1. Mr. Ashley : To ask the Secretary of State for Health whether it is proposed that general practitioners who opt for a practice budget will be entitled to keep any savings that there may be for their own personal use.
The Secretary of State for Health (Mr. Kenneth Clarke) : No, Sir. The Government intend that savings generated within practice budgets should be spent on practice improvements and on offering more and better services to patients.
Mr. Ashley : What would be the criteria for practice improvement expenses? If doctors improve their lifestyles with better suits, cars or holidays, will not patients be tempted to think that that may be taking the place of proper medical treatment? It is not the doctors' fault, but the fault of the Secretary of State for creating a system that replaces trust between patient and doctor with mistrust.
Mr. Clarke : If doctors acquire better cars and suits it will be only because of the generosity of the pay awards that the Government have been implementing following the review body's recommendations. If savings are made on practice budgets we shall expect them to be ploughed back into improvements to the premises or new facilities so that services to patients can be made better. Financial and medical audits will ensure that that is done.
Mr. Sims : Is my right hon. and learned Friend aware that the reaction of some general practitioners suggests that they have either misunderstood or misinterpreted the proposals? First, will he confirm that this is a voluntary matter--that it is up to a group practice to choose whether it takes on the budget system? Secondly, would he care to spell out for their benefit the advantages of the scheme?
Mr. Clarke : We are sending all GPs the working paper on the subject. I agree with my hon. Friend that the proposal is at first sight rather complicated, and I think that the working paper will improve understanding of it considerably.
Certainly, only practices wishing to participate will have a practice budget, but I find that doctors are being tempted to consider the scheme seriously because they see that large quantities of NHS resources will be placed in
Column 820their hands for part of the treatment that they provide, and that they will have much more say in where and how their patients are served. That will enhance the role of the GP in a practice that has such a budget, and I believe that the more go-ahead GPs will be very interested indeed.
Mr. Fearn : Section 16 of the Health and Medicines Act 1988 provides for funds to be given to certain practices through the family practitioner committees, especially in deprived areas. Will that still happen or will the budget knock it on the head? Will GPs still receive the cash to improve their properties?
Mr. Clarke : The practice budgets will be set to reflect the social nature of the practice being served. The proposals in the Health and Medicines Act still stand, with the undertakings given by my hon. Friend the Minister when it was implemented. We shall soon be putting to the profession our proposals for a package on GP remuneration, and that will show how we intend to reflect the extra work that can be imposed on GPs in deprived urban areas.
Mr. John Greenway : Is not the implication behind the original question that money spent on the Health Service can be spent more efficiently? Will my right hon. and learned Friend take this opportunity to confirm that any GPs taking practice budgets will not have any difficulty if they overspend, and that chronically sick and geriatric patients will not be turned away?
Mr. Clarke : I can certainly confirm that. It is another misunderstanding that we should quash straight away. There is no question of a GP not being able to provide proper medicine or care for an elderly or chronically sick patient, or for anyone else. Nothing in our proposals gives rise to any such danger.
Mr. Galbraith: Does the Secretary of State agree that his proposals for practice budgets and, indeed, for general practice overall, reduce both patient and GP choice? Has he read the Coopers and Lybrand health and management update report No. 22, section 8, which says that the Government's proposals will reduce choice for patients and GPs? Will he come clean and admit that, rather than increasing choice, the proposals will simply increase bureaucracy?
Mr. Clarke : I do not agree with the hon. Gentleman's assertion, or with Coopers and Lybrand, if the report supports what the hon. Gentleman says. General practitioners who do not elect to have practice budgets will still have freedom of choice on referrals although they will have to work more closely with their district health authorities than hitherto in deciding on referral patterns from their areas. As I explained to my hon. Friend the Member for Chislehurst (Mr. Sims), a GP practice that elects to have a practice budget will have much greater choice for itself and the patients and much greater control than GPs have had in the past over quite large amounts of NHS resources.
2. Miss Widdecombe : To ask the Secretary of State for Health what percentage of abortions at 25 weeks, 26 weeks and 27 weeks was performed during 1987 because the child was likely to be born handicapped.
