What changes he plans to make to the system for auditing spending by NHS trusts. [52772]

All NHS trusts are currently subject to an annual external audit of their financial statements by independent auditors appointed by the Audit Commission. That will not change, although a new commission for health care audit and inspection will be created from the current functions performed by the Commission for Health Improvement, the value-for-money studies of the Audit Commission and the private sector health care work of the National Care Standards Commission. I expect the new commission to be in place, so that it can audit NHS performance, by 2003–04.

How will my right hon. Friend strike the right balance between ensuring that everyone who uses NHS services can see the benefits of increased investment, and not impeding professional choice or adding unnecessary bureaucratic burdens?

As my hon. Friend suggests, if people are putting more money into the national health service, it is important that they see what they are getting out of it. The truth is that, at the moment, we have a fairly bureaucratic and fragmented system of inspection. That system has evolved in the past few years, but because it is fragmented it weakens inspection. We have an opportunity to combine in a new, strengthened system the integrity and independence of all the various organisations that contribute to regulation not just of the NHS but of the private sector. That system will make the issue of where the money goes and how performance is improving much more transparent to the public.

Does the Secretary of State accept that Mrs. Drew, a constituent of mine, would welcome a thorough audit as soon as possible of the spending of Barnet and Chase Farm Hospitals NHS trust? On 19 April, she was interviewed by the oncology department consultant in the hospital's new unit, which was opened in February. Unfortunately, she was informed that she has cancer; she was also told that she must be treated at North Middlesex hospital, in Edmonton. Although the new unit at Chase Farm is fully equipped to provide her treatment, there is no funding, and North Middlesex hospital is the only alternative to provide her six-month treatment. When such mismanagement is revealed, how can she have faith in the Government's claim that they are providing services for patients?

I have every sympathy with the plight of the hon. Lady's constituent, and if she cares to write to me, I shall look into the matter. However, she might be aware of the horns of the dilemma that she and her hon. Friends now face. She says that she wants more investment, but she voted against it a fortnight ago. She cannot have her cake and eat it. Does the national health service need more investment, or not? Our answer is yes; what is hers?

My right hon. Friend will know that the vast majority of hospitals have excellent accounting arrangements and offer exceptional value for money for the NHS system. Some, however, have been unable to meet the Government's strict requirements, and have had to be franchised. How is the franchising process progressing, and when will the Dartford and Gravesham acute trust, in particular, receive some news on when the process is likely to be completed?

My hon. Friend is aware of the good work being carried out in his local hospital, as well as some past problems with its management and organisation. As he says, a franchising process is under way, and I hope to finalise it before too long. In all parts of the national health service, it is very important that, where there are persistent problems with performance, poor management and lack of organisation, they be dealt with. Every part of the NHS deserves the best management because, as he knows, good management makes a huge difference.

Does the Secretary of State agree that it is unfortunate that, although the audits tell us that money is being properly and legally spent, they offer no guidance on issues of policy? For example, how much extra does the provision of agency nurses, rather than ordinary ones, cost the health service? How much does the existence of hospices save the health service, given that 72 per cent. of the money comes from voluntary donations? Given that the NHS is not a profit-making organisation but a public body, should not the audit provide wider interpretations of what is happening, where money is being spent, how it could be saved, and the ways in which it has not been saved?

That is precisely the idea behind our proposed new audit arrangements. Obviously, the new commission for health care audit and inspection will require legislation, and that will be a matter for debate in the House. The idea is that, for the first time, one organisation will be responsible for examining clinical standards throughout the health service; for considering performance issues, which my hon. Friend the Member for Dartford (Dr. Stoate) rightly described as important; and for considering where NHS money is actually spent—the issue that the hon. Gentleman raises. The public, who put money into the national health service, will therefore know where it is going and the results that accrue from it.

Does the Secretary of State accept that any strengthened and reformed audit system should look at strengths as well as weaknesses? Will the new system be used to promote success, using the staff and the trusts that develop good and modern practices?

My hon. Friend makes an important point. He knows as well as I do of the many examples of good practice in the NHS. Part of the function of the existing Audit Commission and Commission for Health Improvement, to which I pay tribute today, has been to highlight good practice as well as poor practice, so that others can learn from that. That will also be part of the new commission's function. We need to ensure that all parts of the NHS, and every patient, have high standards of treatment and care, and that taxpayers are assured that they are getting a good deal from the extra money going to the NHS.

