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Column 404practitioners to the review is typical of the United Kingdom as a whole. My hon. Friend the Member for Kilmarnock and Loudoun (Mr. McKelvey) is hoping to catch your eye, Madam Deputy Speaker, to raise this point.
Although the Minister was switched from the Foreign and Commonwealth Office to his present role because some people perceived that he had an ability to communicate, he might have to do his job a little better when he has examined a letter that was sent to the Secretary of State for Scotland by the Ayrshire and Arran local medical committee, which states :
"The general practitioners of Ayrshire and Arran held a meeting last night, Monday 17 April 1989.
115 doctors attended and 115 voted against the new contract which was circulated last week."
That letter can hardly be taken as a sign that we should have any confidence in the Government's proposals for the Health Service, especially when we consider their bankrupt approach to community care.
The hon. Member for Southport was generous enough to refer to the Disabled Persons (Services, Consultation and Representation) Act 1986. That Act gained its Royal Assent in July 1986 and has been mentioned in almost all of our debates on this subject. We always plead for its implementation, as do the voluntary and professional bodies that have briefed hon. Members in preparation for the debate. Indeed, they are entitled to do so, because many people recognise that section 7, which, as yet, has not been implemented, contains many of the concepts of Sir Roy Griffiths's approach to the dreadful problem of people being discharged from hospital into community care that does not exist. We want to see the Act implemented.
We find it incredible that the Government's circular, issued in February this year, entitled "Discharge of Patients from Hospital"--the Department of Health has also published a document entitled "Discharge of Patients from Hospital"--states :
"Social Services Departments will expect Health Authorities to liaise with them about the wide range of duties, including those under the Disabled Persons (Services, Consultation and Representation) Act 1986, which fall to social services and to follow the arrangements which apply locally for carrying them out." Given that the Government are already advertising that Act, as MENCAP has pointed out, it is not unreasonable that we should ask them to provide the resources to implement it and to produce a plain person's guide for individuals and for organisations such as the Schizophrenia Fellowship which, like the rest of us, wants to see a strategy for hospital discharge and assessment of long-stay patients before they leave hospital and enter the community so that their needs will be met.
I am sure, too, that the Scottish Society for the Mentally Handicapped would urge on the Government the need, in Scotland, for the kind of joint planning arrangements that have existed for many years in England and Wales, and which we persuaded a reluctant Government to include in the National Health Service (Amendment) Act 1986, shortly after the Disabled Persons (Services, Consultation and Representation) Act was passed.
All this represents cost-effectiveness in terms of crisis avoidance. The Minister did not address himself to that, though it is a worry for hundreds of thousands of patients and their families, carers and communities. The revolving
Column 405door syndrome, to which organisations such as MIND have constantly referred, is, of course, unacceptable. We hear, too, that the Salvation Army estimates that up to three quarters of its hostels' male inmates may be suffering from mental illnesses. We know also that many mentally handicapped and mentally ill persons find themselves in prison simply because the courts have nowhere else to send them.
Last Thursday I raised the question with the Home Secretary, and, in reply, he said that he was consulting the Secretary of State for Health. I had expected, and it would have been reasonable for the hon. Member for Southport to expect, the Government to tell us precisely what they are doing to reduce this scandal. What we are seeing, in the name of so-called community care, is a hospital rundown and a pace of community care provision that simply do not match. Closing hospitals or hospital wards, and throwing people into the community--in many cases, on to the streets-- into hostels, and so on, is not community care in any meaningful sense. We know that for every psychiatric nurse working in the community there are about 25 working in hospitals. So there is a curious emphasis on the reverse. There is a need to recognise the problems where they exist within the community, not necessarily within hospitals exclusively.
The Minister failed to mention--although, in fairness, I have to say that the hon. Member for Southport did mention--the very vexed problem of the immense weight upon carers in this community--people who are saving the Treasury millions of pounds every year. In fairness, I must also point out that, curiously, these people are omitted from Sir Roy Griffiths' report. In terms of these problems, we as a House must recognise the tremendous worth of carers in every part of the United Kingdom. In many cases those people are doing a supportive job that ought to be seen as the role of Parliament itself.
My right hon. Friend the Member for Stoke-on-Trent, South (Mr. Ashley), who would have very much liked to be here for the debate, is very keen that we should urge on the Minister the need for a coherent approach to benefits for disabled people. We are told that the Government are considering these matters, and we are entitled to ask when we can expect a response. Our concern is about poverty, homelessness and neglect. The Spastics Society issued a document--to most hon. Members, I think--in preparation for this debate. It introduced us to very interesting case studies.
