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House of Commons

Tuesday 25 July 1989

The House met at half-past Two o'clock

PRAYERS

[Mr. Speaker-- in the Chair ]

PRIVATE BUSINESS

Associated British Ports (Hull) Bill

Lords amendments agreed to.

City of London (Various Powers) Bill

Order for consideration, as amended, read.

To be considered tomorrow.

Hayle Harbour Bill

[Lords] (By Order)

Queen Mary and Westfield College Bill

[Lords] (By Order) Orders for consideration, as amended, read.

To be considered tomorrow.

Oral Answers to Questions

HEALTH

Nurses (Grading)

1. Mr. Ernie Ross : To ask the Secretary of State for Health if he will make a statement on the progress of appeals by nurses with regard to regradings.

The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : The grading appeals are being dealt with under a longstanding agreement between the management and staff sides of the general Whitley council on procedures for settling differences over NHS employees' conditions of service.

Detailed arrangements for operating this agreement are for local decision.

Mr. Ross : The Under-Secretary will know that today a large delegation of Confederation of Health Service Employees nurses attended the Scottish Grand Committee, which was discussing health. Many of those nurses are still awaiting their gradings which were originally given on 31 October 1988. Can the Minister give the House a guarantee that those appeals will be heard by 31 October 1989?

Mr. Freeman : No, I cannot give that assurance. It is for local health authorities to hold those appeals as expeditiously as possible. I should point out to the hon. Gentleman that the unions, including COHSE, agreed the procedure for grading appeals. We are following that procedure, which involves three tiers, to the letter.

Mr. Holt : Will my hon. Friend take it from me that, whatever scheme is in operation, the midwives in south


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Teesside, who have been given one of the most magnificent hospitals in the country, are thoroughly fed up at having to wait for their claims to be heard? What will the Government do, apart from sitting back and saying that it is in someone else's hands?

Mr. Freeman : The local health authority will be pursuing those appeals as expeditiously as possible. Midwives have enjoyed an increase in salary over the past two years of 28 per cent. on average. The concern is not about pay, it is about other conditions of service. The midwives have had an excellent pay increase and appeals will be heard as quickly as possible.

Mr. Fearn : Is the Minister aware that at the midwives' conference that I attended last week, and which he could not attend the night before, but attended the following day, morale was very low? That was because the grading system still has not satisfied any group of midwives. Can the Minister tell the midwives that perhaps in the next six months they will have a satisfactory answer to the grading system?

Mr. Freeman : Ninety per cent. of all staff midwives are on grade E and higher. They have had a remarkably successful outcome from the regrading exercise and the pay increases.

Mr. Robin Cook : I appreciate that this was before the Minister's time at the Department of Health, but does he recall the Secretary of State lecturing nurses last summer that if they were dissatisfied with their grades they should appeal? As they encouraged nurses to appeal as the remedy, Ministers cannot now wash their hands of the shortcomings of the appeals system. Is he aware that tens of thousands of appeals at district level will not be heard until the end of next year and that 2,000 appeals at regional level will not be heard during this Parliament? What has happened to the Secretary of State's press statement on 5 December in which he promised that appeals would be heard by this spring? Will the Minister at least assure us that they will be heard by next spring?

Mr. Freeman : The smooth running of the appeals machinery to which the hon. Gentleman refers has been clogged up by the unhelpful and unco- operative attitude of COHSE and the National Union of Public Employees.

Operations

2. Mr. Gill : To ask the Secretary of State for Health what action is being taken by individual health authorities to increase the number of operations where their current performance rate falls substantially below the national average.

The Minister of State, Department of Health (Mr. David Mellor) : We expect health authority managers, who now have available to them information on their performance relative to others, to use this to monitor their own performance and then to make any necessary improvements. We have a range of initiatives to help support and sustain such efforts.

Mr. Gill : Does my hon. and learned Friend agree that after the massive increase in spending during the past 10 years on additional staff, new hospitals, other new buildings and modern equipment, the British taxpayer is


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entitled to ask why we still have a waiting list? Is that not of itself sufficient justification for the Government's reforms of the National Health Service?

Mr. Mellor : Yes, particularly when some recent research showed that if every district health authority was capable of using its operating theatres as efficiently as the average--not even as the best--that would create enough vacant beds to allow everyone on the waiting list to be operated on immediately. That is the precise scope, and there are many other examples of what the added efficiency that we propose in the review will do for the National Health Service.