The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : The figures are eight out of 11, six out of nine and all three at 27 weeks, respectively. For the convenience of the House I shall publish in the Official Report a table which presents this information more fully.
Miss Widdecombe : In view of the fact that even at the late ages of 25 and 26 weeks' gestation there are still some social abortions is my hon. Friend satisfied that his Department is complying with the spirit and the letter of the Infant Life (Preservation) Act 1929?
Mr. Freeman : My hon. Friend is certainly right that based upon the figures that I have just given, six of the abortions in 1987 where the gestation period was above 24 weeks were for reasons other than the potential handicap of the child. If the Infant Life (Preservation) Act 1929 were amended to insert "24 weeks" instead of 28 weeks, all 23 abortions would be called into question except where the life of the mother was endangered. My hon. Friend's Bill would call into question only six of the abortions.
Mr. Frank Field : The pro-abortionists claims that there is no majority in the House to amend the Abortion Act 1967. Will the Minister speculate as to why that self-same group spends so much time adopting procedural devices to prevent us from reaching a conclusion on the matter?
Mr. Andrew MacKay : Will my hon. Friend confirm that the answer that he has just given to my hon. Friend the Member for Maidstone (Miss Widdecombe) confirms that, quite rightly, there are very few late abortions --
Mr. Freeman : My hon. Friend is right. I repeat the figure of six late abortions--using my hon. Friend's definition of late as being over 24 weeks' gestation where the reasons were other than for the potential handicap of the child.
Mr. Alton : Does the Minister really believe that the possibility of something as trivial as a non-inherited skin disease represents a gross handicap? Does he not agree that amniocentesis and chorionic vilius sampling are increasingly used as the first part of a search and destroy mission, that far too much pressure is put on people to abort away handicap and disability and that that becomes a quality control on life and what is really needed is help for both the mother and the child?
The information is as follows :
|c|Notification of abortions which took place with a gestation period of 25,|c| |c|26 and 27 weeks showing the number with a mention of ground 4|c| |c|which states "there is a substantial risk that if the child is born it|c| |c|would suffer such physical or mental abnormalities as to be seriously|c| handicapped" |c|England and Wales 1987|c| |(a) |(b) |(c) |All grounds |Ground 4 |(b) as a percentage of |(a) ------------------------------------------------------------------------------------------------------------------- 25 weeks |11 |8 |72.7 26 weeks |9 |6 |66.7 27 weeks |3 |3 |100.0 |------- |------- |------- Total |23 |17 |73.9
The Minister of State, Department of Health (Mr. David Mellor) : Health authorities are already free to use the title of matron for the senior nurse manager in a hospital, and some do so. One of the key aims of the Government's new proposals is to give hospitals much more control over the running of their own affairs, and decisions on the roles and titles of senior nursing staff will continue to be made locally.
Mr. Lord : Is my hon. and learned Friend aware that there is widespread disappointment that the traditional role of matron does not feature more widely in the current review of the Health Service? Is he further aware that the role of matron was unique in that she could deal with consultants and doctors, understood nurses and patients well, yet at the same time as was able to control very carefully items such as bed linen and bandages and had a good overall view of the whole system? Bearing in mind that people rather than structures make organisations run smoothly will he reconsider reinstituting the traditional role of matron in our hospitals?
Mr. Mellor : I recall that that paragon was usually played by Peggy Mount in the films. However, there is nothing to prevent a hospital that is seduced by my hon. Friend's arguments from calling its senior nurse manager a matron, as some hospitals do.
Dame Jill Knight : I suggest to my hon. and learned Friend that it does not matter a row of beans who played the part of the matron in a film. Many people think that almost the biggest mistake ever made in the National Health Service was to get rid of the matron. If we had that particular figurehead, there is little doubt that she would be able to cope with the flood of thefts that is endemic in the NHS, that she would make the wards cleaner--many of them badly need to be made cleaner--and that she would manage the hospital with great efficiency, as she always used to do. Does my hon. and learned Friend acknowledge that apart from the fact that hospitals can bring back matrons, they ought to be positively encouraged to bring them back?
