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House of Commons

Tuesday 21 March 1989

The House met at half-past Two o'clock


[Mr. Speaker-- in the Chair ]

Oral Answers to Questions



1. Dr. Blackburn : To ask the Secretary of State for Health how many doctors there were (a) in 1979 and (b) in the latest available year.

The Minister of State, Department of Health (Mr. David Mellor) : In 1979 there were 60,764 doctors in the hospital and community health and family practitioner services in England. By 1987, the number was 68,777.

Dr. Blackburn : Does my hon. and learned Friend agree that in Dudley health authority during that period medical staff increased by 18 per cent. and more than 25 per cent. more patients were treated? Does not that give the lie to allegations made by trade unions and others about our commitment to the Health Service? Does my hon. and learned Friend also agree that, in view of the reduction in population, the figures are enhanced and outstanding?

Mr. Mellor : I am grateful to my hon. Friend for bringing forward the figures for his own health district. What they show is true of so many health districts up and down the country. Public expenditure on the Health Service has risen by two and a half times the increase in public expenditure as a whole. As a result, a number of areas which under previous Governments did not receive a substantial level of funding, now do so. The resources that my hon. Friend quoted give a clear message to the people of Dudley that the National Health Service is safe in our hands.

Mr. Fearn : Following publication of the recent White Paper, does the Minister consider that general practitioners in rural and inner city areas will now decrease as a result of those recommendations? What recommendations has the Minister received from those particular practices?

Mr. Mellor : There is absolutely no reason for the number of GPs to decrease. As the hon. Gentleman is aware, the number of GPs in England has increased by nearly 20 per cent. in the past 10 years. There are differences between regions in the United Kingdom which mean that some areas have twice as many people per GP as others. However, we are trying to provide incentives for doctors to go to under-doctored areas. It would not make sense to increase provision if such gross disparities still existed.

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Dame Jill Knight : Without pressing my hon. and learned Friend for exact figures, has the increase in other medical experts--such as nurses, midwives, dentists and specialists--been at a fairly similar rate?

Mr. Mellor : My hon. Friend is quite right--the increase in dentists is almost precisely the same as the increase in GPs. The increase in nurses --of about 60,000--is also broadly similar. If, when referring to specialists, my hon. Friend was thinking of consultants, we are committed to achieve a balance and, over the next 10 years, to increase the number of consultants by 5,000. That will dramatically improve the position in most hospitals.

Hospital Trusts

2. Mr. Gill : To ask the Secretary of State for Health what representations he has received from Shropshire regarding the establishment of National Health Service hospital trusts.

The Secretary of State for Health (Mr. Kenneth Clarke) : I have received a few letters from people considering the possibility of forming NHS hospital trusts for cottage hospitals in Shropshire.

Mr. Gill : Will my right hon. and learned Friend use his best endeavours to enable my constituents to keep their local hospitals, either through an independent trust or through a National Health Service trust? Will he also instruct West Midlands regional health authority to facilitate that process?

Mr. Clarke : I know that, with the opening of the new district general hospital in Telford, Shropshire district health authority faces difficulty in deciding which services the hospital should replace, and what pattern of hospitals is needed for the future. The west midlands region and I want Shropshire to deliver the best possible system of health care within the reasonable resources available. Self-governing hospitals in the National Health Service will have to satisfy the Government that they have good, viable plans, and are likely to attract NHS patients from districts and other GPs. We are looking now for the first candidates to be ready to come into operation probably early in 1991.

Mr. Grocott : Will the Secretary of State confirm that, even after the opening of the new Telford hospital, there will be fewer hospital beds in Shropshire than 10 years ago? Will he have a word with the Chancellor and tell him that the £40 million being handed out as a tax bonus for private medical care is completely irrelevant to the people of Shropshire? What is needed is a mere £2 million--that is the most likely estimate- -to prevent any beds or hospitals from being closed.

Mr. Clarke : The number of hospital beds has fallen in just about every advanced medical system in the world over the past 10 years. I trust that the same has been true in every county of England over that period, as I hope that they are all moving towards day care and better use of facilities in line with modern medical practice. I believe that Shropshire, with its new facilities, is now extremely well provided for. It is a pity to see much-loved cottage hospitals closing, but I approved the recent proposals only when I was satisfied that a better service to patients would result.