Mr. Nellist : What does the Minister say to a health authority such as Central Birmingham, which is responsible for the Birmingham children's hospital and which has limited the number of open-heart operations to 320, when the surgeons are capable of carrying out 380, and where the waiting list for children now stands at 140, when a year ago it stood at 110? That was at the time of the tragic deaths of David Barber and Matthew Collier, which my hon. Friend the Member for Coventry, North-East (Mr. Hughes) has raised repeatedly in the Chamber. What does the Minister say to those area health authorities that are putting the lives of bairns at risk? When will they get enough money so that surgeons can carry out the operations?

Mr. Mellor : I have every sympathy with the parents of youngsters awaiting such operations. A great deal of attention has been given to improving the position at Birmingham children's hospital. I am advised that double the number of heart operations on youngsters will be carried out at that hospital this year compared with last year. That marks real progress and I hope that we shall be able to do even more in the months ahead.

Mr. Burt : Will my hon. and learned Friend congratulate my health authority, Bury, on the way in which it has dealt with the issue and is able to treat more patients by increasing the number of consultants by 35 per cent. over the past five years? Will he note that it has achieved that by saving on administration and by putting more services out to tender? Is not that the way that health authorities should go?

Mr. Mellor : What is encouraging is the range of initiatives taken by different health authorities. I applaud what Bury has done and, equally, I applaud other health authorities which, by having a higher proportion of operating cases treated as day cases, have managed to transform their waiting lists. The Coventry and Warwickshire hospital, which I visited last month, has transformed a waiting list of 1,400 to a list of 300 simply by increasing the proportion of day surgery cases from 7 per cent. of the total work load to 43 per cent. We look to such initiatives, and that is the scale of improvement that is possible when people use their ingenuity.

Ms. Harman : Is it not the case that to stay within inadequate budgets, hospital managers are telling doctors to do fewer operations, rather than more? How does the Minister's earlier answer square with a report in yesterday's Daily Mirror that two heart surgeons at Birmingham children's hospital were threatened with disciplinary action because they exceeded by one the ration


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of heart operations that they were allowed to carry out in May? Does that not show that the Government's real interest lies in saving money, not lives?

Mr. Mellor : This year, over 20 per cent. more in-patient cases will be dealt with in the National Health Service than were dealt with 10 years ago and there will be many more operations than there were last year. It is interesting that although the hon. Member for Livingston (Mr. Cook) made his usual call about underfunding, that was specifically not endorsed at the meeting between regional health authority chairmen and my right hon. and learned Friend the Secretary of State last week. The problems of the National Health Service cannot be explained away by a shortage of resources, but have much to do with improved performance. It is about time that the Opposition played some part in making that clear.

Bristol Channel (Pollution)

3. Mr. Speller : To ask the Secretary of State for Health what representations he has received about sickness, including ear, nose, throat or body sores, in bathers, fisherman or other users of the Bristol channel attributable to the poor water quality and high sewage or industrial pollution of this marine cul de sac.

Mr. Freeman : None. My right hon. and learned Friend is aware of recent concern expressed by the National Federation of Fishermen's Organisation to the Ministry of Agriculture, Fisheries and Food about the possible health risks to fishermen from sewage disposal to sea. The public have also expressed concern to my Department and to the Department of the Environment about the state of our bathing waters.

Mr. Speller : I thank my hon. Friend for his clear awareness of some of the problems. Is he aware that not only fishing clubs but swimmers, school parties, parents and all who use the Bristol channel complain bitterly of sore throats, sore eyes, stomach upsets and other unpleasantness, all of which they attribute to polluted water? Is he further aware that the waters of the Bristol channel were last tested in 1987 and that the results of that survey have yet to be analysed or published? Will he request all medical authorities and GPs near the Bristol channel to give him information on the problem, which I suspect is small individually but major nationally?

Mr. Freeman : I give my hon. Friend that assurance. We appreciate and welcome comments from not only district health authorities but general practitioners on reports from their patients about any ill effects from sea bathing. A contract has been placed with the independent water research centre to carry out a study to assess the risk of contracting illness from sea bathing. That study commences this summer, and we shall place the results in the Library.

General Practitioners (Contract)

4. Sir Bernard Braine : To ask the Secretary of State for Health how the new general practitioners' contract will affect the chances of night visits being made by a patient's own doctor.


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9. Mr. Bellingham : To ask the Secretary of State for Health how the new general practitioners' contract will affect immunisation and screening policies.