Mr. Mellor : As I understand the argument in 1966, the feeling was that there were so many different sizes of hospital that one needed a more sophisticated profile for senior nurse managers to reflect the different sizes of units
Column 823that were being managed. It is important that senior nursing offices should be invested with all the powers that are required to do the various jobs to which my hon. Friend refers. If a hospital chooses to call that senior nursing manager a matron, so be it. We have no objection.
Mr. Freeman : The latest information available is for 1984. In England and Wales there were 41 registered, newly diagnosed cases of malignant neoplasm of the cervix in women aged under 25. There were 4,002 cases in women aged 25 and over.
Mr. Wray : Does the Minister agree that over 2,000 women a year are dying from cervical cancer? Why do the Government not spend the additional £20 million that would provide a 90 per cent. coverage? The hospitalisation bill is £15,000 per patient. That is equivalent to £30 million. The project to screen women once every five years costs £30 million. All the Minister needs to do is to spend £20 million and he would be £10 million in pocket.
Mr. Freeman : I confirm that there are 2,000 avoidable deaths each year. If the policy of introducing screening for all women between the ages of 20 and 54 at least once every five years were introduced and if it covered all women between those ages, it would cut deaths by about 85 per cent. Our policy of screening women at least once every five years will enable us to reach more women and therefore to save more lives. To concentrate on a shorter frequency in the long run is, I agree, the ideal, but if we went for a shorter cycle we should inevitably reach fewer women.
Dame Elaine Kellett-Bowman : Will my hon. Friend remember those who die of breast cancer? The numbers are now quite horrendous. Will he therefore expedite the provision of mammography for all women in the particularly vulnerable age group of 50 and older?
Mr. Freeman : I am grateful to my hon. Friend. She is absolutely right that the breast screening programme--which is new, unlike screening for cancer of the cervix, which commenced in 1966--is most valuable and saves the lives of many women. We are keeping that programme under close review, and I shall bear in mind what my hon. Friend has said.
Mr. Freeman : I share some of the hon. Gentleman's concern, but he ought to appreciate that the information that is collected by the Office of Population Censuses and Surveys depends in part on figures that come from voluntary organisations. It is not, therefore, within my power to ensure that comprehensive figures are available for the most recent years, much though I should like to do so.
15. Mr. Dykes : To ask the Secretary of State for Health if he will make a statement on the response from members of the public and the various interest groups to his White Paper proposals on the future of the National Health Service, published on 31 January.
17. Mr. Hunter : To ask the Secretary of State for Health if he will make a statement on his assessment of immediate reactions to the proposals contained in the White Paper entitled "Working for Patients".
Mr. Kenneth Clarke : Reaction to the White Paper "Working for Patients" has been extremely positive. We have published a series of working papers outlining some of our key proposals in greater detail, and we shall be discussing the implementation of these proposals with interested parties in the coming weeks.
Mr. Bruce : I thank my right hon. and learned Friend for his answer. In acknowledging that we have received a warm response from most members of the public and the medical profession, does he believe that the introduction of the White Paper's proposals ought to be fairly flexible? Does he agree that consultations with the medical profession and the consultative committees should take place so that we can provide the absolutely best possible deal for the National Health Service?
Mr. Clarke : The proposals are complicated and go into details about how the service is managed and financed, which normally, as a patient, the average member of the public would not encounter, so understandably there is some public reserve about the proposals. A great deal of discussion is needed, particularly with those who are intimately involved with the way in which the service is run and financed. That is what we propose to embark on in the next few weeks--having published the working papers yesterday--and we are open to all constructive suggestions about how these proposals can best be implemented for the benefit of patients.
Mr. Dykes : Is my right hon. and learned Friend aware that many of his ideas in the White Paper have been received warmly and positively? Does he agree that in principle it is possible for specialist national hospitals to consider opting out while remaining within the NHS system if they are threatened with closure or removal or both, provided that the scheme is viable and the funding properly organised?
