To ask the Secretary of State for Health how many coronary bypass operations have been performed each year for the last 10 available years.

Figures on the number of cardiac surgery operations are collected annually by the Society of Cardiothoracic Surgeons. According to its returns, the number of coronary artery bypass grafts carried out in the United Kingdom in 1977 was 2,881, and in 1985, the latest year for which figures are available, it was 11,800. That is a rise of 310 per cent. over the period.

Is my hon. and learned Friend in a position to confirm that part of the increase has come about because money is available from the waiting-list fund? Is he aware that in one hospital in America—Houston medical centre—more than 3,000 operations are done each year by Dr. Denton Cooley who achieves greater utilisation of the operating theatres by having no trade unionists working in them?

We have been giving priority to coronary bypass grafts for some years, and it is because of that that the numbers have increased so much. It is correct to say—I am grateful to my hon. Friend for drawing attention to this—that about 500 additional such operations have been made possible by the waiting-list fund.

Before the Minister gets carried away with self-congratulations, will he join me in congratulating Councillor Eddie Scott of Calderdale, who has taken a principled stand by not going private in spite of a waiting list of 18 months for a bypass operation? Will the Minister give Councillor Scott and people like him some hope of relief from pain—and, in some cases, some hope of life—by increasing still further the money spent on this vital operation, which, the House realises, was nothing like as advanced in 1977 as it was in 1987?

I am sorry that the hon. Lady thought that I was congratulating myself. I was asked for the figures and gave them. I accept what she said in two respects. First, we need to carry out more of these procedures and are pressing regions to do that. Secondly, I am sad to say that there are districts in this country in which too many patients are made to wait more than a year for treatment. That is not acceptable, and I assure the hon. Lady that we are applying pressure especially to those districts to ensure that waiting lists are brought down. With major procedures such as this people should have to wait the shortest possible time; we shall work to that effect.

To ask the Secretary of State for Health what arrangements he has made for further medical checks and treatment of patients from North Devon who received excessive radiation during 1988 from the radiography department at the Royal Devon and Exeter hospital; when they may expect the first payment of any financial provision; when he expects to receive and reach a conclusion on the reports by independent specialists; what steps he has taken to ensure that treatment now being given is of the highest standard; and if he will make a statement.

These are matters for the Exeter health authority. The report of the independent inquiry by Sir Bryan Thwaites and the conclusions of the medical assessments by Professor Joslin were published by the Exeter health authority on 6 December. All the recommendations have been accepted and are being implemented. I am satisfied that the care and treatment of cancer patients in the Royal Devon and Exeter hospital is being restored to the highest standards.

Does the Minister recall saying in June that there would be no whitewash? May I congratulate her on the fact that both reports indicate no whitewash and are a complete and honest statement of the sad facts.

First, I thank my hon. Friend for those remarks which I am sure will be appreciated by all concerned.

Does my hon. Friend accept that the Devon health authority has been very caring since the accident in trying to look after the patients affected? Does she approve the concept that I put to her that a panel of three, preferably composed of a retired High Court judge, an expert in cancer and an expert in medical compensation, should assess the claims of those people, not to take away their legal rights, but to try and ensure that compensation is paid quickly? That would ensure that those affected are not put to exorbitant costs by solicitors who must be mindful of the fees available when dealing with protracted cases of legal compensation.

I am grateful for the suggestions that have been made by my hon. Friend and other hon. Members about the possibility of using independent assessors. May I refer my hon. Friend to the statement made by the chairman of Exeter health authority on 6 December in which he said that

"the Authority intends to deal with those claims as expeditiously as possible in a way which will cause as little distress to patients and their families as the circumstances will allow. The Authority has instructed its solicitors to reflect this desire".

The Minister should be sacked.

The hon. Gentleman may not be interested in cancer patients in Exeter, but Conservative Members are.

These are tragic events that we all have a duty to ensure do not occur again. Does the Minister agree that such cases highlight the importance of clinical physicists and others in the Health Service involved in the provision of health care? Does she also agree that, over the years, the salaries of such groups have deteriorated in comparison with those of people in comparable professions outside? Will she therefore reconsider her Department's position and once again consider including in the pay review body's consideration clinical physicists and biochemists? If she does not, I fear that the position will continue to deteriorate and we may yet have other cases such as those in Exeter.