A document that is to be published soon refers, for example, to the case of June Morris. I know that we shall never forget that our debates and discussions about these matters are about people, about individuals, about the need for a collective response from society. The document says :
"June Morris is 34 and has lived in a local authority-owned bungalow for three and a half years, having moved there from her parents' home.
She has to wait for a home help to come each week, who stays for an hour. She's waiting to hear whether a laundry service could be made available. Having asked for an emergency phone she's awaiting the outcome. The combination of cerebral palsy and arthritis now warrants the use of a wheelchair. However, the kitchen and bathroom are not suitably adapted. The kitchen was looked at in January and again in August, but still nothing has been done
Column 406June doesn't believe community care exists-- There isn't any. It should mean that there is someone to turn to when you need help. I had no social worker for a year.' "
There is not one hon. Member who could not relate similar cases, similar circumstances, all of them unacceptable in this society. Of course we want to see more respite care ; of course we want to see more assessments ; of course we want to see more crisis avoidance in the carers' situation. But we cannot have these things unless there is proper resourcing, as well as proper recognition of services that have to be provided. The Association of Directors of Social Services has complained--rightly, I think--about the problems of training. It has reminded us of the vacancies in social work in London boroughs--15 per cent., with a turnover of 28 per cent. Happily, the situation is improving, but we have to do far more to recognise that these problems exist and to make sure that there is proper provision.
The Government are particularly mean-minded--especially in view of the dreadful problems of child abuse and the information that is now available to us--about the recommendation of the Central Council for Education and Training in Social Work on the need for an extra year's training. I hope that, on reflection, the Government will give serious thought to that recommendation, which, in the meantime, has been set aside.
Consumers ought to have a say in these matters. I believe that, were they to give us their views--for example, on housing investment--they would demonstrate that they consider our present commitment to be inadequate. Indeed, as consumers they would, in many cases, relate homelessness to drug or alcohol abuse or related problems. I believe, too, that they would join the Opposition in regretting bitterly the inadequacy of arranging for older children leaving care to go into the community. The Government's social security changes help these matters not one whit. If the Minister of State speaks for the Government when the Children Bill comes before the House, he will have an opportunity to correct what amounts to a scandal, and I hope that he will take that opportunity.
The community charge--the poll tax--is, of course, a perverse incentive in terms of our objectives. Even if they qualify for a rebate, many people in my constituency have to find £60 to £80 annually out of their very meagre pocket money. I do not regard that as being helpful to our objectives.
I want to ask the Minister to consider the many representations that have been made to the Government about land sales. Is money going back to the mental health services? There is very little evidence that it is. Some of the conditions that have been identified are absolutely unacceptable. The recent health advisory service reports on our psychiatric hospitals refer to gross overcrowding and to dirty, shabby, badly repaired, unsuitable, drab, depressing hospitals smelling of urine. The list continues. In many cases the hospitals are dilapidated, and institutional life means that there is no opportunity for people to live in dignity.
Despite the Minister's somewhat weak defence, the Audit Commission, even prior to Griffiths--and Griffiths accepted its view--described community care as being "in disarray". That is entirely unacceptable, but how could it be otherwise when, we are told, the Department of Health is responsible for promoting care in the community, the
Column 407Department of the Environment rate-caps local authorities that increase their expenditure on community care, and the Department of Social Security guides people towards a form of semi- institutional care in residential homes and, at the same time, administers the new Social Security Act, which has resulted in substantial loss of benefit for many former patients?
These matters are tremendously important, and there is a growing public awareness of them. The evidence suggests that most community care is provided by a member of a family, a whole family, or close friends. Community care should not be considered a marginal policy to be dismissed as being for a marginal group. It should involve mutuality--the responsibility of people to each other, which creates the fabric of a society of which it is worth being part. Whatever other disagreements we may have with Sir Roy Griffiths--there are many--he was right to say that the status quo is simply not an option.
Mr. Timothy Raison (Aylesbury) : I agree with the hon. Member for Monklands, West (Mr. Clarke) that this is an important subject. I was glad when, at the end of his speech, he talked about the responsibility of all of us for each other. I did not agree with his remark to the effect that carers were doing Parliament's job. It is a great error to examine such matters in terms of statutory provision. It is Parliament's job to pass statutes. However, the hon. Gentleman redeemed himself in his closing remarks. It is important to remember that the statutory services and voluntary services should never take more than part of the responsibility. The major part must still lie with all of us--ordinary people--to care for our own families, relatives and friends.