Mr. Clarke : I agree with my hon. Friend about reaction to the proposals, and I am surprised that we have not had the bitter outpouring of opposition that sometimes comes automatically on any health service subject from a whole range of people. Only the Labour party and a few trade unions have responded in that way.
I confirm that any hospital is potentially a candidate for being self- governing, if it can demonstrate the ability to be so. Some specialist hospitals could certainly be prime candidates. I put in a reservation about whether they are threatened with closure. If there is a place for that part of the service in the NHS--if doctors want to refer to that unit in that hospital--and if there is a continuous need for
Column 825that service, they are ideal candidates for self-governing status. Obviously, a hospital that is facing closure because its services are redundant or because they have been replaced by something better would find difficulty in establishing such a case.
Mr. Hunter : With regard to general practitioners managing their own budgets, will my right hon. and learned Friend take this opportunity to clarify the precise mechanism by which practitioners will have spending power once their indicative budgets are used?
Mr. Clarke : I am not sure whether my hon. Friend is questioning me about the practice budgets, about which we had an exchange a few moments ago, or about the indicative drug budgets which all practices will have.
As for practice budgets, general practitioners will not be obliged to close down or to refuse medicine if they go over the budget that they have negotiated and had set for them, but if they overspend without good clinical reasons that they can demonstrate, they will be expected to recover the overspend. They can always apply for a budgetary review if it turns out that there are good clinical reasons for enlarging the budget.
As for the indicative drug budget, that will be an indication of what a practice of that kind should incur by way of prescribing costs. If any practice overspends by a significant amount over that indicative budget, it will be exposed to advice from other doctors and some questioning from the family practitioner committee and will be expected to take some collective measures to make sure that it gets down to a reasonable level of prescribing costs.
Mrs. Mahon : Will the Minister explain precisely who will be allowed to decide whether a hospital opts out? It is difficult to understand from the discussion documents just what the position will be. Indeed, the discussion papers are bizarre. May we be told in simple terms who will make the decision?
Mr. Clarke : The hon. Lady refers to opting out. She may have been misled by her hon. Friend the Member for Kirkcaldy (Dr. Moonie) into thinking that we are talking about opting out of the NHS, which we most certainly are not.
Mr. Clarke : We are talking about NHS hospitals which will be run by their own managers, doctors and nurses and not be so subject to the district, region and Secretary of State in their day-to-day affairs. The decision as to whether a hospital which wants to become self-governing shall become self-governing will in the end be taken by the Secretary of State for Health after he has received a report and advice from the regional health authority.
Mr. Loyden : The right hon. and learned Gentleman should speak and listen to the consumers of the NHS. Most people see this as the first steps towards privatisation. In that sense, are not the Government abrogating their responsibility for the health of the people of the nation?
Mr. Clarke : If a significant proportion of the population believe that this is a step towards privatisation, they have been absurdly misled by the Labour party. There is not a word in the White Paper which makes it any
Column 826easier, or any more difficult, for any Government to privatise the NHS. It is obvious to anyone who reads the White Paper that its proposals have nothing to do with privatising the NHS, on which the Government have turned their back.
Rev. Martin Smyth : Does the Secretary of State acknowledge that although there are already reservations, greater reservations may arise when the discussion documents are examined? What place will be given to consumers in local committees, especially with the abolition of participation by councillors?
Mr. Clarke : The various bodies in question--family practitioner committees, district health authorities, regional health authorities, and the boards of NHS hospital trusts--will have a majority of non-executive members ; lay people as opposed to professional people. Obviously, we expect to find on all committees people drawn from the local community to represent the consumer interest in its widest sense. They will also be able to make a personal contribution to the management and development of the Health Service.
Mr. Jacques Arnold : Does my right hon. and learned Friend agree that rather than take into account the present situation in attempting to preserve the cumbersome bureaucracy of the Health Service--as the Opposition wish to do--one of the Government's most beneficial proposals is to allow hospitals to opt out of cumbersome district health authorities and into the hands of local management? Will he give an assurance that the determinant of opting out will not be the convenience of consultants but local popular demand?
