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House of Commons

Tuesday 27 June 1989

The House met at half-past Two o'clock


[Mr. Speaker-- in the Chair ]


Hayle Harbour Bill


Order for Second Reading read.

To be read a Second time on Thursday 29 June.

King's Cross Railways Bill

Motion made,

That the petitions of Eileen Tegg and Nicholas Holliman be referred back to the Court of Referees.-- [Mr. Chris Smith.]

Hon. Members : Object.

Oral Answers to Questions


NHS Reform

1. Mr. Day : To ask the Secretary of State for Health whether the intention of the new general practitioners' contract is to increase doctors' list sizes.

The Secretary of State for Health (Mr. Kenneth Clarke) : No, Sir. The sole aim of the new contract is to raise the standard of care patients receive from the family doctor service. There is no possibility that it will lead to any increase in average list size.

Mr. Day : Is my right hon. and learned Friend aware that, in 1965, the British Medical Association, which was in dispute with the then Labour Government, recommended that general practitioners resign from the National Health Service? Is he further aware that the main point of dispute between the then Government and the BMA at the time was seniority payments, to which the Labour Government were opposed? Does he agree that the Opposition's present position is therefore rather hypocritical?

Mr. Clarke : My hon. Friend is right. There was a serious dispute between the former Labour Government and general practitioners on the last occasion when the general practitioners' contract was being revised. Obviously, the attitude of today's Labour party is rather different from that of its predecessor. The hon. Member for Livingston (Mr. Cook) would simply write a letter to the BMA asking what it wants the Labour party to agree to. That was not the practice in former times.

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Mr. Fearn : Does the Secretary of State agree that a general practitioner should have a maximum number of patients? If there is to be a maximum, is it to be categorised according to elderly, young, indifferent, or what?

Mr. Clarke : Nothing that I propose will increase a doctor's average list size. Obviously, patients will join the practice of a doctor whom they think gives them the right quality of care and the right amount of time. I would be most reluctant to contemplate a maximum. It would mean telling patients that they have to leave the list of a doctor whom they think is giving satisfactory service. That is not the way of going about it.

Mr. Nicholas Winterton : Does my right hon. and learned Friend agree that increasing the capitation percentage of a doctor's remuneration could reduce the amount of time that a doctor can spend with each patient and that that could be counterproductive for health care?

Mr. Clarke : No. Although I do not regard myself as a mathematical genius, I believe that most of those arguments are nonsense. A doctor's average list size is determined by the number of doctors and patients. I have no control over either of those things. Because more general practitioners keep joining the National Health Service, the average list sizes keep dropping, and I imagine that they will continue to do so. Patients will not join the list of someone who has taken on so many patients that he starts cutting the time that he spends with each patient. There is no way that anybody should or will react to the new contract by trying artifically to inflate a practice list over the average size.

Mr. Robin Cook : Does the Secretary of State appreciate that the simple and straightforward way by which GPs can increase the average list size is by not appointing new partners? Is he aware of complaints, particularly by women graduates, that since he published his White Paper adverts for new partners have dried up and adverts for part-time partners have practically vanished? How can he possibly pretend that a contract that will make it more difficult for women to become established as general practitioners is likely to encourage more women to come forward for cervical smears?

Mr. Clarke : It is an astonishing allegation that, for purely financial reasons, doctors will reduce the time that they can give patients just by not taking on another partner, and thereby willingly taking on more patients for themselves. The financial advantage to a partner in the average practice would be quite minor. I do not think that many doctors would be so irresponsible as to do that, and I do not think that patients would stay with practices that do that. I do not accept that anything in the new contract is any deterrent to women becoming full partners in general practice. I expect many more women to do so. For the first time, we are making provision for part-time principals, job sharing and so on to recognise that more women are likely to go into practice and have family commitments during some part of their careers.

NHS Reform (Yorkshire)

2. Mr. John Greenway : To ask the Secretary of State for Health what assessment he has made of the prospects for self-governing hospitals in the Yorkshire region.

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Mr. Kenneth Clarke : I am very pleased to have received so far 10 expressions of interest in self-governing status in the Yorkshire region. I cannot yet comment in detail on the prospects for particular hospitals and units in the region.