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Mr. Biffen : Will my right hon. and learned Friend reconsider the judgments that he has been making recently in respect of hospital closures in Shropshire in the light of the latest developments, which cast a shadow over the likely continuation of the orthopaedic hospital at Gobowen?

Mr. Clarke : I will look into the matter, but at present I am familiar and up to date only with the closures that I approved shortly before Christmas. I continue to take a close interest in what is happening in Shropshire, but I am currently waiting for the results of the district health authority meeting which I believe is to take place on Thursday.

I know of my right hon. Friend's great concern for the future of hospital facilities in his constituency. The recent proposals were amended to meet his wishes and those of the inhabitants of Oswestry in part. I have no doubt that the future of the orthopaedic hospital is a matter in which he and I must continue to take a close interest.

Public Sector Laboratory Facilities (NHS)

3. Mr. Cash : To ask the Secretary of State for Health if he will give an assessment of the results of the increasing use of private sector laboratory facilities within the National Health Service.

Mr. Mellor : Quality, speed and cost-effectiveness are the vital attributes of laboratory services, and access to private laboratory facilities widens the range of opportunities for health authorities to achieve these.

Mr. Cash : Does my hon. and learned Friend agree that facilities made available by private laboratories have greatly speeded up cervical investigations, and that such laboratories play a significant part in improving the opportunities available to patients?

Mr. Mellor : I am sure that my hon. Friend is right. There are 385 public sector pathology laboratories in the country, but they have been supplemented substantially by 150 private laboratories and more than 200 private screening centres. There is no doubt that those facilities play a considerable part in health care, and we hope that under the new arrangements in the NHS there will be a much closer interaction between laboratory services in the private and public sectors.

Mr. Loyden : What assurances can the Minister give that tests such as cervical smears will be properly monitored in the hands of private laboratories, and what influence will the Department have on the outcome?

Mr. Mellor : Before the Department or any district health authority allocates work to a laboratory it must satisfy itself that the laboratory is efficient. The hon. Gentleman may be aware that we are funding the national external quality assessment scheme, to which most public and many private laboratories subscribe and which is a way of ensuring appropriate quality.

Working for Patients"

4. Mr. Dykes : To ask the Secretary of State for Health what weight he attaches to the public comments and reaction he is receiving on the White Paper "Working for Patients" in the context of (a) professional groups working within the service and (b) others.

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9. Mr. John Marshall : To ask the Secretary of State for Health what representations he has recently received on his White Paper on the Health Service, "Working for Patients".

Mr. Kenneth Clarke : I have received a number of representations on the White Paper. I have been very pleased by the positive and constructive nature of many of them.

Mr. Dykes : For the sake of those who wish to remain politically deaf--including Opposition Members--will my right hon. and learned Friend repeat that there is no question of privatisation in the proposals, and no question of any disadvantageous effect on the chronically sick or the elderly?

Mr. Clarke : I certainly confirm that. I congratulate the hon. Member for Livingston (Mr. Cook) on having given currency to both those myths before the White Paper appeared as there is nothing in it to support either of them. I assure my hon. Friend and everyone else that we have set our back firmly against any prospect of privatising the Health Service, and that our proposals offer no disadvantages to the elderly and chronically sick.

Mr. John Marshall : Will my right hon. and learned Friend confirm that the White Paper has been subject to a wicked campaign of misinformation, especially as regards the elderly? Will he also confirm that the basic principles of the Health Service remain unaffected, and that the objective of the White Paper is for more patients to be treated by even more doctors?

Mr. Clarke : A wholly predictable string of committees and bodies that I know well have reacted to this as they have to every other reform. People have ignored the fact that the National Association of Health Authorities and the Royal College of Surgeons have reacted favourably to the reforms. The purpose of the reforms is that the interests of patients should be uppermost in mind. We believe that such a change, in addition to all the extra money that we are putting into the Health Service, will produce an improved service to patients which will reflect more closely their choice and preference in the future.