If he will make a statement on the future of cottage hospitals. [52773]

Cottage hospitals continue to make an important contribution to the delivery of the NHS plan by providing care closer to home. We expect them to be key players in meeting our target of introducing an additional 5,000 intermediate care beds by 2004.

I am grateful for the Minister's answer, which is typically feisty in support of cottage hospitals. The 5,000 beds may make a small dent in the 50,000 care home beds that have been lost since the Government came to power. The Minister will know that the future of the cottage hospital in Burntwood is in considerable doubt. Indeed, I wrote to the Minister of State on 24 January on that point, but he still has not replied to me. As for Lichfield, the Minister will know that on 15 May the Burntwood, Lichfield and Tamworth primary care trust will recommend the building of a new hospital in Lichfield. Will that new hospital be funded by a private finance initiative, which the local people and the primary care trust do not want?

As the hon. Gentleman knows, extensive local discussion has taken place about re-providing excellent facilities for his constituents. The proposals are for a new community hospital with 52 in-patient beds, rehabilitation facilities, out-patient, diagnostics and X-ray equipment, a pharmacy, a minor injuries unit, a renal satellite dialysis unit and, I hope, a maternity unit—all under Labour. The hon. Gentleman asks whether the hospital will be funded by a PFI or by traditional procurement. He wants the money and the investment, so I am pleased that on his website he said that the Budget was good for the NHS. If that is the case, why did he not vote for it?

My hon. Friend will be pleased to know that the future of the cottage hospital in Swanage is secured, following the opening of a day surgery unit there in the past 12 months. However, the lack of decent, affordable public transport for patients and visitors—especially from rural areas—to that hospital remains a problem. What steps are her Department and others taking to improve that situation?

My hon. Friend is right. Providing care closer to home means that patients and their families need to be able to reach facilities as quickly as possible. We have a project that is examining transport across the board to see how we can get people to out-patient and diagnostic appointments. Perhaps we need a revolution, with consultants going to the patients rather than it always being the other way round. My hon. Friend makes an important point and we are on the case.

I support the case put forward by my hon. Friend the Member for Lichfield (Michael Fabricant) for cottage hospitals and their funding. Is the Minister aware that the Congleton and District War Memorial hospital was funded by subscriptions from people who paid a penny a week from their wages, that we have fought closure on more than one occasion, that the services at that much valued local facility have changed over the years and that local people want it to continue? Will she give her support to the health authority for the hospital to continue to provide services for all local people?

I am delighted that the hon. Lady's constituents treasure and value that hospital, which is part of their NHS. It is important that we have a wide variety of services, including acute trusts and local cottage hospitals. As the NHS develops, so the role of cottage hospitals will become more important in providing recuperative care, day surgery facilities and a range of new ways of delivering services. That is why the new investment is important, together with the reforms, so that the hospitals continue to have a vibrant role to play. I am not aware of the specific details about Congleton, but I shall respond to the hon. Lady in writing. However, she must recognise that for her hospital to be maintained, she has to approve the extra investment going into the service.

If he will make a statement about funding for child and adolescent mental health services in Birmingham. [52774]

In the past three years, we have invested some £85 million across the national health service and local authorities for child and adolescent mental health services.

May I thank my hon. Friend for the substantial increase in the resources that are now coming through for this vital service for children? Does she agree that it is not just funding that is a constraint but the desperate shortage of psychiatrists and other therapists? Furthermore, as my inquiries into the service provided by the Children's Trust in Birmingham seem to indicate, management is poor and protocols inconsistent. When the Commission for Health Improvement visits the trust in the near future, will my hon. Friend ask it to pay particular attention to those matters, especially in relation to the suspension of one consultant psychiatrist? She was able to manage her work load and keep waiting lists down so that the children did not languish on waiting lists for up to two years, as is the case for children in my constituency. Might I add that that is not the first suspension by the Children's Trust that has caused me concern?

I agree that we need to address the issue in several ways. My hon. Friend is right to say that there is a challenge in recruiting and retaining the skilled staff that we need to provide child and adolescent mental health services. There is also a challenge, as she suggested, particularly in Birmingham, in managing resources effectively. Work is under way to build on the four new primary care trusts as localities for delivering child and adolescent mental health services.