The Government's amendment asks hon. Members to express full support for the Government's policy on community care. I have in mind an amendment to the amendment. I will vote for the Government to express full support for their record, which is quite good, as my hon. and learned Friend the Minister demonstrated. I cannot say that I fully support the Government's policy, because I do not know what it is. It is in a state of limbo. The reason for the debate is that hon. Members are anxiously awaiting the Government's policy. It will be even easier to support it when we know what it is.
It is understandable that the Government have had to take some time over the matter. It is obviously complicated. At the same time, we cannot deny or duck the fact that we face serious problems arising from delay. I beg my hon. and learned Friend to end the delay as rapidly as possible. Delay is affecting morale and recruitment. My county of Buckinghamshire has a good record in the way in which it is trying to tackle community care. It has been keen to progress and it has been doing some good work. I have seen good local authority/county council provision of residential homes of one sort or another for people who come out of long-stay hospitals. A few days ago, I saw an excellent provision which had been set up by the health authority, working in conjunction with the Shaftesbury Society, providing a mixture of residential care and day care for the handicapped. We are doing good things in our county.
However, there is a blockage at present. That has quite a bit to do with difficulties in spending the necessary capital if the crucial transfer of individuals from long-term
Column 408hospitals to other forms of residential care is effectively to take place. We must have decisions. About 95 people in a hospital for the mentally handicapped in my constituency have been identified as suitable for moving out of the hospital into some other form of care. At the moment, nothing can be done because the resources are not available ; they must be unlocked. It was put to me that we need some kind of bridging loan to enable the transfer from the hospital institutional care to the appropriate alternative form of residential care. I hope that the Government will rapidly face that issue. I am not sure whether we have corrected the anomalies that have existed because of the different sources of funding. I understand why we have had such sources--income support, Health Service funding, and so on. The Government have recently been trying to produce a more rational and coherent pattern, but it is important to make sure that we have a better system for dovetailing different sources of funding. I can only repeat a point which was made earlier : areas such as mine with high housing costs have particular difficulties in the provision of residential care when the scales are set on a national basis. To be honest, my hon. and learned Friend's speech lacked an assessment of the present situation. We all accept the principle of moving people out of big mental hospitals when appropriate. We know that the Government have been genuinely trying to back that policy. However, we need to know what is happening. How many people have come out of such hospitals? How much additional care is being provided for those who still need residential care? The matter is complicated. We are not arguing that everbody should go from a hospital into another form of residential care, but some people need to do so. Happily, others can go back to their own homes, and that is the ideal solution. The public are entitled to more information.
It is equally important not to be dogmatic. In its good report, the Audit Commission said that community care is
"not about imposing a community solution as the only option, in the way that institutional care has been the only option for many people in the past."
We still need some long-stay hospital provisions. We certainly need a good deal of residential provision. We also need the truest form of community care--more support for people who are able to live at home. The crucial point--hon. Members have been a little chary of facing up to it--is the problem of where we should allocate responsiblity for seeing that things actually happen. The Government are finding that point difficult to resolve. There are good arguments for the different points of view. Griffiths was justified to refer to "a feeling that community care is a poor relation ; everybody's distant relative but nobody's baby."
The job is to assign the baby.
We must accept that co-operation, good will, and even adequate resources are not enough. They are all necessary, but we must define who is responsible for looking after the people about whom we are talking. Whatever scheme we adopt must bring together or allow to operate effectively the medical, personal and social services side and the cash or social security side. That is a truism. Griffiths was right to state that the crucial need was to pick out one point of reference to make sure that each individual has what he or she needs. That means at the ground floor level--at the level of the community carer, the care manager, or
Column 409whatever we like to call him or her. That is necessary. There must be a responsible organisation to whom that carer may report and for whom he or she would work.
Griffiths was right to say that local authority personal social services departments are best equipped to do the job. Of course the health aspect is important. Nobody--certainly not Griffiths--says that there is not an important health job. Nobody is saying that the social services can do the whole health job. They cannot. Clearly, GPs and community nurses will still be important in future for discovering needs. Social services departments are best placed to do the all-round job of finding out and then making sure that needs are dealt with by a suitable body.
I should have thought that that is in line with the enabling role which the Government nowadays regard as appropriate to local government. My right hon. Friend the Secretary of State for the Environment wrote a pamphlet about that enabling role. Even if there are doubts about piling more and more on to local authorities, it is appropriate that local government should have a co-ordinating role or the job of allocating accountability.