We regard our hospital physicists and other hospital scientists as very important. The reports make that view plain, but they do not blame low pay for the mistakes. In our view, the mistakes were more the result of carelessness and incompetence than anything else. An offer has been made through the Whitley councils to the physicists. They have not accepted it and discussions are continuing.

To ask the Secretary of State for Health if he will make a statement on future funding of regional health authorities under the resources allocation working party.

To ask the Secretary of State for Health what plans he has to make changes to the resource allocation working party formula.

I hope to be able to announce the 1989–90 resource allocations to regional health authorities shortly. When the National Health Service management board's report on the review of the resource allocation working party formula was published, the then Secretary of State for Social Services said that the Government would consider the report within the context of the wider review of the NHS. That remains the position.

Does my right hon. and learned Friend agree that a mockery is made of the assessment formula for regional health authorities when Brighton and Wolverhampton are placed in the same league of social deprivation? May I have his much-needed assurance that if the RAWP is genuinely to fulfil its aim of reflecting the relative needs of the population, as I know that he would wish, he will consider most carefully the method of assessment, and especially its implications for the west midlands? Under current figures the west midlands stands to lose £23 million, which would be a disaster.

My hon. Friend has raised this matter with me on a previous occasion. I know that she and other west midland Members are concerned. We are considering the review body's recommendation of a package of changes. It is true that the west midlands sees itself losing some of its proposed share of resources under the RAWP formula. We thought it best to examine the re-allocation of resources within the context of the review of the service, which is now taking place. We shall present our conclusions when we are able to announce the results of the review.

Does my right hon. and learned Friend agree with the concept that morbidity is a better measure of the needs for the elderly than the standard mortality rate, especially in Herefordshire where there is a much greater than average number of elderly and very elderly among the population? Is he aware that there is substantial concern that a national expenditure rate as a means of measurement does not accurately reflect the different economic health of the elderly, for example, of Eastbourne, Hereford and Sandwell? Will my right hon. and learned Friend give careful consideration to these matters and engage in more work on them before he accepts the review?

With allocations that are based on complex formulae, it is always possible to have serious argument on precisely what criteria should be used. My hon. Friend makes two valid points, especially from the point of view of the Hereford health authority, which comes within the West Midlands regional health authority. In the past, the RAWP allocation has helped to remove some of the wide variations in allocations between different parts of the country. We must be sure that future allocations proceed on a fair basis and accurately reflect, as far as possible, varying needs across the country.

Is the Minister aware that Stoke-on-Trent hospitals are already operating a red alert, before the onset of winter? They desperately need assistance from the resource allocation working party. Any changes in the formula that help better-off areas are bound to damage Stoke-on-Trent and other poorer areas. Surely that is unacceptable.

Stoke-on-Trent and many other areas were historically under-provided compared with more prosperous parts of the country. Since the Government have been in office, they have done extremely well. That is because we have applied the RAWP formula to the distribution of resources. We have brought all regions much closer together financially than they were before we took office. Most of the disparities between districts have been narrowed to a large extent. We must now examine the recommendations and ensure that we arrive at the fairest system possible for the allocation of resources.

Can the moneys that are made available under the RAWP formula be re-examined in the light of the recent public hysteria over salmonella, and can additional resources be expended in particular areas? Bearing in mind the statement by the Secretary of State's junior Minister, is it not about time that the hon. Lady was sacked? She has frightened the British people.

The future of the RAWP formula is of serious concern to those who live in the Northern regional health authority areas and in areas within the hon. Gentleman's constituency. He does no service to his patients or constituents by taking the opportunity to ask a frivolous supplementary question on a serious topic.

In any review of the RAWP procedure, will my right hon. and learned Friend bear in mind that the Nottingham health authority, which covers the areas which he and I represent, is still about 5 per cent. short of the RAWP target? Will he bear in mind that if it is able to make up that percentage, it will be able to do much more in furtherance of the excellent progress that has been made over the past seven years to secure an even better health service in Nottinghamshire?

I am grateful to my hon. Friend for reminding me that Trent will do even worse than the west midlands under the proposals that have been made by the RAWP review procedure. Reactions vary according to which part of the country people come from and the impact that the review procedure proposals will have on their region. We have done a great deal in the past, and this has helped Nottingham to open a new teaching hospital. That has been possible with the extra moneys that it has received. We must now hold the balance and arrive at the fairest method of distribution for the future. That will not he a method that reverses all that we have done over recent years to remove the old inequalities.