What are the plans for the provision of secure units in Birmingham and elsewhere for severely mentally disabled and ill people, many of whom end up, quite wrongly, in prison?

As I suggested in my first answer, the regional specialist commissioning group has allocated £549,000 from the West Midlands specialist modernisation fund to develop an acute assessment unit at the Park View clinic in Moseley, Birmingham, which is due to open later this year. I agree with the hon. Gentleman that, with young offenders, it is also important to ensure better joint working between youth offending teams and the child and adolescent mental health services. In addition, we are investing in mental health services in prisons and for young offenders so that they receive the treatment that they need when in prison in a way that has not happened previously.

Does the Minister also recognise that many young people with mental health problems never reach the health service? Often, in constituencies like mine, their problems arise from traumatic experiences overseas from which they have fled, and they report their concerns in schools. What work is my hon. Friend doing with the education service to ensure proper care for children and adolescents with mental health problems such as those?

My hon. Friend makes an important point. It is crucial that we work across the agencies in a better way than we have done previously. First, we shall include in the national health service framework for children work on standards to improve child and adolescent mental health services. We have recently worked with colleagues in the Department for Education and Skills on promoting mental health in early years and school settings. We are working with it on its programme on improving behaviour. In addition, we are funding, and will continue to fund, innovation projects that look particularly at how to get professionals such as health visitors, teachers and primary care workers working together earlier so that we prevent the escalation of some of the mental health problems that my hon. Friend has outlined.

In Birmingham, child psychiatrists do not have the nurses that they need—they are able to treat only emergencies. The waiting time for seeing a patient on the list is 18 months. At a time when the Department for Education and Skills and the Home Office are making announcements about the problem of disaffected youngsters, will the Minister explain what the Department of Health is doing about adolescents and children with mental health problems? Given that children and adolescents form 20 per cent. of the population, why does only 5 per cent. of the mental health budget go to services for them? Why do places such as Birmingham spend so much less than elsewhere? Is it not time that the Government dealt with the problem of child and adolescent mental health instead of cutting the money as they did last year? Last year, £10 million allocated for mental health was chopped out of the budget and sent off to other priorities. Is it not time that those services were given the priority that they deserve?

In fact, the out-turn figures for 2001 suggest that, for child and adolescent mental health services, Birmingham was the second highest spending authority in the west midlands. Of course, the authority was able to spend that money because of the extra £85 million invested in child and adolescent mental health services by the Government. This year, there are plans to increase services in Birmingham: better services for 16 to 18-year-olds and better services for early intervention, so that the whole of Birmingham is covered. Once again, Opposition Members are willing to whinge about money, but they are not willing to vote for it.

What his policy is on extending the right to adopt to unmarried couples; and if he will make a statement on the technical and practical problems in incorporating such a right into the Adoption and Children Bill. [52775]

The Government's objective is to increase the number of children who have the opportunity, through adoption, to grow up as part of a loving, stable and permanent family. On Second Reading of the Adoption and Children Bill, I told the House that I believed that there should be a debate on adoption by unmarried couples. Since then, there has been a wide-ranging debate and during the passage of the Bill we have received many representations on the issue.

I thank my right hon. Friend for his answer. I am delighted to hear that the issue will be subject to a free vote. The proposal has support on both sides of the House and is likely to increase the number of adopters for the many children in care who need permanent families. Should the amendments be accepted—as I hope they will be—will my right hon. Friend ensure that there is a rigorous process so that the needs of the child are always paramount, rather than the needs or wishes of the adopters?

I very much agree with my hon. Friend's assessment. Indeed, it is important that we understand, when considering the issue and the amendments—which I personally support—that they are simply about widening the pool of potential adoptive parents so that more vulnerable children, rather than being stuck in the care system, have the chance of the stable family life that adoption can bring. If the amendments are passed, it will be for adoption agencies and, ultimately, the courts to decide who is suitable to adopt. No one has a right to adopt. There is a rigorous assessment process and it would not change if the amendments were passed. Indeed, under one of the amendments tabled by my hon. Friend the Member for Wakefield, a couple wanting to become adoptive parents will have to prove not only that they can provide a loving family environment but also that they have formed a long-term, stable relationship. In the end, that assessment process will not be a matter for politicians—still less for Parliament—to determine; it will be for the courts to decide what is in the best interests of the child.