Mr. Greenway : Although I recognise that hospitals facing the threat of closure might not achieve self-government, does my right hon. and learned Friend agree that hospitals that have expressed an interest in self -government should not have their hopes dashed by rationalisation plans formulated by health authorities since his White Paper proposals were published? In particular, will he consider the case of Malton, where the local general practitioner practice, supported by the family practitioner committee, is keen to take on a practice budget in conjunction with Malton community hospital achieving self-governing status, towards which maintaining general practitioner beds and other services is essential for improved patient care and convenience?

Mr. Clarke : I have made it clear that self-government cannot be considered as an alternative to necessary closure and that health authorities must continue with planning their services as now. Nevertheless, I see prospects of a combination of self-government for a community hospital and of practice budgets for some local general practitioner practices leading to an increased use and better financing of popular general practitioner beds in community hospitals. If any expressions of interest come from Malton, I shall, of course, consider them with interest and on their merits.

Mr. Duffy : Earlier this month the Secretary of State announced the regional conference for Leeds on 11 July for the hospitals that he has in mind for self-government and that are showing interest in the idea. As some hospitals in Sheffield, Doncaster and north Nottinghamshire, which fall, as he knows, within the area of the Trent regional health authority, are showing similar interest, will he consider arranging a separate conference to be located in, say, Sheffield for the same purpose?

Mr. Clarke : I shall consider that helpful suggestion. We are not so rigid about regional boundaries as to insist that people attend a centre that is less convenient for their hospital. The meetings that I have attended so far with people from the units where interest has been expressed have been extremely successful, and I am sure that we shall have a full series of such meetings.

Mr. Kirkhope : Will my right hon. and learned Friend accept from me that there is considerable excitement in Leeds at the prospect of self- government for hospitals, and positive and great interest in the possibilities for the future? However, will he join me in condemning the scurrilous scaremongering of the unions and other politically motivated people in Leeds to try to prevent self-government?

Mr. Clarke : Local people are extremely interested in the idea of doctors, nurses and hospital managers having more autonomy over how their hospital is run. When I attend meetings with those interested, there is considerable interest as we explain in more detail how our proposals will work in financial and personnel terms and how they will be able to develop their own services. I agree with my hon. Friend. All that is happening despite the daft campaign in

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some locations where people are still claiming that the proposals will lead to hospitals leaving the Health Service or to disruptions in the service. That argument is simply not sustainable when one considers the details of our proposals.

Mr. Crowther : Is the Secretary of State aware that some consultants in the Yorkshire region are privately expressing fears that a hospital that does not become self governing may suffer a hidden penalty in the allocation of resources? Will he give the House a cast-iron assurance that that will not happen?

Mr. Clarke : Under the new system, resources will be allocated to the health authorities and to general practitioners who hold practice budgets. They will decide the hospitals with which to have an agreement for the provision of the services that they need. The fear that the hon. Gentleman has described is based on a fundamental misunderstanding of how the new arrangement will work.

NHS Reform

3. Mr. Cousins : To ask the Secretary of State for Health whether he intends that reduction in length-of-stay targets should form part of hospital contracts.

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : Length of stay could be one element which health authorities might discuss with hospitals when reaching an agreement on a contract as it might be an important factor in determining how many patients could be treated within the resources available. The contract itself need not, however, specify how long a patient should stay in hospital.

Mr. Cousins : Does the Minister accept that it would be disgraceful to build into a system for hospital contracts financial pressures that could lead to patients being discharged before their social circumstances in the community are right and before their medical needs are correct? Does he agree that that would simply be shifting the cash responsibility from the hospital contract on to social and community service--another sector of the budget?

Mr. Freeman : The quality of care available in hospital is not related to and cannot be correlated with the length of stay of patients. The average length of stay of patients over the past 10 years has decreased from 13 days to 10 days. That is a reflection of the substantial increase in day surgery and of advance in medical technology.

Mr. Redwood : How serious is the Minister about improving quality of treatment? Will he use the contracts as one way of improving quality? What progress is being made with the appointments systems as part of that package? Could those also be enforced through the contracts?

Mr. Freeman : Quality is extremely important in hospital care. I commend to my hon. Friend and the House the new document published by my right hon. and learned Friend the Secretary of State for Health on 20 June entitled "Self-governing Hospitals", which goes into some detail about the importance of quality in contracts for care of patients in hospital.