10. Mr. David Nicholson : To ask the Secretary of State for Health how the new general practitioners' contract will affect the assessment of the development of young children.

The Secretary of State for Health (Mr. Kenneth Clarke) : The new contract will introduce a higher visit fee for those doctors who visit patients themselves, or who arrange night cover in small rotas of no more than 10 doctors. I believe that this will encourage general practitioners to carry out more home visits themselves or ensure that their patients see a doctor whom they know.

The new payments for the achievement of specified levels of childhood immunisation and cervical cytology will offer GPs a powerful incentive to raise protection against diseases for ther patients.

The new contract will introduce for the first time a fee for GPs who provide services to monitor the development and well-being of their child patients.

Sir Bernard Braine : Although a deputising service clearly has its uses, does it not make sense for general practitioners to have an incentive to visit their patients rather than to encourage the attendance of deputies, who may have had absolutely no contact with the patients, particularly elderly patients? If anyone had any doubts before, does this not clearly show that the function of the new contract is to improve the quality of service to the patient?

Mr. Clarke : I am grateful to my right hon. Friend. His point will be endorsed by his constituents who much prefer, wherever possible, a visit by a doctor from their own practice or one in close contact with it. I am glad to say that the majority of GPs do not use commercial deputising services. It is fair that they should be paid a higher reward for that. I regret to say that, at the moment, the general medical services committee is seeking to reopen discussions with me on the higher fee. I see no basis for that. We must remember the patients' interests and the public interest in settling the contract.

Mr. Bellingham : I am grateful to my right hon. and learned Friend for that reply. Does he agree that good doctors have nothing to fear from the new contract? Will he confirm that, in future, in places such as west Norfolk, where there is a large retired population, people will get even better service from their GPs and will not mind them receiving extra rewards?

Mr. Clarke : We are very conscious of the increasing number of elderly patients and the increasing needs of elderly patients, particularly those beyond the age of 75. That is a growing feature of the population of Norfolk. Patients would welcome the introduction of a new higher fee for GPs in return for keeping at least in annual touch with all their patients over the age of 75.

Mr. Nicholson : My right hon. and learned Friend will be aware of my concern that the National Health Service should cope with the needs of patients of all ages, particularly young children. Does he agree that his earlier replies give the lie to claims that the new contract would


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work against patient care? What can he do to bring home to GPs the considerable benefits to patients from the new contract?

Mr. Clarke : I am glad to say that the new payment for child surveillance, which is monitoring the development and health of children under the age of five, was put into the contract at the request of the medical profession and the GMSC. It is one of many features of the contract that should encourage much better service to patients. Many GPs have still not altogether understood all the details of the contract on offer. They should realise that the resulting contract must be on a balance between the legitimate interests of the profession and the legitimate needs of patients to ensure that general practice maintains the highest international standards.

Mr. Foot : As the right hon. and learned Gentleman was originally appointed to his post because of his great powers of communication--we might call him the "Kenneth Baker of yesterday"--can he give the House an estimate of what would have been the response from doctors to the new contract without his great clarity and vision?

Mr. Clarke : I remain a colleague of Kenneth Baker today. I have certainly communicated with doctors. I and my negotiating team have had 19 meetings with the GMSC negotiators, spent 110 hours in negotiation and produced 38 papers as bases for discussion. We eventually reached an agreement that the GMSC recommended to the profession.

Obviously, I regret the fact that GPs have decided to reject the recommendations of their own negotiators, but at least it was not by the nine to one vote that greeted Aneurin Bevan when he tried to persuade the British Medical Association to accept his terms of service when the NHS was founded.

Mr. Duffy : The hon. Member for Norfolk, North-West (Mr. Bellingham) referred to the elderly. Is the Secretary of State aware that in Sheffield the most freely expressed fear about the new contract is that it will prejudice the dedication of services and resources to the elderly, especially in respect of night visits? Will he comment on the effect of the new contract on Sheffield's elderly population, especially as it is expected that the number of those over the age of 85 will increase by 82 per cent. during the next decade?

Mr. Clarke : I do not accept the interpretation that the hon. Gentleman claims has been put upon the contract by some doctors in Sheffield. As I have already said, we are introducing a new, higher payment in exchange for regular contact with patients over the age of 75. The new contract will benefit the elderly, who would much prefer that, whenever possible, night visits are made by someone from their own practice whom they are likely to know.