The Secretary of State will know that the new clause tabled in my name and in the names of many colleagues on both sides of the House is similar to the newly tabled amendments of the hon. Member for Wakefield (Mr. Hinchliffe). I welcome a free vote as progress on the Government not giving their view on the matter. British Agencies for Adoption and Fostering, which represents a coalition of relevant bodies in the interests of children, also recognises that concession. Having said that, does the Secretary of State agree that it is unfortunate that he has not been able to give full Government support for something that he accepts is in the best interests of children and provides for equality in this area? Liberal Democrats look forward to a time when there will be an opportunity to expand the number of people who can adopt children into suitable homes.

I am grateful—at least I think I am—for the hon. Gentleman's support. Let us remember that, during the passage of the Bill, we established a Special Standing Committee to look in depth at those issues and to take evidence from a variety of quarters. What the hon. Gentleman recognises, and what I recognise, is that there are many different views on this issue. Given the sensitivities of the issue and the fact that there are many different views, it seems appropriate to have a free vote as the right way forward.

May I welcome my right hon. Friend's statement today and thank him and the Minister of State for listening to the representations made from both sides of the House on this issue? Does he accept that the welfare principle—the duty to secure the best interests of the child—has been at the heart of the success of the Children Act 1989? Does he agree that our difficulty with the Adoption and Children Bill as drafted is that children's best interests would not be secured if those interests would be furthered by their being adopted by an unmarried couple?

I agree with my hon. Friend's remarks. I am grateful to him for his consistent support on the issue and for the help that he has given to many organisations in taking forward their views on it. There is a simple principle here: it is not about extending the right to adopt to anybody, but about extending the right of more children to be adopted. Surely, if we can do that, and if we can make it easier for more children to be adopted, to form part of a stable, loving family environment, that is precisely the right thing to do. I hope that right hon. and hon. Members on both sides of the House will feel able to lend their support to the amendments tabled by my hon. Friend the Member for Wakefield.

The whole House will acknowledge that we should congratulate all adults who step forward wishing to adopt children, which must be a better option than the alternatives. In saying—rightly so—that the interests of the child are paramount, will the Secretary of State confirm that the stable, loving environment about which he talks must, in every situation, include a mother and a father? Will he confirm that that is the kind of stable couple that he has in mind?

The amendments tabled by my hon. Friend the Member for Wakefield refer to two-sex couples and same-sex couples. He is aware that, under current adoption law, it is perfectly possible not just for married couples to adopt but for single people, regardless of their sexual orientation, to adopt. In the end, my view is that the question of who is suitable to adopt is a matter for the courts to determine.

We have only one opportunity in a generation to implement adoption law, and the last time was 1976. Children have waited too long, so it is vital that we get the legislation right. We must also remember that 19 out of the 20 professional and voluntary agencies that gave evidence to the Special Standing Committee supported the amendments that I tabled in Committee and that have subsequently been tabled by my hon. Friend the Member for Wakefield (Mr. Hinchliffe). May I also praise the Minister of State, Department of Health, my hon. Friend the Member for Redditch (Jacqui Smith), for her excellent work in taking the Bill through Committee?

It will be for the business managers to agree when the Bill should come back to the House on Report. Obviously, the amendments will be dealt with then.

Given the House's concern for the well-being of children, we want to ensure that we get the legislation right. However, has the Secretary of State been made aware of recent figures that show that, when a child comes along, there is a higher degree of breakdown in relationships among people who cohabit? We must therefore be careful that children who have already suffered one trauma do not suffer another.

I understand that and the hon. Gentleman's views on the issue. I am also very familiar with the statistics. When the hon. Gentleman has an opportunity to consider the amendments tabled by my hon. Friend the Member for Wakefield, he will see that they amend the Bill so that couples wishing to go forward as potential adoptive parents will have to demonstrate that they have formed an enduring, long-term relationship. However, that is not a matter for me or the hon. Gentleman to determine; it must be a matter for the courts to decide. If we can make it easier for more children to be adopted, that surely must be the right thing to do.