The Royal College of Nursing has argued that we should have a newly designed service, brought about by merging district health authorities, family practitioner committees and the personal social services, all of which, in the view of the college, should be funded by the health side. That is worth considering. No doubt the Government have done so, but I am a little chary of setting up a big new organisation of that kind.
The same doubt would apply to the proposals put forward by the Association of Directors of Social Services, which wants a national community care development agency. If we want to get on with the job, rather than devising grandiose mechanisms, it would be better to keep the social services departments that are in being. They might need more backing and resources to carry out the role, but I would prefer that instinctively to a new mechanism.
Griffiths also talked about the need for a Minister of State with responsibility for community care. One has to recognise that under our constitution Ministers of State cannot have ultimate responsibility ; that has to lie with the Secretary of State. However, there is a great deal to be said for a Minister of State working under the Secretary of State to provide a focus. If I may draw an analogy from my experience, I was Minister for Overseas Development ; I was not Minister of Overseas Development. I think that few people recognise the distinction. The Foreign Secretary is by statute Minister of Overseas Development. I was Minister for Overseas Development under him and I had to get on with the job. That parallel is perhaps reasonable, although the ultimate responsibility has to lie with the Secretary of State, who is the crucial person when it comes to the scramble for funds in the public expenditure round. We have had to wait too long. It is urgent to have a decision. I know that the Government are thinking hard about the matter and I understand their difficulties. Unless there are compelling reasons, Griffiths provides the best formula. I look forward to hearing soon from the Front Bench what the Government propose.
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Mr. William McKelvey (Kilmarnock and Loudoun) : I add my congratulations to the hon. Member for Southport (Mr. Fearn) who has given us the opportunity to debate what many people regard as an important issue. I was disappointed at the lacklustre and somewhat arrogant approach of the Minister.
I support strongly the comments of the right hon. Member for Aylesbury (Mr. Raison). If it were up to me, which of course it is not, he would be moved to the Front Bench and I would dispatch the present incumbent back to the Foreign Office where he was doing an excellent job. His attitude towards the Palestinians was much more understandable and correct.
It is not a mistake that the White Paper, which is euphemistically called "Working for Patients", omits any reference to community care and care for the elderly. That does not mean that the Government are not aware of the inadequacies and the disorganisation of community care. I think that they are fully aware of the position. That is why the then Secretary of State for Health, who is now Secretary of State for Employment, appointed Sir Roy Griffiths to make recommendations on care in the community. Most people would agree that the impetus for the report was not concern for the elderly but, rather, concern about money.
There were serious criticisms of the Government's community care policy by the Audit Commission, which was alarmed that much of the £6 billion spent annually on the mentally handicapped was being wasted and was not being spent properly. Sir Roy Griffiths was not appointed to create a model for adequate community care with no cost spared ; indeed, quite the reverse was the case. His remit was
"To improve the use of funds as a contribution to more effective community care."
Hon. Members should note that no further resources were brought into the equation. We should underline that.
The Griffiths report was published in the spring of 1988, yet still there is no response to its recommendations other than the answer that we get on every occasion when we raise the question--that the Government are looking at the matter. We have had nothing apart from vague representations from the Minister that something is likely to happen in the near future. That is all we have been told. Why have the Government remained silent for so long on a report which was excellently prepared, although there is much in it with which I disagree? The suggestions in the report worry the Government. The right hon. Member for Aylesbury outlined some of them. The hardest nut to crack and the worst thing for the Government to swallow is the suggestion by Sir Roy Griffiths and his team that they should give local authorities a leading role as providers of care, assessors and co- ordinators. The Minister indicated clearly that he has no faith in any local authority carrying out those duties. There has been reference in the debate to the suggestion in the report for a Minister of State for community care, with appropriate departmental support. That proposal is not popular with the Government. If such a post were established, people who are hungry for the financial aid needed to carry out their programmes would have someone to target for funds, and the Government would be seen as attempting to put all those pleas to one side. It is not surprising that the Government are not enamoured
Column 411of the report. That is supposition on my part, because to date they have not said whether they are enamoured or otherwise. While they are considering the report, hundreds of thousands of people in a very distressed state, out on the streets and elsewhere, need the care that we want to see established.
I disagree fundamentally with some of the Griffiths
recommendations. For instance, young unemployed people should not be press- ganged through the youth training scheme or any other scheme into home-help -type jobs, as suggested by Griffiths, simply as a means of getting community care on the cheap. That is not the way that we should go about it.