Does the Secretary of State appreciate that it is rather a weird definition of deprivation that has the net effect of taking cash away from the north-east and the north-west and redistributing it to the south coast and East Anglia on the ground that those areas are more deprived than Merseyside and Tyneside? Does he not also appreciate that he will bring the whole RAWP process into disrepute if that formula is now to be fixed in exactly the same way as the rate support grant formula is now rigged?

The Health Service management board comprised a wide range of people including the regional chairmen of regions the length and breadth of England. Its report is an attempt to revise the criteria of the original RAWP allocation to reflect objective scientific study. It proves that it is almost impossible for anyone to get it right. There are losers and gainers in the north and the south and we have to ensure that whatever method we finally arrive at is fair and broadly acceptable to the bulk of the population.

To ask the Secretary of State for Health what is the average time taken for an appeal concerning pay and conditions, including grading, in the National Health Service to be heard; and if he will seek to reduce the time taken.

We do not collect information centrally on the average time taken to process appeals. However, on 5 December I wrote to regional health authority chairmen asking health authorities to adopt a range of measures aimed at ensuring that the appeals process works quickly and effectively.

Is it not becoming clear that the Royal College of Nursing was absolutely right to resist industrial action and to pursue claims through the appeals procedure? Is my right hon. and learned Friend satisfied that all health authorities are moving to hear those appeals at the same speed? Has any consideration been given to hearing a number of those appeals together to expedite a solution to the problem?

The Royal College of Nursing always pressed for the regrading arrangement and the new grading structure. Since we introduced it, the college has tried to help with difficulties and has discussed with me means by which we speed up the appeals process. I am sure that all the authorities will try to proceed as quickly as possible. The difficulty is that a few are flooded out by many speculative appeals which people have been encouraged to put in when there is no real basis for claims. We believe that the appeal process, properly implemented, can deal with legitimate grievances and, I hope, sort them all out by the spring of next year.

Can the Minister confirm that the Royal College of Nursing and the Royal College of Midwives and the unions have received the guidelines? When will he talk to the unions?

I have made it clear that I will not talk to representatives of the Confederation of Health Service Employees and the National Union of Public Employees while they are still trying to organise industrial action. I know that not much industrial action is still taking place, but they have not yet withdrawn their attempts to stir it up. I cannot have discussions with anyone in which I seek to substitute myself as Secretary of State for the management side of the Whitley council. The regrading exercise was worked out through negotiations between the management side and the staff side and includes all the trade unions of the appropriate Whitley council. The money was set by the review body, that was accepted by the Government and we provided the cash to fund it. In due course I have no doubt that I will have talks on relevant matters with union leaders, but I will not re-open the Whitley council negotiations with people who are trying to cause strikes at the expense of patients.

Does my right hon. and learned Friend agree that in future, questions of pay should be dealt with on a local basis? To resolve local difficulties such as the shortage of intensive care nurses in Birmingham by imposing a national solution is clearly incorrect. The private sector will not resolve Birmingham's problems by imposing a solution suitable to Bristol or Burnley.

I have strong sympathy with my hon. Friend's views and his point applies to the way in which the pay and terms and conditions of a wide range of staff are settled in the National Health Service, which is too centralised and too monolithic at the moment. We have put proposals to the review body on nurses' pay for a small experimental fund next year which can be used to try to devise methods for more local discretion in settling pay to meet particular improvement needs. I wait to see what response that receives from the trade unions and I wait to hear the recommendations by the review body.

Does the Secretary of State appreciate that in the case of Rotherham health authority, any successful appeals, of which there should be a great number because of the many anomalies that have been created, will inevitably result in a reduction in patient services on the present allocation of resources? Does he believe that it is proper to refuse to fund successful appeals knowing that patients will suffer? Is it not better to ensure that both staff and patients are treated fairly?

No, we provided full funding for the nurses' award after the grading exercise was completed and we used the health authorities' own figures to arrive at the figure for full and final funding. I have no reason to believe that Rotherham district health authority has made huge numbers of mistakes in applying the grading structure to its particular staff, although it will no doubt find individual mistakes and correct them. I am quite satisfied that the deal can be implemented without any threat to patient care.

To ask the Secretary of State for Health how he is encouraging health promotion schemes for women.