How many people were waiting 13 weeks or more to see a consultant on (a) 31 March 2002 and (b) 31 March 1997. [52776]

On 31 March 1997, there were 247,488 patients waiting 13 weeks or more for a first out-patient appointment. The figures for 31 March 2002 will be published shortly.

I am grateful to the Minister for that somewhat inadequate reply. Can he give me the figures for my local hospital, the Queen Elizabeth hospital in King's Lynn? Will he join me in congratulating all the staff at that hospital on the superb work that they do in serving the local community? They do an excellent job. However, is he aware that there are serious shortages of radiographers and radiologists, which means that people wait far too long for CAT and MRI scans? Serious nursing shortages are also building up, so what guarantees can he give my constituents that the extra money promised for the health service will solve local problems?

I certainly agree with the hon. Gentleman that it is important to keep the investment coming through to the national health service, but he and his hon. Friends have some explaining to do. They come here and talk about the need for extra investment but, when they are given the opportunity to vote for those resources to go the NHS, they vote against the increase. He should go away and rehearse his lines.

Will my right hon. Friend comment on the fact that there has been a marked improvement in waiting times to see consultants in my region of Yorkshire and Humber? However, as one talks to hospital administrators, it is emerging that one of the side effects of the Coleman recommendations on training and on the continuous training of surgeons is the significant and growing number of surgeons who are suspended. Will my right hon. Friend look into that to see whether it is a national problem, because there is real concern in the Yorkshire region about it?

I am not familiar with the problem that my hon. Friend raises. I will certainly look into it, however, and I am sure that he, like me, welcomes the progress on reducing waiting times in Yorkshire.

The reason I voted against the tax on jobs was that I did not believe that the money would get through to pay for the nurses, doctors and extra beds that we clearly need at the Royal Berkshire hospital in my area or, for that matter, anywhere else in the country with a similar problem. If the Minister wishes to change my mind, will he promise us that the number of nurses, doctors and extra beds that the Royal Berkshire says it needs will be met immediately from the new money, so that we can clear the waiting list? Does he agree that the waiting list is far too long and that people are waiting too long in pain? Is he not really saying that he has no intention of appointing those nurses and doctors in the foreseeable future?

I can only assume that the right hon. Gentleman is being ironic. He asks me to commit investment next year, but he and his right hon. and hon. Friends have just voted against such increases. He has no credibility in making that point in that way. I strongly believe that, in addition to the investment, we need to reform the way in which we organise and deliver health care, and that will be part of our approach. I honestly believe that the right hon. Gentleman needs to go away and think about his position more carefully than he has done since the Budget was published.

Does my right hon. Friend agree that more progress would be made in cutting waiting times if we ensured that consultants who are trained by the NHS and paid full-time by the NHS actually worked full-time for the service? What progress is being made on reforming consultants' contracts to ensure that that happens?

I agree that it is right to follow the principle that those who make the greatest commitment to the NHS should get the greatest reward. We published our proposals, as my hon. Friend will be aware, to reform key elements of consultants' contracts in February of last year. Those negotiations are under way. We are making good progress in general and I hope that they will he concluded in the near future.

Do the figures that the Minister gave include the hidden waiting lists? Will he confirm the figure in the "Not the waiting list" report in The Sunday Times last weekend—that at least 250,000 people who are waiting for tests to determine the type of surgery or other treatment that they need are excluded from the Government's published figures? Does he think it legitimate for senior NHS executives to warn hospitals against "overstatement of waiting lists" and to order chief executives to keep certain people who are waiting for diagnostic tests off those lists? Given the National Audit Office exposé of hospitals fiddling waiting times last year and now this, why should anyone believe any figures produced by the right hon. Gentleman's Department?

The figures are reliable. The hon. Gentleman is doing a disservice to the NHS by claiming anything else. The figures that he relies on to make his point about access to diagnostic testing and so on are collected in the same way as his party collected figures when it left office in 1997. There has been no change whatsoever in the collection of that data. The hon. Gentleman and I may agree on one thing, however: it is important that we increase access to important diagnostic treatments and, in particular, to therapeutic treatments. That is why the NHS cancer plan includes, for the first time, an important commitment to reduce the waiting time for treatment, and I hope that the hon. Gentleman will be able to support that.