Rev. Martin Smyth : Does the Minister recognise that while some interest groups may express their own responses, there is unease in many parts of the profession and among patients that the end that the Minister has in mind may not be achieved by his methods?

Mr. Clarke : To take up the hon. Gentleman's last point, the joint consultants council yesterday was the latest medical group to say that it entirely shared the Government's aims of strengthening the service. There are plenty of questions about the means that we propose, but none of our critics has put forward proposals of any substance for reform or improvement. When we continue the prolonged process of discussion with consultants and GPs in practices and hospitals throughout the country and implement the proposals with care, we will demonstrate to the profession and to others that we are strengthening the service through the process of reform on which we have embarked. Mr. Andrew F. Bennett : Does the Secretary of State accept that extremely caring GPs in Stockport and in Denton in my constituency had not one good word for the

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Government's proposals when they met me? Will he answer a specific question from them? If they are to have control of their own budgets as a group practice, will they be able to contract with a variety of hospitals or with just one hospital? How does that square with giving patients choice? Will the patients have free choice, or will it be the doctors who have the choice so as to control their budgets?

Mr. Clarke : If GPs choose to have their own practice budgets, they will be able to place their contracts with as many hospitals as they wish. They will be able to control a large sum of NHS resources to put together a mix of potential care and offer individual patients a choice when that care is needed. That is one of the attractions of practice budgets for many GPs. I know of many GPs who are interested in taking on their own practice budgets. If GPs in Stockport feel that they cannot take on that responsibility, they need not be too troubled as GP practice budgets are available only to practices which want them and can negotiate a satisfactory budget with my Department.

Mr. Watts : Is my right hon. and learned Friend aware that some of my constituents have been concerned by what they have been told about the proposals by representatives of vested interests but have been reassured when they have read the proposals? Will my right hon. and learned Friend consider taking steps to ensure that more patients have the opportunity to read the proposals rather than having to rely on the distorted views peddled by producers in the Health Service?

Mr. Clarke : We have a short popular leaflet setting out the proposals and we are trying to distribute it as widely as possible through post office counters and GPs' surgeries, where they will carry them, pharmacists' counters, and so on. I agree with my hon. Friend that, while we respect the right of anyone to have a different opinion about the reforms, it is a pity when some people get carried away. As my hon. Friend the Member for Hendon, South (Mr. Marshall) said, I hope that there will be no outburst of misinformation to patients, telling old ladies that they will be deprived of treatment, as only a fringe few of the medical profession will be inclined to indulge in that.

Mr. Robin Cook : The short answer to the hon. Gentleman's question is that the Secretary of State does not intend to attach any weight to the public reaction to the White Paper, as if he were to do so it would sink under the weight of criticism. Does he admit that in the past couple of weeks alone it has been rejected by the Royal College of Nursing, the British Medical Association, nine royal colleges and a meeting in Nottingham attended by 160 GPs, many from his own constituency, who unanimously rejected his proposals? In retrospect, does he agree that the panning that his White Paper received shows how wise he was after the 1982 restructuring when he said : "Anybody who comes along in any successive Government and talks about yet another restructuring wants his head examined."

Mr. Clarke : I could have told the hon. Gentleman before we started that the British Medical Association, the Royal College of Nursing and the Joint Consultative Council would come out against these or any similar proposals. I understand that the meeting of general practitioners in Nottingham was concerned largely with the GPs' contract, about which there is a later question on

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the Order Paper. All the information that I have received is that the meeting came to no clear conclusion. That is no doubt a matter that I shall take up with the local medical committee when it comes to its conclusions. In my contacts with consultants and GPs, I have found that many of them are interested in the process of reform. They know that the Health Service has had a 40 per cent. increase in expenditure in real terms and they know that on top of that growth in expenditure improvement is needed in the way in which the Health Service is managed, the way in which it adapts to modern services and the way in which it responds to patients. There is a great deal of goodwill throughout the profession which will put the reform into practice as long as we discuss the detailed implementation carefully with it.