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4. Mr. Roy Hughes : To ask the Secretary of State for Health what representations he has received from professional bodies and trade unions concerning the Government's review of the National Health Service.

5. Mr. Knox : To ask the Secretary of State for Health how many representations he has received from members of the public about the White Paper "Working for Patients".

Mr. Kenneth Clarke : I have received in total about 8,000 representations so far.

Mr. Hughes : Would it not be wiser if the Secretary of State were more candid with the House and admitted that all those bodies have been positively hostile to his proposals, believing that they can cause serious damage to patient care? If he did so, he could scrap his proposals and go back to the drawing board. Certainly many of his Back-Bench Members would be relieved.

Mr. Clarke : I fear that if I say anything of the kind, it will be a long way from the truth. Although there is a great deal of public campaigning, I am having extremely helpful and constructive meetings not only with those who lead the professional organisations, but with large numbers of their members. It is obvious that the process of implementing the reforms is already under way, because the great bulk of them have been readily accepted by the majority of the medical profession and others.

Mr. Knox : Will my right hon. and learned Friend confirm that he is giving serious consideration to all constructive representations made to him?

Mr. Clarke : I can. The whole basis on which we have proceeded is to issue a White Paper and working documents inviting constructive contributions. We intend to work out in detail matters such as self- governing hospitals and general practitioners' practice budgets with willing volunteers. I keep telling my organised critics that they must choose whether they wish to remain spectators on the sidelines, merely shouting abuse, or to take part in constructive and sensible discussion on how the Health Service might be improved.

Mr. Grocott : If it is true that the Minister is listening to constructive criticism, which some of us have reason to doubt, can he give the House one or two concrete examples of the way in which his proposals have changed as a result of the almost universal objections that he has received?

Mr. Clarke : I spent 10 hours in the time-honoured method of beer and sandwiches in an almost locked room resolving difficulties over the general practitioners' contract and bringing to an end a very protracted period of negotiation.

If the hon. Gentleman would look at our latest documents for those interested in self-government, he will find that there is an overall statement and a working paper describing financial and contractual difficulties, and that thinking has moved on quite a lot. Since we produced the White Paper we have put in much more detail, precisely in response to the detailed questions that have been put to us.

Dr. Reid : I congratulate the Minister on being more restrained in his comments about doctors than he was at the previous Question Time. A careful reading of Hansard for the previous Question Time will reveal that he and his hon. Friends branded the medical profession and doctors

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as being unscrupulous, misleading and liars. Will the Minister take the opportunity to dissociate himself from the comments that were made on that occasion about the medical profession?

Mr. Clarke : I would normally rely on the hon. Gentleman to read Hansard with a little more care than he appears to have been doing. Both I and many of my hon. Friends have made strong comments about some of the advertising material put out by the British Medical Association. We believe that it is an extremely unscrupulous campaign. We have made no attacks on the medical profession or on individual doctors, except on those doctors who are misleading their patients and are making wild allegations that they know to be untrue. As I said in reply to a previous question, there is an enormous gulf between some of the public protestations on behalf of the associations and what is said in private discussion with the leaders of the BMA and others. The BMA is obviously in favour of better financial management systems, medical audit and money following the patient. We should build on that and ignore all the rather silly propaganda that appears in the newspapers.

Dame Jill Knight : Will my right hon. and learned Friend always bear it in mind that the reactions to the review from the medical profession, especially the BMA, are as predictable as Pavlov's dogs? It has always rejected every suggestion for reform in the National Health Service. Does he agree that, if he had listened to it and had not pressed through the reform of the limited list, we would have had £73 million per annum less to spend on patients?

Mr. Clarke : My hon. Friend and I can remember many such campaigns that the BMA has run, under successive Governments, against suggestions for reform. On the strength of my latest meeting with the BMA leadership I am more hopeful on this occasion. The BMA began by accepting our aims and various features of the reforms, but it has not yet been able to put forward any positive proposals of its own that might further those aims. However, the initial outright rejection that is customary from the BMA has already begun to modify.