How many cancelled operations there were in the last year. [52777]

In 2000–01, the last full year for which data are available, there were 77,818 operations cancelled by the hospital for non-clinical reasons when the patient was due to be admitted for treatment.

I thank the Minister for that response. Given that there has been a 50 per cent. increase in the number of cancelled operations since 1997, what estimate have the Government made of both the cost to local government and the effect on council tax of their latest policy of fining councils for bed blocking in hospitals?

Clearly, too many people are having their operations cancelled, but the most recent quarterly figures show that the number of cancellations is dropping and progress is being made. It is right that social services departments support the reductions in NHS delayed discharges, and that is exactly why they are getting a substantial increase in their resources—way above the increases that they got under Conservative Governments.

Does my hon. Friend make the connection between delayed discharges, cancelled operations and the fact that, in my constituency, Conservative-controlled Cambridgeshire county council is still spending only 85 per cent. of its standard spending assessment on services for elderly people?

Obviously local councils that are not making the right decisions on delayed discharges will have to take responsibility for those decisions. That is why we are effecting reforms, as part of the Budget package. This is about investment and reform: investment that the Conservatives have decided to vote against, and reform that is essential to provide everyone with the incentive to improve NHS care.

Does the Minister expect that when the Government have increased the proportion of national income spent on health in England to the levels already prevailing in France and Scotland, the number of cancelled operations, waiting lists and other indicators of health performance will have reached French levels or Scottish levels?

Waiting times and cancellations are already falling. Substantial improvements are already being made throughout the NHS as a result of the extra investment. The right hon. Gentleman really must join his party in making a decision on this. Do the Conservatives want the extra investment to go into the NHS to bring down waiting times and improve services for NHS patients throughout the country, or not? They have said that they want to see the improvements, but they will not back the investment that we need.

May I support the Minister's efforts to reduce delayed discharges as a way of reducing cancellations? I draw her attention to the single most effective measure that is being taken in Milton Keynes to deal with delayed discharges, which is a single social care assessment protocol agreed by social services and the NHS. May I urge her to try to make sure that a national social care assessment protocol is agreed, so that all social services and NHS personnel throughout the country can work more effectively to reduce delayed discharges?

Yes, and I can also say that considerable work is being done throughout the country to improve the co-ordination between social services and the NHS. That is part of a broader modernisation programme, including an £8.5 million programme by the modernisation agency to cut cancelled operations.

The Minister will be aware that if an operation is cancelled at the last minute, it should take place within a month, but for 21 per cent. of patients that does not happen. Is the Minister happy with that state of affairs? If not, what is she going to do about it?

That target was introduced on 1 April, and it will be addressed as part of the performance management framework throughout the NHS, including the work of strategic health authorities.

Given South Staffordshire's success in reducing the number of cancelled operations and cutting waiting times for cataract operations by using modernisation fund money to establish a cataract surgical unit, will my hon. Friend support places such as South Staffordshire in establishing orthopaedic surgical units to enable similar success in cutting the number of cancelled operations and reducing waiting times for hip and other joint replacements?

My hon. Friend is right; changing the way in which services are provided can make a substantial difference, particularly in the separation of emergency care from elective care, which is exactly why we are supporting a substantial number of new diagnostic and treatment centres that are being developed and invested in across the country.

But those appalling figures for cancelled operations are not the whole story, are they? What does the Minister say to the trust which advises that

"if there is doubt as to whether admissions can be accommodated the following day, the cancellation should occur the day before",

"this will enable the Trust to deliver our target of NIL same day cancellations"?

The hon. Gentleman knows that that is nonsense. The figures have not been changed; the latest quarterly figures show that the number of cancellations is falling. It is important, however, that we carry on making progress. The hon. Gentleman has to decide whether he wants to support additional investment for the extra beds needed to bring the number of cancellations down; the extra capacity that is needed; and the extra doctors that are needed. Or does he want simply to carry on cutting, as the previous Administration did?

Even by this Government's standards on evasive answers, that was fairly appalling. Let me give the Minister another problem and offer her a second chance. Given that bed blocking is one of the major causes of cancelled operations and that the Government's policy is to fine local authorities that have bed blocking in their areas, will she confirm not only that that will cost about £400 million, which will be passed on to the council tax payer, but that it will offer the ultimate perverse incentive? GPs in areas where there is bed blocking will realise that the best way to get patients into a local nursing home is to admit them to hospital, which will increase pressure on hospitals, worsen bed blocking and increase the number of cancelled operations. Will the Minister admit that that is the craziest of all the Government's insane policies on health, and will she stop doing damage now before it gets even worse?