Mr. Clarke : I share my hon. Friend's dismay over the Opposition. I have been a Member of the House and in health politics long enough to recall that, over the past 20 years, the Labour party has opposed every proposed change to the Health Service. They vigorously fought the proposal to establish district health authorities in the form that they now have, and now oppose changes to reform them further. The Opposition opposed Griffiths and every advance in the Health Service, as long as anyone can remember. The acid test of a self-governing hospital, as of any of the reforms, must be whether it improves the service to the nation and makes it stronger and more effective in delivering care to the community. That must be the test which, above all, we apply to suggestions for implementing reforms.
Mr. Robin Cook : Does the Secretary of State include among the positive responses to the White Paper last week's poll showing that of those members of the public who know of the right hon. and learned Gentleman's proposals, only 14 per cent. approve of them and 71 per cent. disapprove? Is that why the working paper published yesterday makes it clear that the Secretary of State will not risk a ballot on any proposal to opt out? If opting out is about local self-government, why is it that only the right hon. and learned Gentleman will make the decision on every single opt-out? If response to the White Paper is positive and favourable, why is the Secretary of State so reluctant to put opting out to the vote?
Column 827altogether understand the proposals' details. They are complicated proposals, and the average member of the public does not understand what is done by a family practitioner committee, for example, and how the Health Service is managed and financed. While discussing matters with staff, we must at the same time explain to the public how the proposals will work in strengthening the service. I have no idea who the hon. Member for Livingston (Mr. Cook) thinks we should ballot. I presume that he asks for a ballot of trade union members in the hospital in question to determine the matter. We expect that when the proposals for self-governing hospitals are publicised and fully discussed locally, the decision will be made on the basis of whether that change will improve the ability of the Health Service to deliver care to its patients.
Mr. Moss : I thank my hon. and learned Friend for those figures. Does he agree that they hide substantial local variations, and that it is especially welcome that the Government are introducing, on a trial basis, arrangements to encourage dentists to set up in shortage areas by providing financial incentives?
Mr. Mellor : My hon. Friend is right. The sharp increase in the number of dentists working in the NHS is welcome news to everybody, but it disguises considerable variations. For instance, there are twice as many dentists per head of population in North East Thames as in the Trent region. Plainly, we must do something to make the spread more even.
Mr. Key : Will my hon. and learned Friend take another look at his Department's policy of discussing dental issues with only just over half the dentists, who are members of the British Dental Association, and ignoring all the others who are members of the General Dental Practitioners Association, because I, for one, find that confusing?
7. Mr. Wareing : To ask the Secretary of State for Health what consultations he has had with representatives of the medical profession in respect of the Government's review of the National Health Service ; and what their response has been.
Mr. Kenneth Clarke : I have had a number of useful discussions with representatives of the medical profession. I look forward to hearing their views on the implementation of the Government's proposals when they have had time to consider the detailed working papers that I published yesterday.
Column 828is being sacrificed on the altar of a preparatory stage on the road to privatisation? Can the Minister confirm that one hospital that had opted out could concentrate on diabetics, another could concentrate on obstetrics and another on hip operations, creating a Health Service in which care was fragmented? Is it not true that whereas after the war the Labour Government created a comprehensive NHS, this Government are proposing a fragmented one?
Mr. Clarke : Many doctors have many different opinions. The most common reaction that I have encountered from doctors and their representatives is a requirement for more detail in order to discuss the matter further. They now have the working papers and I await their reaction. No doctor has so far taken up with me the privatisation argument. I do not think that any doctor takes that seriously. They regard it as knockabout political nonsense put about by the Labour party. I have heard of fears about self-governing hospitals suddenly electing to go for some narrow specialty. Apart from those that are specialist hospitals already, such as the royal national orthopaedic, which my hon. Friend the Member for Harrow, East (Mr. Dykes) may have had in mind, I cannot see any sensible reason why any hospital trust and its doctors and managers should decide to start abandoning particular specialties in serving their town, and nothing in the proposals gives them any incentive to do so.
Mr. Favell : As the medical profession is there to serve patients, if a patient is not satisfied with the treatment that he receives or with the length of wait, will he be able to take his business elsewhere?