Mr. Robin Cook : May I give the Secretary of State the thanks of the official Opposition who, since the publication of his White Paper, had our best election results for 20 years? It is about time that he started listening to what the electorate is trying to tell him. Having told my hon. Friend the Member for Newport, East (Mr. Hughes) that he has received 8,000 representations, will he now share with the House the breakdown of those representations and tell us how many supported his White Paper and how many wanted him to drop the whole idea and get back to the real problems of axed beds and closed wards?

Mr. Clarke : I am afraid that I do not see my role in life as a good Samaritan to the Labour party. My principal duty is to carry through a process of reform that will produce a better National Health Service. Sooner or later, the Labour party must decide what it is saying rather than maintain its present outright opposition to everything that we propose.

I am glad to say that many of the 8,000 representations that I have received deal with the serious detail of the White Paper and, for that reason, they do not break down

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into yes and no answers. It is only the Labour party which is continuing to reject outright each suggestion that happens to come from the Government.

Sir Peter Hordern : Has not the unscrupulous and misleading campaign carried out by the BMA so confused the doctors that they do not know whether to sign the contracts that have been placed before them and which the BMA has recommended?

Mr. Clarke : I fear that that is the case. The BMA has run a strident campaign, but when it called a conference to endorse the deal that its leaders had negotiated with me it was unable to get consent. Now, no doubt, it is trying to explain it to many doctors who mistakenly fear that they will lose income as a result of the changes, and who also feel that they should be left to decide entirely for themselves what they do and how and when they do it. That is not the basis on which we should proceed given that the BMA began by agreeing with me that a new and better contract was required by April 1990.

6. Mr. Cox : To ask the Secretary of State for Health what financial help is to be given by his Department to those hospitals that are seeking to explain to local communities the Government's White Paper on the National Health Service ; and if he will make a statement.

The Minister of State, Department of Health (Mr. David Mellor) : No specific financial allocation has been made to health authorities for this purpose. However, health authority chairmen and senior National Health Service managers have attended national and regional conferences, and received written material and visual aids to help them to explain the proposals and their implications to NHS staff and the public. This commitment to communication will continue throughout the period of the implementation process.

Mr. Cox : Is the Minister aware that the document entitled "Working for Patients" contains an obligation to explain to patients the implication of the White Paper? Today we have repeatedly heard the Secretary of State bitterly condemning doctors who are seeking to do that because he does not like the points that they are making to their patients. Wandsworth health authority, whose area the hon. and learned Gentlemen and I represent, wants to explain the White Paper, but it cannot do so because it does not have the money. Therefore, the very people whom the White Paper is supposed to be about will not have the opportunity to have it explained to them or to have their queries answered. That is a typical example of the Government imposing decisions on the very people who will not be given any opportunity to voice their objections to them.

Mr. Mellor : A shortened version of "Working for Patients" has been made widely available to the public and there is ample opportunity for lively debates on the merits of the White Paper to be conducted in the local press. The hon. Gentleman knows that that is happening in our local press.

The hon. Gentleman knows that we have been working for patients in his constituency by building a new 700-bed, £35 million hospital-- something inconceivable in the decade when the Labour party was in power, when capital spending was slashed to the bone. We shall continue to work in that constructive way for patients in Tooting.

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Dame Elaine Kellett-Bowman : Does my hon. and learned Friend agree with the leading article in my local paper which pointed out that local communities would have to be deaf, daft, or both, if they were not already well aware of the Government's proposals? Does he accept that excellent hospitals such as that at Lancaster and outstandingly good general practitioners, who are already providing many of the services for which they are not yet paid, will benefit enormously, as will their patients?

Mr. Mellor : I am sure that what my hon. Friend says is right. The danger of a public debate arises if some people choose to use a debate about a great national service merely to spread propaganda, rather than truth, which means that the public debate becomes muddy. However, I am sure that the fact that the Government have proposals for improving patient care will stand us in good stead in the next decade when, as we all know, there will be unprecedented pressures on the NHS. It is better that we do that rather than act like those who throw mud around, but have no constructive proposals of their own.

Ms. Harman : Why is it that although local communities receive an unwelcome dose of Government propaganda about their Health Service proposals, they have no say as to whether their local hospitals should be opted out of their local health authorities? If the Minister really believes, as he says, that more Health Service decisions should be taken locally, why does he not give local people a ballot before their local hospital is opted out?