Ms. Mowlam : Will the right hon. and learned Gentleman make it clear that doctors will not be paid for immunisations and screenings if they do not achieve a minimum target of 70 per cent. of their patients? In an area such as Teesside, doctors, however hard they try, will have great difficulty in reaching that high target. It is a question not of good or bad doctors but of a target that is unattainable.


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Mr. Clarke : Vaccination is part of the ordinary duties of every GP. I am sure that they all accept that they must strive to raise the level of immunisations. The 70 per cent. target is already being met by the majority of practices, certainly in England, and it can be achieved regardless of the social status of an area. It is important to try to secure a National Health Service that meets the highest international standards of patient care. The target that we have set is that recommended by the World Health Organisation, and none of us should recommend second-rate or lower standards for the NHS than those regarded as reasonably attainable in developed countries.

Mr. Cormack : Although it may be true that, as my hon. Friend the Member for Norfolk, North-West (Mr. Bellingham) said, the majority of doctors have nothing to fear from the new contract, does my right hon. and learned Friend accept that some excellent doctors are apprehensive? Despite his efforts through meetings, papers and discussions, does he agree that there is a need for a concerted effort during the next three months, when Parliament is not sitting, to talk to doctors throughout the country in as conciliatory and constructive a manner as possible, in the hope of persuading them that they have nothing to fear?

Mr. Clarke : My two ministerial colleagues and I hold meetings with hundreds of doctors each week, and they have been successful and productive. One of the main actions that we can take is to explain the impact of the contract to individual GPs, many of whom are labouring under unreasonable and unnecessary fears about a possible loss of income in their practices. In fact, the best doctors will gain under the proposals, but some will have to improve their performance. Many doctors are labouring under a misunderstanding because they have not absorbed the detail of the new contract. I shall take my hon. Friend's advice and I shall almost certainly communicate in writing with all GPs, setting out the terms on offer.

Community Care

5. Mr. Simon Hughes : To ask the Secretary of State for Health if he will make a further statement on his plans for community care.

Mr. Kenneth Clarke : As I said in my statement on 12 July, we will publish a White Paper on community care in the autumn.

Mr. Hughes : Will the Secretary of State elaborate on the arrangements for community care between now and 1991? He will be aware that many elderly and mentally ill people are already being discharged into the community, particularly in inner-city areas such as mine, and that facilities are already insufficient. Will he examine projects such as that proposed for St. Olave's hospital in my constituency where there is a danger that half the land will be sold for housing at market value rather than for the community care provision that would allow his plans to be implemented in the near future rather than having to wait until 1991 or thereafter?

Mr. Clarke : Our response to the Griffiths report aroused great enthusiasm among local authorities for the opportunity that it offers to improve the level of community care that we provide. I am sure that local


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authorities and health authorities are beginning to draw up their community care plans and to plan for new developments. Therefore, as a result of the announcement, increased priority will be given to community care immediately. I trust that that means a steady development before we reach 1991. I shall look at the constituency case to which the hon. Gentleman referred when he sends details to me and if there is ministerial responsibility, the Minister responsible will respond to him.

Mr. Butler : Do the community care proposals involve a review of attendance allowances with a view to making them more prompt, efficient, generous and sensitive?

Mr. Clarke : All of us become involved in appeals against refusal of attendance allowance, and I know how difficult many of those cases are. The Griffiths report did not specifically address the important matter of the benefits and financial assistance given to disabled people and those who care for them. I shall draw my hon. Friend's remarks to the attention of my right hon. Friend the Secretary of State for Social Security and I have no doubt that he will bear his point in mind.

Mr. Tom Clarke : Will the Secretary of State explain why, in his recent statement on community care, he made only a passing reference to Lady Wagner's report? Does he accept that, in view of the huge explosion in residential care, especially in the private sector, there is a need for minimum standards in the private and the public sectors and for proper inspections, too?

Mr. Clarke : Lady Wagner's report was excellent and the Government are grateful to her. Many of its recommendations have already been implemented. We endorsed it yet again in my statement, and we touched on her suggestions for the inspection of nursing and residential homes where we did not see any need for change in the statutory position at the moment. We introduced the legislation that brought in the system of supervising standards and we have made important recommendations which will help local authorities so to organise matters that the same attention is paid to the standard of care in public sector homes as should be paid in private sector homes.