Mr. Allason : Last Saturday morning, I had a meeting with the GP who represents more than 100 GPs in my constituency. My right hon. and learned Friend may be interested to know that, by and large, that GP expressed broad support for the White Paper. He said that many of the items in it were matters for which he had pressed for a number of years. Will my right hon. and learned Friend also accept, however, that there is a widespread anxiety, especially among patients who have expensive complaints such as those who have had colostomies, who are worried that there is no guarantee from the Government about their continued support? Will my right hon. and learned Friend take this opportunity to give that guarantee?

Mr. Clarke : We have sought to address that in the working paper, which makes it clear that for very expensive patients there will have to be a ceiling above which expenditure cannot be carried by any GP's budget. I will bear my hon. Friend's point in mind as we work out the details. I agree with him that we must come up with a system in practice which guarantees that such patients will in no circumstances be deprived of the necessary treatment. It is clear that such a system is perfectly feasible and it will be worked out in discussions with the profession over the coming months.

GPs (Rural Areas)

5. Mr. Livsey : To ask the Secretary of State for Health if he has any plans to meet the British Medical Association to discuss the income of general practitioners in rural areas.

Mr. Clarke : I met the British Medical Association's general medical services council yesterday. We discussed the subject of general practice in rural areas among other issues arising from the discussions that have taken place throughout the past year on proposals to amend regulations for the remuneration of general practitioners.

Mr. Livsey : Is the Secretary of State aware that in the county of Powys, which has the sparsest population in England and Wales, members of the BMA met on Sunday and rejected the NHS proposals as they affected rural areas on the grounds that they abolish choice, reduce income and redistribute money from rural areas to inner cities, without making special provision for inner cities? The proposals will make some rural practices non-viable, so the GPs are unhappy about them as they affect rural areas.

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Mr. Clarke : I cannot understand the argument about reducing choice because our new contract proposal is based on a background of making it easier for patients to change and choose their GPs, and GPs will be allowed to advertise to make that choice easier. We are putting forward a new proposal for a rural practice allowance to replace the previous allowance for rural areas. As the hon. Gentleman's constituency is so sparsely populated, I was surprised to hear that his GPs believe that they will lose by the proposal. I will try to ensure that the hon. Gentleman is given further details of our proposals. We have addressed ourselves very much to the fact that in rural areas with a sparse and scattered population it is necessary to weight the basic practice allowance in favour of doctors because they will not have the same opportunity of earning income through patient lists and capitation fees as is possible in more populated areas.

Mr. Maxwell-Hyslop : Can my right hon. and learned Friend tell the House what proportion of the rural practitioners who receive the allowance at the moment will be excluded by the new arrangements? Will he reassure general practitioners that the total on which the percentage target for cervical smears is calculated will exclude virgins and those who have been invited to take the test but have refused?

Mr. Clarke : My proposals for a new contract, based on where I say that we have got to after 12 months of negotiations, were issued after the General Medical Services Committee put its version of where we are at the moment to its members. When we met yesterday we exchanged arguments about rural practice. The GMSC prefers the present system whereby doctors qualify for rural practice supplements if they practise in an area which was served by a rural district council before the local government reorganisation in the early 1970s. I prefer a system based on density of population. We are still discussing the matter. When it is resolved, it will be clear whether practitioners in my hon. Friend's rural constituency are advantaged or disadvantaged.

On my hon. Friend's second point, it is right to set targets. It is no good paying for every smear test because they are part of the ordinary routine day-to-day duties of a GP. We are setting targets for good performance so that extra payments are made to those who achieve levels of screening for which we think good practice should aim. However, I agree that we must define the target group carefully. People who have had hysterectomies, people who have moved off the list, nuns and virgins must be taken into account.

Mr. Foulkes : Is the Secretary of State aware that most people in my rural constituency cannot even choose their doctor, let alone the hospital to which the doctor sends them? Is he aware that that is why, without any encouragement from me, GPs in Ayrshire have unanimously rejected his proposal, including all the GPs in the marginal constituency of the Secretary of State for Defence? Is it part of the Minister's tactics to remove one of his main competitors for the post of Leader of the Opposition after the next election?