Mr. Mellor : There is a lack of coherence in the criticism from the Opposition. The Government were criticised by the hon. Member for Tooting (Mr. Cox) for apparently not having made money available to tell local people about the proposals and are now being accused of putting forward a barrage of propaganda. The hon. Lady knows that no National Health Service hospital will opt out of anything ; it is simply a matter of whether it becomes self governing within the NHS. Parroting slogans like demented mynah birds does the Opposition no good because people will realise that self-governing status is quite different from opting out. The decision as to whether a hospital should have self-governing status, like other decisions made within the NHS, will depend on whether, having taken account of the different voices, there is a good management case for doing so. The NHS has never been run by ballot, and it will not be in the future.

7. Mr. Colin Shepherd : To ask the Secretary of State for Health what will be the effects of the proposals for medical audit outlined in the White Paper "Working for Patients".

16. Mr. Butterfill : To ask the Secretary of State for Health if he will explain the intended effects of the White Paper proposals for medical audit.

Mr. Mellor : The objective of the comprehensive system of medical audit proposed in the White Paper is to provide necessary reassurance to doctors, patients and management that the quality of medical care is under continual examination, and that clinical outcomes are being measured and thereby the best possible service provided for patients.

Mr. Shepherd : Does my hon. and learned Friend recall that at the outset there was considerable hostility to the concept of medical audit, but that with further

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understanding there has been near-universal acceptance, and even welcome, of this valuable concept? Does my hon. and learned Friend think that, with careful consideration, the BMA might find some useful pointers for the future conduct of its campaign?

Mr. Mellor : My hon. Friend makes an interesting point. Clinical audit was pioneered by doctors and we are merely proposing to systematise it. As I made clear in an announcement to the House earlier this month, we made available £1 million for pilot projects, for which we have had enthusiastic applications across the length and breadth of the country. As my right hon. and learned Friend made clear at our last meeting with the BMA there was a welcome not only for that part of the White Paper, but for improved information systems, the concept of money following patients and so on. I hope that the public propaganda battle will soon come into line with the obvious measure of agreement which exists on a number of key points in the document.

Rev. Martin Smyth : Will nurses be included in the medical audit programme and how much money have the Government targeted to put the system into operation to provide the back-up to the National Health Service?

Mr. Mellor : The measurement of clinical outcomes will show the effectiveness of all parts of the clinical process. So far, the sum of money made available for pilot studies is in excess of £1 million. We shall obviously move forward and ensure that as this becomes systematised, fresh resources will be made available at every stage.

Mr. Hayes : I am sure that my right hon. and learned Friend the Secretary of State is not at all surprised that medical audit, which is about quality control, has been welcomed by all the medical professions. Is he encouraged by the fact that not only medical audit but money travelling with patients and resource management have been accepted by the BMA and other bodies? Does that not explode the myth that the medical profession is wholly opposed to the White Paper?

Mr. Mellor : I hope that that also demonstrates that a barrage of inaccurate propaganda will not drive the Government off the reforms. Then we can have more sensible discussion of the merits and the detailed application of the proposals, and less propaganda calculated to mislead rather than to shed light on what everyone knows to be the vital necessity to change the service to fit the 1990s, when it will be subjected to unprecedented pressure. I believe that as time goes on more and more people will be compelled to admit that there is much merit in our proposals.

Mrs. Mahon : When the Minister goes on his round of regional consultations with management, will he discuss medical audit in detail? Will he also tell us where his meeting with management in Leeds at 10 am on 11 July will take place? When I contacted his Department last week I could not find out.

Mr. Mellor : I shall communicate that to the hon. Lady willingly. The meeting is about self-governing hospitals, but there will be plenty of opportunities to discuss other key proposals in the White Paper.

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Handicapped Children

8. Mr. Thurnham : To ask the Secretary of State for Health whether he has received any representations about the number of handicapped children in institutional care ; and if he will make a statement.

Mr. Freeman : My right hon. and learned Friend the Secretary of State met a deputation from Exodus earlier this year to discuss mentally handicapped children in hospital care. We have not received any representations about other groups of handicapped or disabled children in recent times.