Limited List

6. Mrs. Maureen Hicks : To ask the Secretary of State for Health how many complaints he has received from patients and general practitioners in the last four years as a result of the introduction of the limited drugs list.

Mr. Mellor : Since the selected list scheme was introduced in April 1985 the Department has received some 6,000 letters about the scheme, but not many recently. Recent correspondence has tended to recognise that the selected list scheme has produced worthwhile financial savings while fully protecting the interests of patients. None of the dire predictions made at the time of the introduction of the scheme by the British Medical Association and others has proved to be true.

Mrs. Hicks : My hon. Friend will recall only too clearly that the outcry and fears expressed by general practitioners four years ago before the introduction of the selected list was not dissimilar to the present outcry from general practitioners about prescribing costs. For the sake of those


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vulnerable patients who are completely confused, will my hon. and learned Friend take the opportunity to bang on the head once and for all the untruth going about that any patient might be denied medicine? Will he reassure the elderly and those on long-term medication that they have nothing to fear under the Government?

Mr. Mellor : I am very happy to give my hon. Friend the reassurance that she seeks. Every patient will receive the medication that they require --that is a categorical promise. Despite the controversy over the limited list, it establishes that worthwhile savings of about £75 million per year can be made, which can be deployed elsewhere in the Health Service to the greater benefit of patients. The controversy shows also that, unfortunately, some groups within the Health Service are so resistant to changes that they will seek to blackguard them with the most wild charges-- none of which, in respect either of the selected list or of other reforms, has proved to be true. The same will doubtless be true of the dire predictions made about the White Paper.

Mr. Rooker : One of the drugs that is the subject of most concern and, I suspect, of most representations, is Mucodyne--which was restored to the list, but only in the children's version. Many elderly people suffering from bronchial complaints, including a number of my constituents, have found no substitute for Mucodyne that meets their needs, and must fork out about £13 or £14 every time that they purchase a bottle. They have no choice because there is no proven, practical alternative. Mucodyne has also been the subject of many parliamentary questions, and I ask the Minister to bear my comments in mind if the list is ever reviewed.

Mr. Mellor : The hon. Gentleman knows that the drugs included on or omitted from the selected list were the subject of professional evaluation by an advisory committee, so those decisions were taken not by the Government but on specialist advice. The hon. Gentleman will know also that we offered the British Medical Association an appeal mechanism but it did not take us up on it. That would have been a way of dealing with any residual points.

Dame Jill Knight : Is not the simple truth that if my right hon. and learned Friend and his colleagues had listened to the BMA's campaign against the limited list, £75 million per year less would have been available to spend on patients?

Mr. Mellor : Yes, and that £75 million equals the cost of building a new Great Ormond street hospital every year for the past four years. That is what the debate is all about. Of the £2 billion currently spent in the NHS on prescribed drugs, tens of millions of pounds is misspent because of the refusal by some general practitioners to prescribe generic alternatives, slack repeat prescribing, and other reasons. Just as it is necessary for patients to have the drugs that they need, it is important that patients are not prescribed drugs that they do not need.


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Hospitals (Self-governing Status)

7. Mrs. Mahon : To ask the Secretary of State for Health if he has issued any guidance to health authorities on balloting National Health Service staff or members of the public on whether they agree with proposals to allow National Health Service hospitals to opt out.

Mr. Kenneth Clarke : No National Health Service hospitals are going to opt out of the National Health Service.

Mrs. Mahon : Is the Secretary of State aware of the overwhelming wall of hostility against his proposals for futuristic private hospitals? If the right hon. and learned Gentleman believes that his proposals have the support of doctors, nurses, patients and the public, why does he not put them to the test by balloting Health Service workers and the public? He has spent enough taxpayers' money trying to sell that rotten idea.

Mr. Clarke : Recently, the hon. Lady, together with some of her colleagues, gatecrashed a meeting that I was holding with the staff of various hospitals in Leeds. The hon. Lady and her friends found themselves listening to a very serious discussion about the potential benefits of self -government for hospitals and units in the Leeds area, and found it so daunting that they left after a little while. If the hon. Lady and her friends had stayed, they would have understood my proposals more clearly. Clearly, the hon. Lady still does not understand them--and obviously she is not ready herself, let alone her constituents, to cast a vote on the matter. If we receive any applications for self-governing status from NHS hospitals, as I am sure that we shall in due course, we will consult most thoroughly--as we always do on any serious proposal.