Neither do I wish to see a two-tier system for the elderly, with tax incentives to encourage private health care, as suggested in the report. My party and the people whom I represent do not think that residential care should be means-tested. We do not want to return to a system with deserving and non-deserving poor. All the people should be treated equally and their needs should be met. There should be greater choice and greater independence for all who require care in the community. That can happen only if the right amount of cash is injected and if it is directed at the right targets. The aim of moving more care into the community and away from residential institutions is laudable, but only where real support and care are available. An aim set for Sir Roy was to reverse the financial incentives operating in favour of residential care.
Residential care is the biggest growth industry in Ayrshire, where there are nearly 10 times as many homes as there were four years ago. There has been an incredible increase in the number of homes. I have visited many of them, and have talked to the people who manage them. The vast majority are run very well. I have no objections to the way in which they are run. The people who live in them are happy, but many of them would be happier if they had been allowed to remain in their own homes, which they cannot do.
The Government must recognise that there must be proper finance available for looking after elderly relatives at home. The carer's benefit should be paid for looking after that person and should not be included as income when establishing a person's level of income support. After all, when one considers how small that benefit is, when compared with the cost of keeping a person in a residential home, there is no reason why the Government should not make that a benefit which is unrelated to income.
The Griffiths report may not be completely to everyone's liking, but it is important because it provides a basis for developing the policies for care in the community which are long overdue. They should have been in place before we witnessed the large-scale closures of hospitals and large-scale openings of residential and nursing homes. We are trying to close the door after the horse has bolted.
I urge the Government to make their responses to the Griffiths report known as quickly as possible, or at least to initiate a whole day's debate on community care for the elderly, the mentally handicapped and all those whom we genuinely wish to assist. I shall cite one case that will clarify my misgivings about the Government's intentions for community care and, for instance, the community care grant.
Yesterday it was reported that more than 40 per cent. of the money made available for community care grants in the Scottish districts is being returned because the money
Column 412has not been taken up. That is not because people are not trying to get the money, but because the guidelines are so tightly defined--there is no discretion at local level--and the money has not been properly used.
My hon. Friend the Member for Dundee, East (Mr. McAllion), raised with the Minister the case of his constituent who was in a mental hospital for 10 years and was being released into the community. The district council gave the woman a house and an application was made for a community grant of £500 to assist. She was refused that grant because her income was 4p over income support due to her invalidity benefit. That woman really could have benefited from being allowed to live in the community and having a proper start in a new life. However, because of the barriers presented by that extra 4p, she was refused a grant. She may end up back in hospital because she will be unable to cope. There should not be such a rigid attitude towards people who are trying desperately to come back into the community. We should not have such tight legislation which stops a person taking his or her rightful place in the community and being given back much of the dignity that he or she has lost.
Mrs. Gillian Shephard (Norfolk, South-West) : I am pleased to contribute to the debate. While the NHS review and the new GPs' contract may have been the focus of much professional attention during the last couple of months, a more consistent interest has been expressed over a number of years about the current and future structure of care in the community.
That interest is entirely predictable, given, first, the demographic changes at each end of the spectrum, which eventually will mean that there are fewer people to look after more people ; secondly, rising public expectation ; and, thirdly, changing family patterns, with implications for carers and the public services. I mean by that the breakdown of marriages. While it might be fairly expected by many that they would look after one mother-in-law, looking after two or three, if they enter into a second or third marriage, might be stretching it a bit. That is a flippant way of saying that obvious lines of responsibility within changing family patterns may be weakened. I believe that we must consider that. We must also accept that there is a growing involvement of the private and voluntary sector. It has already been said that expenditure in the private and voluntary sector is now approaching £1 billion, which is a considerable sum. It was most unfortunate that the Opposition made a quite unwarranted slur on the motives of people who run the private and residential homes, which I believe will not go unnoticed by them.
The Audit Commission argued that community care is about "changing the balance of services and finding the most suitable placement for people from a wide variety of options. It is not about imposing a community solution as the only option in the way that institutional care has been the only option for many people in the past."
It is important to stress that definition of community care, which makes it an option within a spectrum. While Governments may always have regarded it as such, until the last two or three years it has been regarded in health and social services circles as a policy leading inexorably away from institutional care of any kind.
Column 413Clearly, community care should provide a range of care services through which people may move, both in and out, and including as one of its parts in-patient care, whether short-term, respite or crisis care.
As services are at present organised, community care requires very close and effective co-operation between a number of agencies--health authorities, local authorities, housing agencies, social services, social security, the voluntary and private sectors and, of course, relatives and carers. To quote the Audit Commission again, it must "cover prevention, treatment, rehabilitation, health maintenance and social supportive networks."
