless measures of harmonisation instead of putting forward the real free trade measures so very much required by British industries such as the insurance industry? Is there really nothing that the British Government can do to stop the Commission from using its anti-dumping powers as a measure of blunt protectionism?

I agree with my hon. Friend that this is a matter on which we must remain watchful. We want the single market and the Common Market to come into effect by 1992. We do not want to see highly complex regulations or new barriers set up around the Community. We want freer trade and the restraints on trade removed. We shall be watchful so that we do not have a complex plethora of new regulations. Where the regulations are particularly important, as in tax and the movement of peoples, all of us in the European Community have arranged to require unanimity to bring those directives into effect.

Does the Prime Minister realise that Mr. Delors was wrong in the 80 per cent. forecast? Is she not aware that we have already, since 1958, reached that forecast of EEC legislation, let alone the amount in 10 years' time? Does that not suggest that the prime problem is not a future United States of Europe, but the legislative competence which is already enjoyed by the unitary but interlocking institutions of the EEC? What legislative competence for originating legislation is beyond that of the Commission today?

The Commission is committed to carrying forward all the programme of some 300 measures in its 1985 White Paper. The hon. Gentleman is very much aware of that. Where there is an extremely important directive, for example on tax matters, there must be unanimity, and therefore we would have to vote for it. Where there is any change in legislation in terms of the treaty, that matter, too, must come before the House. I know that the hon. Gentleman is keen that we should have maximum scrutiny of all these orders. It is very necessary that we do.

My right hon. Friend has opened up in her characteristically forthright and effective way a major debate on the future political structure of Europe. Does she ever envisage a time when a representative of the Council of Ministers stands before the Dispatch Box of the European Parliament as she does at the Dispatch Box here, answering for the policies and actions of that Council over which national Parliaments no longer have effective control and over which the European Parliament has not yet gained any influence?

I would not quite like to forecast that, but it has been impressed upon me that the Parliaments in other countries belonging to the European Community do not seem to have quite the cross-examination process to which Ministers are subjected in this country. Therefore, Parliament does not play such a central role in some of those countries as it does in ours.

Will the Prime Minister confirm that Commonwealth citizens who presently have the same status as British citizens—

Order. I remind the hon. Gentleman that the question is on the Single European Act.

My question is on the European Act. Will the Prime Minister confirm that those citizens will have the same status after 1992 as they do now—the rights to vote and to stand for Parliament, and so on?

As far as I am aware, the 1992 Act does not alter that. We are concerned that the immigration rules which we have now shall not be affected by the Single European Act. We are concerned to keep controls at borders to ensure that that is so.

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

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

Is my right hon. Friend aware of the growing action of local communities, highlighted by the Daily Express, in removing litter, graffiti and fly posting from our streets? Should that not be encouraged and more people involved so as to rid this blot from our streets, towns and cities?

I wholly agree with my hon. Friend. There could be a major improvement in the appearance of our towns and cities if people did not throw down litter, if any litter thrown down was promptly picked up and if people did not leave large black refuse bags outside restaurants and shops in London. I congratulate Tidy Britain Group on its efforts. I also congratulate the Daily Express on its effort and I am delighted that so many groups have been organised to keep Britain tidy.

I beg to move, That this House doth agree with the Lords in the said amendment.

Good.

The hon. Member for Peckham (Ms. Harman) says, "Good". It is nice to have some non-partisan support for what we are doing.

In subsection (2), consequential on (1), which was mentioned, will the Minister explain what the consolidated fund is at the moment?

Will the hon. Gentleman extend his question so that I can give it the due care and consideration which it obviously requires? Will he explain to me at a little more length exactly what he is talking about?

So that the Minister can get the answer in time, I shall explain. Subsection (2) enables the balance of a discharge of liability to be paid into the consolidated fund. Originally, all moneys were to go into that fund. I am not sure whether that is good or bad.

I am very grateful to the hon. Gentleman for raising this most important point. As the Bill stands, clause 1(12) provides that any sums received by the Secretary of State under paragraphs (a) and (b) in connection with the reconstitution of the GPFC must be paid into the consolidated fund, which is, as I am sure the hon. Gentleman knows, the account into which all public money due to the Exchequer is usually paid. That is because it was envisaged that the GPFC's indebtedness to NILO would be repaid by the purchaser and not by the Secretary of State. The National Loans Act 1968 provides that all money raised by the creation of debt is payable into the national loans fund together with receipts representing repayments of loans made from the fund or, before that Act came into effect, charged directly on the consolidated fund, and interest on those loans. The national loans fund is the channel through which all the Government's borrowing transactions, and most domestic lending transactions, pass. It is still likely that the purchaser will repay the NILO debt directly, but there could be a premium payable for premature redemption which reflects the difference between the prevailing gilt redemption yields. I am sure that the hon. Gentleman is following carefully. That will be only on fixed rate stocks—variable rate stocks will, as I am sure the hon. Gentleman knows, be repaid at par value.