We are very proud of the action that we have taken to promote women's health. We have implemented screening programmes for breast and cervical cancer to reduce the number of women who die each year from these diseases. The maternal death rate continues to fall. The Health Education Authority is planning to give more prominence to women's health. In June, we sponsored both a debate in this House and a national conference, and this year we are supporting a large number of national voluntary organisations concerned with women's health.

I thank my hon. Friend for that reply. Although it is true that deaths from cervical cancer have fallen by about 14 per cent. in the past 10 years, the number of deaths is still higher than it should be. Can we hope for improvements in that figure over the next few years?

Yes, it is our hope that the new national call and recall system, which is implemented throughout the country, will bring about a reduction in the toll from this particular preventable cancer.

As the Minister still holds the view that most of the eggs in this country are contaminated by salmonella, why has she not included the advice not to eat eggs in her advice for women, under the health promotion scheme?

rose—

Come on.

The hon. Gentleman asked a question and he will get the answer. The Government's view is as follows. Although the risk of harm to any healthy individual from consuming a single raw or partially cooked egg is small, it is advisable for vulnerable people such as the elderly, the sick, babies and pregnant women to consume only eggs that have been cooked until the white and yolk are solid—in other words, hard boiled.

May I ask my hon. Friend to assure the House that she is as concerned about the health of men at risk as about the health of women at risk?

Yes, very much so. As my hon. Friend will be aware, the main thrust of the heart disease programme—the "Look After Your Heart" campaign—is directed at middle-aged men. I was concerned that we were not doing enough for the health of women and I hope that we have put that right.

To ask the Secretary of State for Health what is the number of hospitals where staff are in dispute over the 1988 pay award regarding nurses' grading.

I understand that some appeals against individual gradings have been registered in most, if not all districts. That is hardly surprising in the regrading of some half a million nursing and midwifery staff.

That reply does not reflect the grave dissatisfaction and sense of injustice that nurses throughout the country feel over their grading in the recent pay award. Does the Secretary of State accept that if dedicated people, such as midwives and nurses working in intensive care units, take such action, that is a real expression of their sense of injustice? Does he accept that, if the matter is to be resolved, nurses must be heard and must not be subject to the abuse and attacks that he and other Ministers in his Department have heaped on them in recent weeks? When will the Secretary of State listen to what the nurses are saying and act on that?

It must come as a considerable disappointment to the hon. Gentleman that comparatively few nurses have taken industrial action anywhere, and that action is undoubtedly on the wane. That is not surprising when one considers that the pay increase for the profession as a whole is 17·9 per cent. and in London, the hon. Gentleman's own part of the world, there have been supplements of 5 per cent. to 9 per cent. on top of that. The nursing profession has received its biggest pay award in the history of the National Health Service.

Does my right hon. and learned Friend agree that one of the lessons of the regrading exercise is that matters could be much better managed if the districts had all the necessary powers to recruit, retain and motivate staff and were not second-guessed by the regions?

We have a system of national pay bargaining, from which the regrading exercise emanated in the first place. The exercise started with a national agreement between six trade unions—including the two now organising strikes—and management. I am very much in favour of having much more discretion at district level. However, in a large organisation such as the Health Service, there has to be a national structure in which sensible local discretion can be set. I shall be very glad if we make progress in that direction this year, but we shall have to wait for the response of the review body to our modest suggestions.

Does the Secretary of State acknowledge that we are not only talking about the problem of applying the decisions at national level, and that at district level, too, there seem to be anomalies in the grading structure? Does he realise that, although there may not be much industrial action, there is deep unrest throughout the nursing services, which is spreading in particular to health visitors and school nurses?

I do not accept that there are anomalies. I accept that difficulties arise when people who have all previously been paid the same rate find themselves paid at three different rates according to the grade of the post that they originally held. For midwifery sisters, that can mean the difference between an increase of £500 and an increase of £4,500 a year, and people naturally feel strongly about the grading of their posts. The regrading exercise has been conducted in line with a UK—wide agreement and we have a perfectly satisfactory appeals process to ensure that individual cases are sorted out and that nurses and midwives are put where they belong in the new structure.

Is my right hon. and learned Friend aware that during my hospitalisation last month at the eye, ear and throat hospital in Shrewsbury, a number of members of staff commented about the grading system—one of them starting to do so as early as ten past six in the morning? Although they had genuine grievances, which, after a few days, I could understand in some detail, they continued to give the benefit of their expertise and compassion to the patients, and that is the significant factor. They were not led astray by union agitators or persuaded to demonstrate. My right hon. and learned Friend is absolutely right not to be drawn down the path proposed by COHSE and NUPE, which would be a betrayal of the nurses, sisters and midwives who have stuck by their patients rather than deserted to the picket lines.