Mr. Clarke : For the past 12 months we have been negotiating changes to a contract which was last changed in the mid-1960s. The local medical committees tend to pass resolutions saying that they prefer the contract that

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they have rather than any changes. If changes are made to determine who receives more or less than the average, it is inevitable that some will be gainers and some will be losers. I suspect that the losers are running along to the local medical committee meetings with more enthusiasm than the others. We are discussing the matter with the GPs and their representatives. The object of changing the contract, from my point of view and from the patient's point of view, is that we must particularly reward those doctors who do most of the work and those who introduce new services and hit performance targets for key services such as vaccinations and screening. Some doctors will do well because that will benefit them, but others will not do so well and will have to improve their practice. That is what a patient-oriented, consumer- conscious NHS is all about.

Mr. Conway : When I meet the GPs in Shropshire on Tuesday night what message would my right hon. and learned Friend like me to give them to assure them that GPs in rural areas will be treated equally favourably with those in the larger city areas at which many of his proposals are aimed? When my right hon. and learned Friend next meets the BMA, will he remind it that the Labour Government cut spending on the NHS, so there is no point in looking to the Opposition for genuine support?

Mr. Clarke : First, I ask my hon. Friend to point out that the only disagreement between myself and the GMSC is about the form of help for those who live in rural areas--the way in which we weight the capitation payment for rural areas. We agree that all the basic practice allowances need to be added to the capitation fees in rural areas to compensate for the sparsity of population. My hon. Friend can also tell his no doubt excellent practitioners in Shropshire that those who can achieve the performance targets that we have set and introduce the new services will benefit under our contract proposals. He might also point out that many parts of the contract are agreed. For example, a new payment for child surveillance services was first put forward by the practitioners representatives four or five years ago. After my meeting yesterday, I think that it is still generally welcomed by those who represent the doctors and by the doctors themselves.

Mr. Galbraith : Is the Minister aware of the statement made by the Under-Secretary of State for Scotland, the hon. Member for Stirling (Mr. Forsyth), that capitation fees will be banded? Can the Minister confirm that he is discussing that point with the BMA? Can he also explain the further statement by the hon. Member for Stirling that banding will ensure that, irrespective of the number of patients on a list, the income from capitation fees will be exactly the same in each practice?

Mr. Clarke : My hon. Friend the Member for Stirling (Mr. Forsyth) is having separate discussions with the Scottish branch of the GMSC, not about the whole proposition but about certain aspects of it which affect Scotland, and reassurances were given to rural practitioners in Scotland in particular in the White Paper "Working for Patients". I can only ask the hon. Gentleman to refer his question to my hon. Friend the Minister responsible for health in Scotland because I am not party to discussions between him and the GMSC on the subject of the Scottish Health Service or any Scottish variations on the contract that I am negotiating.

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Hospitals (Wage and Salary Rates)

6. Mr. Ashley : To ask the Secretary of State for Health what estimate he has made of the effect on the National Health Service wage bill of allowing individual hospitals to set their own wage and salary rates.

Mr. Kenneth Clarke : None. In common with other White Paper proposals, the aim of freeing self-governing hospitals from central control over pay is to get the best value for money in terms of patient care from the resources that are made available.

Mr. Ashley : I am not surprised that the Secretary of State should try to dodge that question. Is he aware that these proposals are a recipe for chaos, because the BMA simply will not agree to doctors having variable rates, and because those other workers in the National Health Service who may be forced to accept them will be bitterly and deeply resentful? Why does the Secretary of State always allow ideology to override common sense?

Mr. Clarke : There is nothing ideological about it. There are many towns and cities in this country where the district general hospital is the largest single employer, and if it becomes self-governing and local people are put in charge of it, I can see no earthly reason why it should be said that they are not capable of settling the pay and conditions of their own staff if they want to. There would be advantages if they did, because the present national, centralised system is often too inflexible to enable local management to deal with local shortages of skilled staff.

I am sorry if the hon. Gentleman thinks that the BMA will automatically oppose the proposal. Sometimes I too am guilty of leaping to the conclusion that the BMA will always oppose things. Many doctors and other staff in the hospital concerned will feel loyalty to their own hospital and town, and will not be at all averse to the idea that pay and conditions should be settled more locally.