Mr. Clarke : Certainly. We should make sure that the patient is completely free to do so. The rules that inhibit that freedom which are occasionally respected at the moment, will be removed by the Government.
Mr. Heffer : Is the Minister aware that my constituents are very much opposed to the idea of the Walton or Fazakerly hospitals opting out? Is he also aware that we are very much opposed to the closure of the Walton hospital and the concentration of all services at the Fazakerly hospital? Therefore, will he give us an assurance that the Walton hospital will not be closed and that the ideas and high concepts of the people of the area will be accepted?
Mr. Clarke : I am interested to hear that the hon. Gentleman wishes both hospitals to be subject to the direct control of the district and regional health authorities, but then expresses his strong opposition to a policy that those authorities might adopt. The closure of Walton hospital and the concentration of services at Fazakerly hospital will have to be decided first by the health authorities that are responsible for both hospitals at the moment ; there will then have to be public consultation, and, if the community health councils disagree, my hon. and learned Friend the Minister of State will have to make the final ministerial decision. That is the present system and will remain the system after the White Paper has been implemented.
Mr. Ralph Howell : May I tell my right hon. and learned Friend how pleased I am to hear that all hospitals will be eligible to opt out, not just the large ones? Will he consider the opting out of Wells and district cottage hospital in my constituency, which would be a most excellent step to take?
Mr. Clarke : Any hospital contemplating becoming an NHS hospital trust will have to draw up its business plan and proposals for serving patients in the area. It will then have to be examined to ensure that the hospital is capable of taking such control over its own affairs and that there is a satisfactory level of demand for its services in the area with an expected level of referrals to justify its existence as an NHS hospital trust. All that is set out in the working paper and I have no doubt that people in Wells and elsewhere will be studying it carefully to see whether it fits the circumstances of their hospital.
Ms. Harman : Has the right hon. and learned Gentleman consulted GPs about referring patients to hospitals? What will happen under his proposals where the patient and the GP choose a hospital with which the DHA does not have a contract and the DHA refuses to use its contingency reserve? Will the patient get treatment where he or she chooses and who will pick up the bill?
Mr. Clarke : In the precise situation set out by the hon. Lady the same situation could arise as arises now. A GP is free to refer his or her patients if he wishes, but the hospital is not obliged to accept all referrals. Increasingly, in recent years, referrals have not been accepted because there have been no funds for treatment for an out-of-district patient. All our changes in the White Paper will make it easier for money to cross administrative boundaries, and it will be up to the GP to consult his own district health authority about referral patterns. If he wants to be free of the DHA he will have to contemplate having his own practice budget.
9. Mrs. Ann Winterton : To ask the Secretary of State for Health how many abortions at 18 weeks and over were carried out in 1987 in clinics run by charities ; and if he will distinguish between United Kingdom residents and non-residents.
Mr. Freeman : Two thousand seven hundred and twenty eight in charitable, as opposed to non-charitable private clinics. Of these, 2,214 were performed on women resident in the United Kingdom and 514 on non- resident women.
Mrs. Winterton : When will my hon. Friend implement the recommendations of the 1973 Select Committee on abortion, which proposed that links between doctors and agencies referring women for abortions and the clinics in which they were carried out should be broken and that there should be after-care and follow-up facilities for women who come to this country from abroad for abortions?
Mr. Freeman : We have these matters under consideration, but I can tell my hon. Friend that the majority of abortions performed in 1987 on women after a gestation period greater than 18 weeks were in private clinics. The proportion of non-resident women was just under one half and that proportion has fallen by about one half since 1983.
Mr. Fearn : Is the Minister aware that the 60 per cent. of abortions carried out in private clinics bring in £2 million to the private doctors concerned? Does he not think that those doctors should be defenders of life not destroyers?
Mr. Freeman : The private clinics and the doctors who work in them have an important role to play in the health care of the nation. Whether the abortions performed in those clinics or in NHS clinics are ethically correct is a matter for the hon. Gentleman's conscience and for mine.