I agree with my hon. Friend. For the reasons that I have just given, many nurses were inevitably disappointed by the outcome of this year's grading review, although they have all received substantial pay increases. Even so, most of the nurses who were disappointed would treat with contempt attempts to persuade them to take strike action against their patients to get themselves put on to a higher grade. That is why the action taken by COHSE and NUPE has been so unsuccessful throughout the country.

Is not the Secretary of State worried by the fact that, by 28 December, 40 of the 50 midwives at north Middlesex hospital will have resigned? Does he really believe that he can provide a maternity service with those who remain? Does he not realise that the departure of those midwives and of many disillusioned nurses and midwives could be averted if he accepted the unions' offer to go to binding arbitration? If he is so confident of his case, why is he so afraid of arbitration?

I am pleased to hear that talks with the midwives at north Middlesex hospital have resumed. They are plainly dedicated people, and I hope that they will reconsider their present declared intention and continue to work at the hospital. Meanwhile, they are arguing that they should all be put on the higher grade, which would mean an increase of almost £2,000 a year over arid above the £2,000 a year increase that they have already received. That would simply not be consistent with the agreement reached with all the unions, including the Royal College of Midwives earlier this year. We followed the review body's recommendations and I see no reason at this stage to go to arbitration. The regrading deal was carried out in line with the agreement that we had with the unions and has been accepted by the review body. It has been finished and implemented. We should be looking to next year rather than trying to arbitrate on a settled matter.

To ask the Secretary of State for Health when he next expects to visit the Oxford regional health authority to discuss its future plans.

My hon. Friend the Under-Secretary of State will be conducting the annual review of the Oxford regional health authority on 15 February 1989 when she will discuss the region's performance in 1988–89 and its plans for next year.

Is it not true that the Oxford regional health authority is taking a number of new initiatives, including community-oriented mental health facilities, better health promotion and better information for the disabled throughout the region? Are not those just a few examples of the initiatives that the region is taking, not only on its own, but in conjunction with the voluntary and private sectors, and are not those, in turn, indicative of the increasing number of initiatives that regions throughout Britain are taking to promote better health care?

I thank my hon. Friend for his constructive interest in the health services in his area, which extends, among other things, to chairing meetings about income-generation schemes which are greatly valued. The Oxford regional health authority has the largest increase in population of any region and it is extremely impressive that it has managed to cope with that and bring forward those fresh initiatives. Among the many that my hon. Friend mentioned, all of which we commend, I particularly commend the authority's impressive record of keeping all its districts up to or over the 90 per cent. target rate for vaccinations, so much so that it is now aiming for 95 per cent.—something which other regions could usefully emulate.

Is the Minister aware that earlier in the summer I raised with the Government the impending crisis in the Oxford region resulting from the chronic understaffing, high vacancy rates and high staff turnover at the regional blood transfusion centre? Is he further aware that this week in the Oxford region a circular is being distributed which warns of the partial suspension of some of the services of that critical centre? That will have a disastrous effect on the blood service and some other services such as tissue typing. Will the Minister convene an urgent meeting with me, the regional health authority and other interested Members in the region so that we can get that critical service back on the footing on which it should be for all the region's population?

The blood transfusion service is important in any region. Without notice, I cannot comment on the hon. Gentleman's precise points, but I am available to any hon. Member to discuss such important services and I shall be happy to see him.

When my hon. Friend the Under-Secretary of State visits Oxford regional health authority to discuss its future plans, will she canvass its views on the need for compulsory clinical assessment of the work of consultants within that region? The British Medical Association has been established for over 130 years and the royal colleges for centuries more and there is still no compulsory clinical judgment on consultants' work. When my hon. Friend visits Oxford will he see whether it is prepared to become a trial area to assess the work of consultants?

My hon. Friend refers to medical audit, in which there is growing interest in Britain. We have recently announced the expenditure of a further £250,000 on research into medical audit, the techniques of which are helpful to the development of a good Health Service. Everyone stands to gain from that, not just people in Oxford.

To ask the Secretary of State for Health if he plans to add to the advice given by his Under-Secretary of State, the hon. Member for Derbyshire, South (Mrs. Currie) at Reading, to pensioners on keeping healthy during the winter months.