Dr. Glyn : Does my right hon. and learned Friend agree that this flexibility will allow us to adjust local conditions, which will probably result in a more efficient service and better pay?

Mr. Clarke : I agree with my hon. Friend, and many people in our great hospitals up and down the country will find this possibility one of the more attractive features of self-government.

Ms. Harman : Is the Minister aware that the Health Service Journal this week carries an advertisement for a finance director for a London teaching hospital, which it indicates is going to opt out? Will he please name that London teaching hospital or, if he does not know the name of it, will he find out and tell me by the end of today? Is it not reprehensible-- [Interruption.]

Mr. Speaker : Order.

Ms. Harman : Is it not reprehensible that the process of opting out should be done in secrecy and by stealth?

Mr. Clarke : I know that the hon. Lady keeps picketing outside a certain hospital in case it becomes self-governing, but I am not going to help her by letting her know whether she is picketing outside the right one. She will have to find out for herself in due course. When proper applications are put in for self-government, of course they will be dealt with openly ; we will publicise them all and discuss them fully

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with any interested members of the general public. I am not responsible for the advertisements, or even the copy that appear in The Health Service Journal.

Statistical Information

7. Mr. Jack : To ask the Secretary of State for Health what categories of statistical information his Department receives on a regular basis from district and regional health authorities.

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : From 1 April 1987 districts have been collecting a new range of statistical data. From this new data we are producing a set of 350 basic health service indicators. Following consultation and verification with health authorities, these will be published in July. We plan to publish the indicators for 1988-89 in January 1990.

Mr. Jack : My hon. Friend will know how useful such statistical returns as the performance indicators are in indentifying hard-working health authorities such as my own in Blackpool, Wyre and Fylde. He will also know that in the case of the financial returns of the Health Service it is taking some time to receive this information. Will he tell the House a little more about the steps that he is taking to achieve more timely availability of that information and to find a new set of performance indicators?

Mr. Freeman : After initial problems last year we are now satisfied with the timely receipt of information from districts. The provisional figures for 1987-88 for my hon. Friend's own health district demonstrate that there is a continuation of the excellent trend of treating more patients at relatively low cost. My hon. Friend is to be congratulated, as is his district health authority.

Dr. Moonie : What estimate is being made of the accuracy of the data that are being received?

Mr. Freeman : As I said, we are now circulating provisional data for 1987-88 to the regions and the district health authorities so that, over the next two to three months, the data can be verified. We will publish in July, when the data are verified. In January next year--that is to say, nine months after the end of the financial year which ends this month--we will publish this year's figures.

Yorkshire Regional Health Authority

10. Mr. Riddick : To ask the Secretary of State for Health what has been the average annual increase after inflation in the capital investment programme of the Yorkshire regional health authority between 1979 and 1988 ; what was the figure for the years 1974 to 1979 ; and if he will make a statement.

Mr. Freeman : A direct comparison between 1978-79 and 1987-88 shows an increase in real terms of 15.6 per cent. in the rate of capital expenditure in the Yorkshire region. A similar comparison of 1974-75 with 1978-79 shows a decrease in real terms of 7.9 per cent. measured at 1987-88 prices.

Mr. Riddick : Can my hon. Friend confirm that those excellent figures have led to increased and improved patient care in Yorkshire? Does he agree that, despite the noisy rhetoric of Opposition Members, not least the hon. Member for Livingston (Mr. Cook), the figures

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conclusively demonstrate that Labour cuts hospital building and that the NHS is safe only in Conservative hands?

Mr. Freeman : I am happy to confirm that. The additional capital investment that has gone into the Yorkshire region--indeed, the whole of the National Health Service in England--has manifested itself in greater patient activity. In Yorkshire, over the past 10 years, out-patient cases have gone up from 2.5 million a year to 3 million a year, and in-patient activity over the last five years is up from 450,000 per annum to 550,000 cases per annum.