The necessary co-operation between a range of agencies with different power bases, and such a complex range of care to provide, sets a task whose complexity is awesome, although, of course, many achieve it. Indeed, if Governments had set about making community care provision as difficult, as time-wasting, as bureaucratic and as committee-bound as they could, they could hardly have done worse than the present system against which providers have to battle. Especially with reference to joint financing, I was most interested to note the simple pride with which the right hon. Member for Plymouth, Devonport (Dr. Owen) announced yesterday that he had devised the system. Within that complicated structure, the Government's achievements have been good. For example, the need for mentally handicapped children to live in long-stay hospitals has been virtually eliminated. The adult hospital resident population of mentally handicapped people has been reduced by more than one third. It is difficult to assess the Government's record by public spending measures, precisely because the responsibility for funding is spread between a number of agencies. However, I believe that we can all accept the evidence of the National Audit Office, which found a significant increase in spending on the elderly, the mentally ill and the mentally handicapped between 1977 and 1985. None of us should forget that the debate is taking place within the context of a record spending on the National Health Service of £26 billion and a social services budget of £3.3 billion. We are not talking about a service which is being starved of funds.
Since 1979, much more money has been put into joint finance. That has increased by about 60 per cent. and, more significantly, its take-up has increased from 52 per cent. to nearly 99 per cent. That has been encouraged by interesting new conditions, such as the dowry system, which unblocked Health Service funds for use in the community by the simple expedient of transferring the funds with the patient into the community.
There are some excellent examples of good and innovative work, which demonstrate that quite highly dependent people can be cared for in the community. That is the message emerging from 28 pilot schemes set up by the Department of Health and Social Security in 1983, which were funded by an additional joint funding budget. I mention in particular the Kent community care scheme for frail elderly people, which links devolved budgetary management with the design of individual care packages. In my county, which is
Conservative-controlled, we have excellent schemes. For instance, the Lawns in Great Yarmouth, which was formerly a residential home for the elderly run by social services, now provides an interesting, acceptable and popular range of care and help for elderly
Column 414people. In the Norwich health district we have community care groups with proper appraisal, and West Norfolk and Wisbech health authorities have well-developed day care and drop-in centres linked to private residential care.
The picture of the last 10 years of community care under the Government shows steady progress, although it has been a little unevenly distributed. We have seen increased spending and some solid evaluation of what does and does not work. That is important. The Government face a daunting task in framing their response to Griffiths. Whatever structure is devised, the problems that I have mentioned will remain. There is the complexity of the mechanisms which involve many agencies and at least three Departments of State. There has been steadily increasing expenditure on the private and residential sectors, mainly for the elderly, which many of us welcome, and in which standards of care are monitored, thanks to the statutory agencies. However, it must be accepted that criteria for admission, and therefore for financial support, are not monitored. This is becoming a bottomless purse.
The Government also need to consider a number of models for the provision of community care. Some hon. Members have mentioned the local authority model. There are elements that can be commended to Ministers in the response to Griffiths by the Association of Directors of Social Services. The response mentions a mixed economy for care and service provision, a good national framework for regulation of monitoring, which everybody welcomes, and strengthened local accountability by care managers.
There is also the health authority model, in which existing community health services might be grouped together and subsume local authority services that are being nationally funded. There is the possible client group model, where we might transfer responsibility for the mentally handicapped to social services and responsibility for the mentally ill and some elderly people to the health authorities. Then, of course, there is the model of an entirely new agency which might plan and buy in care from local authorities, health authorities, voluntary organisations and the private sector. In preparing their response to Griffiths the Government will want to consider the not inconsiderable amount of change planned for the National Health Service, especially in primary care. It might be difficult at present to give the National Health Service something else to worry about, although many of the worries expressed in yesterday's debate are entirely unfounded. I do not wish to see any more delay in the Government's response to the Griffiths report because some planning decisions are being held up pending that response. Given the complexity of the task and its importance to patients, which can only increase, I hope that the Government will take the time that they need to produce the right and most effective response, because I suspect that the ramifications will be with us long after the White Paper has been absorbed into professional practice.