To ask the Secretary of State for Health if he has received any representations from pensioners or pensioners' organisations about the advice given by the Under-Secretary of State, the hon. Member for Derbyshire, South (Mrs. Currie) at Reading on the subject of keeping healthy during the winter.

On pensioners' health day in Reading the Government drew attention to simple advice on self-help which can make a difference to winter mortality. For the second year running we have a "Keep Warm, Keep Well" campaign, involving the five Government Departments and voluntary organisations, which is proving to be very effective. We have received around 400 letters on the topic. The telephone helpline, run by Help the Aged, is now receiving over 700 calls per week. We are very pleased with the success of the campaign.

On reflection, does the hon. Lady consider that her remarks were ill-judged and stupid? For how much longer will she be allowed to act as court jester, deflecting attention from the fact that for many pensioners this Christmas the choice will be between heating their houses and eating? Is she aware that the best Christmas present that she could give most pensioners, and, indeed, many Conservative Members, would be a month's silence.

The hon. Gentleman seems to have forgotten that the worst winter in recent years for excess winter mortality and hypothermia was 1979. If the Opposition had their way, there would be no such campaign. There was no campaign in the 1970s when winter mortality was much higher than now. The advice is plain common sense and the Opposition would do better to back it.

I congratulate my hon. Friend on her advice for the elderly. Will she confirm that about 20 per cent. of body heat can be lost through the top of the head and that if one wore a hat, the heat loss would be reduced.

My hon. Friend would look very fetching in a woolly hat.

Will the rather expensive and perhaps hard-boiled Under-Secretary restrict her more extravagant comments to cold days since the heat of the anger that she usually arouses may produce more gigajoules than a woolly hat?

The hon. Gentleman is being niggardly in his approach to the "Keep Warm, Keep Well" campaign, which is proving to be popular. We printed 750,000 leaflets on the subject and already demand has been sufficient for us to order a reprint. I am pleased with the way the campaign is going.

Is my hon. Friend aware that in Scotland where we frequently have low temperatures, grandmother's remedies are often the best? Among the remedies that grandmothers in Scotland regularly suggest is that one should wear wool mittens, wool socks and wool hats. In cold weather that helps to keep the elderly warm.

I am glad to receive that further advice. My right hon. and learned Friend the Secretary of State for Scotland also has a campaign in Scotland for keeping warm in winter, and that is going very well.

Given that any attempts made by pensioners to assist themselves to guard against the cold must, of necessity, be cash-limited, is the Minister at least prepared to discuss the possibility of implementing a continuous cold climate allowance for the winter months?

That question should be referred in some detail to my right hon. Friend the Secretary of State for Social Security. There is no doubt that elderly people and others can keep their homes warmer if they have them insulated. One organisation supporting the campaign is Neighbourhood Energy Action, which has already insulated over 500,000 homes and would like to do more.

Does my hon. Friend agree that she should add to the advice she gave about keeping warm in one's own home? The one thing from which pensioners have suffered most grievously—some of them are still suffering—is the inflation that ruined their savings back in Socialist days, and the best advice she could give is for them to ensure that we keep a Conservative Government.

Yes, that is good advice. There is no doubt that whoever we are talking about, they would be well advised to ensure that they do not get cold in winter, especially when they go out. Chills can promote heart disease and may bring on strokes, and that is what causes most of the excess winter mortality.

To ask the Secretary of State for Health what representations he has received on the implementation of the recommendations of Sir Roy Griffiths' report on community care.

We have received over 250 representations from hon. Members, organisations and members of the public about Sir Roy's recommendations. We are studying all of them carefully, as we frame our own proposals.

Does the Secretary of State agree that the weight of opinion is with Sir Roy Griffiths in maintaining that the local authorities are best placed to assess local needs, set priorities and monitor performance? Will he make a categorical statement to that effect?

I have just told the House that we are still considering our own proposals. We have had a variety of responses from all the representations I have described. Everyone agrees that there is a serious problem. We have to look at how best to provide care in the community and how best to arrange responsibility for it. We have to look at all the various models put before us before we can come to a definite conclusion.

My right hon. and learned Friend will know how anxiously his decision on the Griffiths' report is awaited, not just by statutory bodies but by voluntary organisations. Can he tell the House when he hopes to reach a decision?