No; clearly there is an issue about delayed discharges, but the proportion of older people waiting to be discharged has fallen in the past few years. Additional investment is going in, and it is right that it should continue to do so, which is why the Budget included proposals for an extra 6 per cent. in real terms for social services, compared with less than 0.5 per cent. under the Conservative Government. The hon. Gentleman has to explain how he expects councils to tackle the issue of delayed discharges with the level of funding provided by the Tories, who year after year managed less than 0.5 per cent., which is pathetic. The hon. Gentleman's party is unable to fund the NHS or social services.

What estimate he has made of the cost to the NHS of the increase in national insurance contributions announced in the Budget. [52778]

I estimate that the changes to employers' national insurance contributions announced in the Budget will cost the NHS about £200 million in 2003–04.

I still think that we will have to scrutinise that figure carefully. Will the Secretary of State provide an estimate of the increase in national insurance contributions for senior house officers, ward sisters and consultants as a proportion of their average take-home pay? Will he explain carefully to the House of Commons how the increase will help recruitment and retention in the NHS?

I have never yet met a member of staff in the health service who does not believe that the NHS needs more investment; the only people I have met who believe that are Opposition Members. I do not know whether or not the hon. Gentleman is mathematically challenged, but even if the NHS has to make £200 million worth of extra national insurance contributions, it is worth remembering that in the same financial year it will get an extra £5,500 million. Our party supported and voted for that, but the hon. Gentleman's party opposed it.

The message from my constituents is clear: they want a massive injection of extra funding in the health service, particularly in my area, where there are a lot of health inequalities. However, I am sure that my right hon. Friend will agree to look at their concern that the extra money be spent well and efficiently and that the whole service should be better managed, particularly by getting management structures in place. Are the Tories not putting up a smokescreen to try to hide their policy of privatisation, not public funding?

I know that my hon. Friend and his constituents, like most people in this country, want to see an expanded national health service. They want more of the national health service, not less. They want more doctors, more nurses, more beds, shorter waiting times, improved diagnostic services and a cut in health inequalities. My hon. Friend is quite right about that. The only way to bring it about is to get some reforms into the NHS and to accompany them with investment.

Is the Secretary of State aware that for Littlehaven's—a children's hospice in my constituency—the increase in the wage bill as a result of the national insurance contribution increase in the Budget will be well over £20,000, and that Littlehaven's is funded almost entirely by voluntary contributions, topped up by a tiny amount of grant money through the NHS? Will he increase the money that the hospice receives to compensate it for the increase in national insurance contributions, so that it does not have to sack medical staff?

I join the hon. Gentleman in at least one respect—paying tribute to the work of the hospice movement, not just in his constituency, but throughout the country. Hospices do a first-rate job of work. We want to strengthen the partnership between the national health service and the voluntary hospice movement, and we want more NHS money to go into palliative care—not just into hospices, but into palliative care services more generally. That is what we want to see, and what we voted for. It is no use the hon. Gentleman coming to the House and complaining of lack of investment in the NHS or in his local hospices, if he is not prepared to vote for it. On two occasions in the past fortnight he has voted against more money for the NHS. That is what he should go and explain to his constituents.

May I ask the Secretary of State a direct question? I fully appreciate the additional cost to the national health service of the increase in national insurance, but will he give me an assurance this afternoon that that will not prevent the Government, acting on behalf of the national health service, from encouraging the recruitment of additional midwives? I attended the Royal College of Midwives conference in Bournemouth last week, as did the Minister. There is a grave shortage in many parts of the country. If we are to provide maternity services of the quality that I believe we should, midwives are essential. Will the right hon. Gentleman assure me and the House that the increase in national insurance will not prevent the recruitment of additional midwives?

No, I do not believe that it will. Already, the number of midwives is increasing, as the hon. Gentleman knows. He is also aware of the substantial commitment that we have given to expanding midwifery services. We expect an extra 2,000 midwives to be working in the NHS by 2004. Of course, that is partly a question of pay and making sure that people who are working very hard in the NHS are properly paid, but it is also a question of making sure that their working conditions and their working environment are right. So yes, I am confident that we will continue to recruit midwives in ever larger numbers in order to give women and families the sort of services that they deserve.