Mr. Madden : Does the Minister accept that in Bradford the combination of cutting expenditure and creeping privatisation is creating widespread concern among those who depend upon the National Health Service for their health care? Will he nail the rumour that he has it in mind to appoint councillor Eric Pickles as the chair of Bradford district health authority? His appointment would have a devastating effect upon the morale of those who serve in the Health Service in Bradford and would be most unwelcome to the citizens of that city who depend on the service for their health care.

Mr. Freeman : What I can confirm is that, in terms of allocations to the Yorkshire region, as to all regions of England, there is a substantial real increase in resources going to the Health Service in the next financial year. In the case of Yorkshire, the increase is 2.5 per cent. in real terms.

The chairmanship of the district health authority is a matter for consideration and announcement in due course.

Deprivation and Illness

Mr. Wray : To ask the Secretary of State for Health what research his Department is funding or carrying out regarding the relationship between deprivation and illness in general.

Mr. Freeman : The Department and the Medical Research Council are funding a number of research projects into the relationship between social conditions and health. I will place a list in the Library later today.

Mr. Wray : Does the Minister agree that there is great concern in my constituency about the Greater Glasgow health board, because of the standardised mortality rate in the age groups 40 to 69 which is 70 per cent. higher than in Sweden, Norway and Switzerland? In the east end of the city the rate is 43 per cent. higher than in any other part of Scotland.

Mr. Freeman : As the hon. Gentleman knows, that is a matter for the Scottish Minister with responsibility for health. The formula for allocating resources in future, the replacement of RAWP--the resources allocation working party--will reflect not only the resident population in each district health authority but morbidity. If social conditions manifest themselves in higher sickness rates, the allocation will be greater. Mr. Hind : Is my hon. Friend aware that we have a very high level of unemployment in Skelmersdale in west Lancashire, and as a consequence there are certain types of disease that need to be treated? At a recent meeting of the local branch of the British Medical Association, it was said

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that under the new White Paper there might be a temptation for doctors who work in trust hospitals to overtreat their patients. Will my hon. Friend undertake that the research and detailed information that is available will be used to make sure that throughout the country that does not occur?

Mr. Freeman : The activities of consultants and doctors in all hospitals within the National Health Service, including self-governing hospital trusts which will remain within the NHS, are matters for the very high standards of professional organisations governing the conduct of consultants and doctors.

Mr. Robin Cook : Did the Minister see last week's report by the Health Visitors Association on homeless families and their health? Did he note its findings that, among the children of families in bed-and-breakfast accommodation, diarrhoea because of poor sanitation, respiratory infection because of dampness, and infestation with lice and fleas, are common? Does he accept those findings, and, if he does, will he minute his colleagues at the Department of the Environment and spell out to them the appalling impact on the health of our children from the sevenfold increase in homelessness under this Government?

Mr. Freeman : The standard of health of the children of this country has consistently improved under this Government. The Department is now undertaking some £18 million of research, including research into various aspects of child health that I referred to earlier. Next year, the amount spent on research by the Medical Research Council, including investigation into child health, will total about £176 million.

Mr. Michael Morris : Has my hon. Friend seen the parliamentary answer to my hon. Friend the Member for Beaconsfield (Mr. Smith) on average per capita prescribing, which seems to suggest that the highest prescription expenditure is in the most deprived areas of the United Kingdom? Does that not suggest that indicative budgets should be reconsidered?

Mr. Freeman : There is no question but that some doctors--I stress some--are over-prescribing. The purpose of our proposal for indicative drug budgets is to bring the practice of all doctors up to the best.

Child Minding

12. Mr. Archer : To ask the Secretary of State for Health if he will make a further statement on the carrying out of child minding by children.

Mr. Mellor : I am afraid that I can add nothing to the reply given to the right hon. and learned Gentleman on 6 March by my hon. Friend the Parliamentary Under-Secretary of State.

Mr. Archer : But does the Minister agree that a statutory provision serves no purpose unless it is effectively monitored and enforced? Does not the fact that the Minister is answering this question indicate the need for co-ordination among the numerous Government Departments that are responsible for enforcing the law on child employment? Is not the primary need for more resources for the law enforcement authorities?

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