I realise that it is essential that we reach conclusions as soon as we can. It is an important matter, and I believe that few people think that the status quo is highly satisfactory. It will be some time next year—I hope, early next year—before we can reach any final conclusions,because the reactions we have received are so varied and there are a number of options before us.

The Government have dilly-dallied over the Griffiths report, which was published the day after the Budget. Is not the Secretary of State worried that the growth of uncontrolled expenditure by the taxpayer on private residential homes that Sir Roy identified has now reached the £1 billion mark? Is it fair that the chaos in community care that so worried Sir Roy should continue, particularly in view of the Government's clear opposition to a democratic role for local government, which Sir Roy himself accepted?

There has been a huge increase in public expenditure of all kinds on care in the community, most of which reflects the increased priority that the Government have been giving it. I accept that we must look at the situation again, to ensure that there are clear responsibilities for delivering the care and that the right relationship exists between all the various agencies involved. We shall announce our conclusions as quickly as we can.

To ask the Prime Minister if she will list her official engagements for Tuesday 13 December.

This morning I visited St. George's hospital in Tooting to visit some of those injured in yesterday's train crash, and to thank the hospital staff and the emergency services. In addition to my duties in the House, I shall be having meetings with ministerial colleagues and others later today. This evening I hope to have an audience of Her Majesty the Queen.

Will my right hon. Friend take this opportunity, in the aftermath of yesterday's appalling rail crash, to record the thanks of the whole House, first, to the emergency services and secondly, to the master and boys of Emanuel school who happened to be passing when the accident occurred?

Yes, I gladly respond to my hon. Friend's remarks, and the whole House will wish to record its congratulations and thanks to the emergency services and to the hospital staff for the excellent work that they did yesterday. I thank also those of Emanuel school who saw quickly what was happening, and who were thoughtful and swift in their reactions. They are a credit to the young people of our country.

I join the Prime Minister in expressing my deep sorrow for the pain and grief suffered by those hurt in yesterday's accident, my sympathy for their loved ones, and my admiration for and thanks to those in various capacities who helped the injured. I am sure that the whole House will want to return to that question, which is one of deep public concern.

Order.

Will the Prime Minister take the advice offered by myself and by others, and consider proceedings under the Criminal Law (Jurisdiction) Act 1976, especially since the Irish Attorney-General commented in his statement today that the charges are of a most serious kind and should be investigated by a court?

The Government utterly repudiate the assertion that Patrick Ryan would not receive a fair trial in this country. The effect of the Irish decision is that a person accused of very serious crimes will not now be brought to answer them in an English court of law. That underlines how right we were to say that the existing extradition arrangements are inadequate, and we look to the Irish Government to honour their pledge to re-examine them.

The Prime Minister can repudiate as much as she likes. She is faced with the fact that Patrick Ryan will not be extradited to Britain and it is primarily her fault. I understand that the Prime Minister is very disappointed; that feeling is shared by many others, including myself. But she is also culpable. She blew the possibility of extraditing Patrick Ryan. May I ask whether she will ensure that both she and the Attorney-General will avoid making again the errors so far committed—errors of judgment, fact and conduct?

Let me answer the right hon. Gentleman by pointing to the facts. The Irish Extradition (Amendment) Act 1987 itself requires the Irish Attorney-General to state that he is satisfied that the United Kingdom prosecuting authorities have sufficient evidence on which to prosecute. I understand that the Irish Attorney-General agrees that that is so. He made his decision on an entirely different ground.

All that the Prime Minister has said about Belgium and the conduct of affairs there was well known a fortnight ago. Why, then, was she so poisonous about the conduct of affairs by the Irish Government?

"The charges which have been brought against Patrick Ryan are of a most serious kind, and they should be investigated by a court. The Criminal Law (Jurisdiction) Act 1976 provides a means whereby certain serious offences committed outside this jurisdiction may be tried here."

"Such a trial may … take place before a court of three judges … Heavy penalties are prescribed by Irish law for those offences."

Order. Let us hear the Leader of the Opposition.

Is it not the case that because the Prime Minister cannot get everything that she wants she is going to settle for nothing?

The fact is that the Irish Attorney has refused to back our warrant on grounds that do not arise from the 1987 Act. The result is that someone accused of very serious crimes will be at liberty in the Irish Republic. I notice that the right hon. Gentleman does not put his weight behind trying to secure the extradition of Ryan.