Mr. Alex Carlile (Montgomery) : I propose to speak about general practitioner services, but before I turn to the merits of the case I should like to speak about the way in which the Minister of State, Department of Health approached the question of how general practitioner services should be run in future. I think he knows that I have a considerable regard for his political and forensic
Column 415and especially his legislative abilities. However, in his approach to general practitioners he has given the impression of coating himself with testy arrogance as a biscuit with bitter chocolate. That has caused great offence, not only to general practitioners but also to members of the public interested in the National Health Service. It seems that the Minister is not too keen on listening to reasonable argument in the debate, but I know that he is always prepared to listen to opera. I shall draw a brief operatic analogy. General practitioners look upon the Government's blandishments in relation to general medical services rather like Bluebeard's bride at the entrance to his castle. I do not allege that the Minister is Bluebeard--that is his right hon. and learned Friend the Secretary of State. The Minister is merely the doorkeeper. General practitioners believe--in my view, rightly-- that every time they, like Bluebead's bride, pick up one of the gilded offerings inside the castle, they find beneath it the curse that the Government are bringing upon the National Health Service.
I remember the bad old days of general practice. I am the son of a general practitioner who practised in an industrial Lancashire town. He is retired now and is a very old gentleman, but he had experience in private medicine, albeit not in this country, experience in hospitals and many years' experience in general practice. At one time he, like many other GPs, was single-handedly stemming the tide rather like King Canute. All over the town where we lived one could see queues of sometimes 30 or 40 patients outside each poorly maintained surgery, especially on Monday mornings. My father was a single-handed practitioner and on his half day off we had to escape from the house in which he had his surgery. He had to arrange that half day with another doctor, and if we stayed at home he would have no rest. As a result of the pressure he faced, I was sent by him to a good school with a foundation that provided for the sons of dead general practitioners to be educated for nothing. Many people were educated by way of the medical foundation in Epsom college.
In the mid-1960s and early 1970s, times changed, very much for the better. Nowadays, in most if not all parts of this country, we have group practices with much better facilities and offering a good service to patients. That happened in my father's practice. Those group practices are also able to contribute to the community. For example, the Department of Social Security depends upon general practitioners for its medical boards. How many GPs will still be able to do that work after they are compelled to work 20 hours a week in their surgeries?
Since childhood, and especially since I became a Member of the House, I have had an opportunity to observe a rather different sort of general practice, the rural medical practice. In preparing the new GP contract and in planning whatever strategy they have for general medical services in England and Wales--interestingly, there is a difference in Scotland--the Government have chosen to ignore almost completely the special needs of rural areas and rural medical practice.
Rural practices in my constituency, in other parts of rural Wales and probably elsewhere in the United Kingdom are, on the whole, well organised and provide a high standard of service. If a patient has an accident in my constituency the chances are that he is 30 miles from the nearest major casualty hospital. He goes either to his GP
Column 416or to one of the little local hospitals where the GP carries out the casualty work and performs small operations and stitches up people. If he lives in a rural area such as mine, the chances are that he will be able to go to a branch surgery not in a far distant town but in a nearby village. The chances are that when he telephones the doctor's surgery and asks for an appointment and outlines any difficulties in getting to the surgery the doctor, assessing the needs of the patient, will take the entirely reasonable decision that the patient should not come to the surgery but that the doctor should visit the patient.
That is the special nature of rural medical services as they have developed and, on the whole, they are good, very good. I pay tribute where it is due to the Government for allowing those services to develop in a way that is beneficial to the community. But I ask the Minister why the Government have now decided to pull the rug from under good rural practitioner services. I shall refer to some specific matters which are evidence that the Government want to do just that.
As a direct result of the changes proposed to the GP contract, there is absolutely no doubt that doctors will be unable to visit their patients as often as they have in the past. A very good general practitioner whom I know well told me recently--and this was confirmed by other doctors at the meeting--that sometimes in a morning he can visit only three or four patients because of the distances involved. My recollection of my childhood in a busy town is that my father used sometimes to visit six or seven patients in one street. It is quite different in rural areas. If rural doctors are forced to spend 20 hours in their surgeries, they will spend some of that time twiddling their thumbs, looking for something to do, when they could be out visiting their patients. That cannot be in the public interest. What is more, our community hospitals in places such as Welshpool, Llanidloes, Machynlleth and Newtown depend upon the GPs not sitting in their surgeries but going to the hospital to carry out the hospital services. This they will be unable to do if they are forced to sit in their surgeries for as long as 20 hours a week. The Government have set targets for vaccination and cervical smear rates. In order even to maintain their income--the doctors in Montgomeryshire are not suggesting that their incomes are too low and should be substantially increased--doctors are to meet certain targets if the new contract comes into being. But these targets are wholly unrealistic in rural areas. The 90 per cent. vaccination target is impossible to achieve. Whooping cough vaccination, included as it is in the compulsory criteria for payments, will set ethical dilemmas which will affect all doctors, for not all are as convinced as perhaps the Minister is about the value of that vaccination. One of my local practices campaigned especially hard on the need for cervical smears by writing and speaking to patients when they come into the surgery ; but it still fell short of the target of 80 per cent. which the Government seek to set for cervical smears. Because it is unrealistic to try to reach those targets in rural areas, some doctors will decide that the targets will never be achieved, that as a result they will not be paid for the work they do and that they may just as well withdraw the service and leave it to somebody else to provide cervical cytology. That cannot be in the interests of women in rural areas.