What recent discussions he has had with Lancashire county council concerning the provision of services for the elderly in Lancashire. [52779]

I met leading members of Lancashire county council on 29 April, together with some hon. Members representing constituencies in the county. In addition, the social services inspectorate has been closely monitoring Lancashire county council since it was placed under special measures in February 2000. Following the publication of the council's proposals to close a number of its care homes, the SSI is closely following the work undertaken by the council to assess its current care provision and to consult on future strategies with the NHS, local people and other interested parties.

I thank my hon. Friend for the work that she is doing in that area. She is aware of my concern that the consultation document prepared by Lancashire county council, which recommends the closure of 35 care homes, does not include any analysis of the capacity of the voluntary or the private sector in Lancashire. I am sure that my hon. Friend will share my concern that on Friday last week the Galloway society for the blind in Penwortham, in my constituency, announced the closure in July of Howick house, a home for the elderly blind, which will mean that in a few months 20 elderly blind people will lose their home.

I can assure my hon. Friend that the social services inspectorate is taking a very close interest in developments in Lancashire. I share his concern about ensuring that both the independent and voluntary sectors are fully engaged in any changes. Of course, that was the reason why the Government published the agreement—alongside investing £300 million in building up capacity and in reducing delayed discharges last October—which makes it very clear that we expect local authorities to work in their commissioning behaviour with the private, independent and voluntary sectors, as well as with their partners in the national health service, to ensure that we commission and develop the services that are necessary for older people.

As the Minister is aware—when she is not adopting an ostrich-like approach to the problem—in the past five years, 50,000 beds have been lost across the whole long-term care sector. Is she also aware that, in the next five years in Lancashire, county council placements in the private sector will decrease by about 1,200—the number will fall from 1,860 to 600—and that 35 of the 48 council homes will close, with the loss of 700 beds? Given the pressures that that will cause in relation to placement of elderly people in long-term care, how will the Government's policy of using the stick rather than the carrot and penalising local authorities involved in delayed discharges be implemented? How will it help in tackling the serious problems that Lancashire faces with finding placements for the most vulnerable and frail in our society?

Lancashire has already used the extra investment put in by the Government—not least the £5 million from the building capacity grant to improve services, including, for example, an 18 per cent. increase in the number of people receiving intensive home care. It is right that we build into the system incentives to ensure that our health and social services work together better, so that older people are not stuck in hospital when they would be better off in care homes, in their own homes or being supported in some other way in the community. That is why the 6 per cent. annual average real-terms increase in the next three years from which Lancashire will benefit will enable it to build the services to ensure that our older people have the right care, in the right place, at the right time. We are taking responsibility as a Government not only for the policy that brings health and social services together, but for the investment that enables that to happen.

What plans he has to extend NHS Direct. [52780]

Building on the very successful roll-out of NHS Direct, I expect the service to expand its capacity significantly over the next six years. By 2008, NHS Direct will be able to deal with more than 30 million callers a year. It will, for example, handle all out-of-hours calls to general practitioners and be in a position to deal with up to 1 million lower priority ambulance calls.

I thank my hon. Friend for that reply. I congratulate NHS Direct and its partner BT on having recently answered their 10 millionth call since NHS Direct was set up. I am sure that she agrees that there is still a need to educate some parts of the population about the use of NHS Direct, especially in respect of out-of-hours service replacement. Will the extension of NHS Direct be not only quantitative, as she has described, but qualitative, in terms of bringing new services into the NHS Direct family?

Absolutely. My hon. Friend is right; NHS Direct can really help to contribute towards the reform agenda. For example, in west Yorkshire, NHS Direct is involved in an innovative scheme for people with long-term lung complaints. They can be monitored at a distance via the telephone and computer software, and when their life signs start to deteriorate an emergency response can be triggered. Similarly, Hope hospital, in my constituency, has an innovative programme for people with diabetes. NHS Direct can offer a contact centre to all patients around the country with diabetes, who can get advice through e-mail, the telephone and interactive online services. NHS Direct is truly the kind of service that we want for the 21st century; it is a very exciting development indeed.