To ask the Prime Minister if she will list her official engagements for Tuesday 13 December.

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

Does my right hon. Friend believe that a permanent postal monopoly can be justified if this vital public service is continually undermined by strikes?

I am very pleased that some 60 per cent. of Post Office counter staff continued to work. That is very good news. However, I agree with my hon. Friend that if we continue to experience sporadic troubles the permanent monopoly of the Post Office will come under review, and, we shall have to consider a reduction in the present level of £1.

It is obviously a quite unacceptable insult to the people of this country to say that Patrick Ryan would not receive a fair trial in Britain. That belief should be conveyed to the Irish Government as coming from everyone—[Interruption.]

Order. It is a very serious matter.

Furthermore, is it not bound to mean that the Anglo-Irish Agreement is now questioned by everyone in Britain? Will that also be conveyed to the Prime Minister of the Irish Republic?

I am very pleased that the right hon. Gentleman agrees with us in repudiating utterly the assertion that Patrick Ryan would not receive a fair trial in this country. Of course he would, but the arrest of anyone on charges of that nature inevitably will receive front-page treatment. It would be a matter for the courts if there were any prejudice to the trial which inevitably would be heard very far from the time that we had the problem. We must use the Anglo-Irish Agreement to make our point vigorously to the Irish Government on this matter. At the time, the Irish Government promised to review their 1987 extradition Act if it was not working satisfactorily. It is not working satisfactorily, so we shall call in that promise for them to honour.

Have we not conferred upon the Government of the Irish Republic, by treaty, a place of special privilege in relation to Northern Ireland? Since Northern Ireland has suffered more grievously than any other part of the United Kingdom at the hands of terrorists, is it not a signal irony that the Irish Government are presently the harbourer of a suspected terrorist?

My hon. Friend makes his point very cogently. Under the Anglo-Irish Agreement we can tackle the Republic of Ireland about matters of security just as much as they can tackle us. The difficulty is that the Republic of Ireland unilaterally passed a different extradition Act, when we already thought that arrangements had been agreed between us. That Act is not working properly, and the decision taken under that Act, not for any reasons within it, has caused the present trouble.

Does the Prime Minister remember her elegant words in 1964 at the Conservative party conference when she said:

"Any country or Government which wants to proceed towards tyranny starts to undermine legal rights and undermines its own law."?

The Act to which the hon. Gentleman refers gives two grounds for refusing extradition. Those are not the grounds which the Irish Attorney-General has used. He has used nothing related to those grounds. He has chosen something totally different, which is a great insult to all British people. We must make that very clear, and I hope that the hon. Gentleman will look at the Act and agree with us.

Is my right hon. Friend aware how widespread devastation in the egg industry has become? The Sunday papers tell us that 10,000 people will become redundant before Christmas and millions of egg-laying hens will be slaughtered prematurely. All this has occurred because of the ill-considered and negligent remarks of one of her junior Ministers. Does my right hon. Friend agree that one more redundancy should be added to that list, that of the Parliamentary Under-Secretary of State for Health, the hon. Member for Derbyshire, South (Mrs. Currie)?

So far this year 49 cases of salmonella affecting just over 1,000 people have been traced to eggs. That is why the Government have taken steps in conjunction with the industry to issue codes of practice. Those figures demonstrate that there is a problem.

Order. These are matters of grave concern not only to the House but to those outside it.

To ask the Prime Minister if she will list her official engagements for Tuesday 13 December.

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

The Prime Minister started her Question Time by congratulating hospital staff. Is she aware that many nursing staff in Lanarkshire and throughout the country have been denied fair grading because they have been deemed to be working under supervision, even when the supposed supervisor is off duty, asleep and at home? Does the right hon. Lady agree that there can be no adequate supervision when people are miles apart and completely out of touch with each other? Does not her relationship with the Chancellor of the Exchequer prove that very point?

The grading structure was agreed between the management side and the nursing staff and went before the review body. The review body added an amount necessary to implement that structure. That was not sufficient, so my right hon. and learned Friend the Secretary of State for Health and my right hon. Friend the Chancellor provided an extra amount. Together. the sums came to nearly £1 billion. The structure and the money have to be applied through the regions and the districts. There is no way in which Government can undertake the regrading of 500,000 nurses. The overwhelming majority of nurses are more than satisfied with the extra that they have received, which is considerable—an average of 18 per cent., and the highest amount that they have ever had.