Mr. Thurnham : Will my hon. Friend do all in his power to assist British Agencies for Adoption and Fostering, and other such bodies, to find homes for handicapped children when they are needed? Does he accept that the figure of 5,500 handicapped children in institutional care, shown in the the first-ever survey by the Office of Population Censuses and Surveys, is far too high--about twice as high as previous estimates?

Mr. Freeman : About three in 100 children are born with some disability--that is, about 360,000--and about 5,500 are in institutional care. I share my hon. Friend's enthusiasm for putting as many of them as possible into proper family care : we provide the agency to which he refers with about £300,000 a year, and support it strongly.

Mr. Ashley : Is the Minister aware of the staggering increase in the number of children and adults in short-term institutional care--from 11,000 in 1975 to 36,000 in 1985, according to the Audit Commission? Is there any way in which he can avoid the charge that those figures are an absolute condemnation of the level of support services in the community?

Mr. Freeman : The right hon. Gentleman is certainly right that the number of children undergoing short-term care in institutions has risen. That is partly a reflection of the fall in the number of children in long- term institutional care. Most children going into temporary care are there for between one and three months.

Mr. Favell : The Griffiths report recommends that each social services department should ensure that adequate facilities exist for handicapped people in the community in each local authority area. That is fair enough, but is it sensible to suggest that social workers should assess the individual needs of each handicapped person? Would it not be far better for general practitioners to do that, and to take responsibility for their patients? After all, primary health care teams have doubled in size in recent years, and there are adequate facilities to deal with the problem.

Mr. Freeman : I agree with my hon. Friend's sentiments. Doctors have an important role to play, and we shall keep his suggestion under careful review.

Mr. Alfred Morris : Is it not an affront to handicapped children in institutional care, and also outrageous, that many of the most important sections of the all-party Disabled Persons Services, Consultation and Representation Act 1986 are still awaiting implementation three years after Royal Assent? Does that not diminish the standing of the House? Is the Minister aware that local authorities of all persuasions now complain about a lack of resources with which to provide services under the

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parent Act, the Chronically Sick and Disabled Persons Act 1970? When will he respond to the just demands of disabled people and their organisations?

Mr. Freeman : The Government announced yesterday that there would be a response to Griffiths before the summer recess, and that there will be a debate, in Government time, at the appropriate time thereafter. The issues that the right hon. Gentleman raises will be addressed then.

Electoral Registration

9. Mr. Harry Barnes : To ask the Secretary of State for Health in how many constituencies in England electoral registration has fallen by 1,000 and more in the last year and if he will make a statement.

Mr. Freeman : The Office of Population Censuses and Surveys is responsible for statistics relating to electoral registers. A volume entitled "Electoral Statistics 1989" is available in the Library. This indicates that the electoral register fell by 1,000 or more in 76 English constituencies between 1988 and 1989, and there were increases of 1,000 or more potential voters in 63 constituencies.

Mr. Barnes : The report by the Office of Population Censuses and Surveys shows also that there was a decline in England of 82,491, and offered as a reason for this that, as it could not be demographic changes or migration, it could have something to do with registration or with the postal strike of 1988. Unfortunately, the postal strike does not account for a similar collapse in Scotland between 1987 and 1988. Who is fiddling the franchise in Finchley and another 75 constituencies in England? Is this the only way that the Government feel that they can hold on to seats?

Mr. Freeman : I am somewhat baffled by that supplementary question. My right hon. Friend the Home Secretary is responsible for the electoral registration procedures and the franchise is not being fiddled.

Mr. Jessel : As to demographic aspects of the electoral register, has my hon. Friend any information about how many centenarians are on the electoral register? Are they not tending to increase in number, and does this not show an improvement in the nation's health?

Mr. Freeman : Yes. What is more, the doctors' contract makes specific provision for improving care for the very elderly through doctors visiting the over-75s on an annual basis and through higher capitation fees for the elderly.

NHS Reform

10. Mr. Andrew Smith : To ask the Secretary of State for Health what further representations he has received in respect of his proposals to cash-limit general practitioners' budgets.

Mr. Mellor : General practice budgets are not to be cash limited.

Mr. Smith : Under the White Paper proposals, both the larger practices that become budget holders and all the rest, through the indicative budgets set for family practitioner committees on drugs costs, will be subjected to cash limits. Is it not the case that that can only have the effect of undermining the confidence of patients in the

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