Column 417I urge the Minister, who I know is listening to these points, to consider them seriously, for they are all real problems put to me by real doctors.
Another problem relates to minor surgical operations. In Scotland the principle has been recognised that in rural areas, provided the doctor does five procedures in a month, he will be paid for those procedures. But under the contract which is sought to be imposed in England and Wales, on rural as well as on urban doctors--and it is only the rural doctors who can do large-ish numbers pro rata of surgical procedures--they are told that they will be paid for minor surgical procedures only if they do five in a session.
I can tell the Minister what will happen. A patient will go to see Dr. Jones. Dr. Jones will explain that he would like to do his surgical procedure but will be paid for it only if he does five in a session. He tells the patient that he will collect five and then the patient can come back and have his surgical procedure carried out. So Mr. Evans visiting Dr. Jones may have to wait a month before his surgical procedure is done.
What happens now is that Mr. Evans, a patient who may live 15 miles from his doctor's surgery, will go to the surgery and will have the minor procedure done on a one-off basis by appointment. That is serving the consumer. That is fulfilling the aspiration that the Government rightly have for the medical profession.
Mr. Richard Livsey (Brecon and Radnor) : The 20-hour rule for GPs will prevent doctors in rural practice from carrying out the procedures that my hon. and learned Friend the Member for Montgomery (Mr. Carlile) has mentioned. This will restrict their opportunity to carry out minor surgical procedures. I am sure that my hon. and learned Friend will agree.
I wrote to the Secretary of State in detail on 30 March setting out my misgivings about the GP contract for rural services, and I await his reply to those specific questions with great interest. I will mention two now. The Government's proposals mean that there will be far fewer part-time general practitioners. This is very much against the interests of women, in particular, for there are many women doctors who are perforce rather than by choice part-time practitioners. Some live in my constituency. The payment arrangements--effectively, the removal of the basic practice allowance--mean that practices will be disinclined to employ women part- timers in the future. As it is, it is very difficult in some areas for women to find a woman practitioner to go to--and many wish to, for very good reasons.
I ask the Minister to consider this and to try to ensure that the part- timer, particularly the woman doctor, providing excellent service can continue working in general practice.
The last point I wish to draw to the Minister's attention is that of reimbursement to GPs for ancillary staff and for premises. One of the great developments that I saw as I grew up in a doctor's household was the improved ancillary facilities provided by successive Governments and the chance given by those Governments to doctors to have better surgeries. It happened in our family practice
Column 418and in many others that I know well. This sort of provision gave a great impetus to good-quality general practitioner services. The new arrangements suggest, however, that those reimbursements to GPs for ancillary staff and for rents are liable to be cost-limited and reduced. As a result, general practitioners will seriously reconsider any increase in their staff numbers. Some of my local GPs now employ practice nurses who can provide in some cases a rather more intimate service in minor matters than can the busy GP in his surgery. Practice nurses are a very important part of medical practice in rural areas. But doctors will have to reconsider employing them.
In addition, I am aware of at least one £500,000 surgery rebuilding scheme--not in my constituency but in that of my hon. Friend the Member for Brecon and Radnor (Mr. Livsey)--that the practice is now considering abandoning as it cannot rely on the reimbursement initially promised to service its great undertaking. The practice consists of doctors who are, in mid-Wales terms, in a medium-sized town. If they do not develop their new medical centre, because of changes in the contract and in the arrangements for payment for GPs, it could be another 20 years before the town's services are improved. That would be a matter for regret.
I ask the Minister, therefore, to go back to his Department and have another look at rural GP services. In particular, we should bear in mind the fact that there is no logical case for saying there should be one thing for rural services in Scotland and something quite different for Wales and rural England. As the proposed contract stands, those rural services will suffer and, I am afraid, it will be the Minister and his right hon. Friend the Secretary of State who will be blamed.