Mr. Hayes : Does my hon. and learned Friend agree that balloting hospitals and the community would be as ludicrous as it would be unworkable? Does he agree that it would divide communities and hospitals, and divert valuable time and resources away from the Health Service?

Mr. Clarke : I am accused of challenging one or two of the Health Service's traditions, but I am not very much in favour of traditions that lead to inefficiency. However, I cannot recall a single occasion in the past 40 years when anyone has suggested that managerial changes should be the subject of a local ballot. At this stage, people should concentrate on seriously studying the Government's proposals, and wait to see what applications are made and what would be the benefits to the patients concerned.

Mr. Galbraith : I presume that when the Government presented their proposals they discussed the decision that the managers and consultants involved would determine whether hospitals should opt out of local health authorities, and that the local community would be considered. If the majority of consultants in a hospital were opposed to that hospital's opting out, would it still be able to do so?

Mr. Clarke : I have never used the phrase "opt out". It has not featured in any of my documents or speeches. The self-governing hospitals, like other hospitals, will look to the district health authorities for funds, as money comes with the patients referred by those authorities.


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Let me suggest again that the description of the proposal that we have heard is based on misunderstanding, or is misleading. We shall consult in the ordinary way when applications are made, but I do not believe that such matters can be decided sensibly by means of a yes or no vote among any particular section of staff, or in any other part of the community. Those responsible will put forward considered applications that will be examined in the same way as any other important changes in the service.

NHS Reform

8. Mr. Norris : To ask the Secretary of State for Health if he will make a statement on the allocation of the extra £40 million to help with the implementation of the White Paper "Working for Patients".

Mr. Kenneth Clarke : I have undertaken to ensure that the costs of implementing the NHS review will be met by the taxpayer over and above the resources provided to maintain the growth of services to patients. The provision of the additional £40 million brings the total available this year for the implementation of the review to £82 million, of which £70 million is for the hospital and community health services, £5 million for the family practitioner services and the remainder to meet administrative costs in my Department.

Mr. Norris : Does my right hon. and learned Friend agree that hard- pressed managers in the NHS deserve our full support, and that those additional resources are a welcome and constructive step towards implementation of the White Paper proposals? Does he agree that they are especially to be welcomed as new money that will leave untouched the existing record level of resources for patient care?

Mr. Clarke : I am grateful to my hon. Friend. As he knows, the great majority of managers in the service are very enthusiastic about the reforms proposed in the White Paper, and are working extremely hard to ensure their implementation. Some investment up front will, as I have said, be required, and we shall continue to provide it over and above the necessary increase in resources required to maintain the growth in patient care.

Mrs. Dunwoody : How much of that new money will be allocated to patient care, and how much to the provision of hardware, accountants and software to be employed in billing procedures? It is rather important for the patient to know what he is spending the money on.

Mr. Clarke : As the hon. Lady knows, in last year's public spending round we increased total spending on the National Health Service by £2 million. With additions during the year, we have brought the amount to be spent on the implementation of the review to £82 million. That covers a wide range of services, including grants for the training of more people with public health expertise who will be able to identify patient needs. Those needs will be resourced much better once the new system is in place.

Mr. Favell : Has my right hon. and learned Friend made any assessment of the savings that will be made by the streamlining of the decision-making process in self-governing hospitals? At present, as he well knows, major decisions must go first to the district health authority, then to the regional health authority, then to the Elephant and


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Castle and then all the way back down the line. Is it not true that savings will be made and that for all but the third rate, this will be a far better process?

Mr. Clarke : Over the years we have moved steadily towards replacing the second-guessing of decisions that has been traditional in the Health Service, when Ministers and their civil servants supervised the regions, which supervised the districts, which supervised hospital management. With self-governing hospitals, we shall put real responsibility into the hands of local people. I agree with my hon. Friend that great improvements will be made in efficiency, and that at the same time the hospitals will be made even more responsive to local opinion, local patients' needs and perceived gaps in the present health care provision.

Mr. Robin Cook : Will the Secretary of State accept that we agree that this latest share-out shows the Government's priorities? Is he aware that three quarters of the new money has been spent on more finance staff and more computers for them, but only a couple of million pounds on the medical audit? Does it not speak volumes for the priorities of his White Paper that the accountants who treat no patients need 12 times the new resources that are given to doctors? Is not the truth that his priority is cost control, not patient care?

Mr. Clarke : The hon. Gentleman makes a specialty of picking out details of the White Paper that he blows up into misrepresentations. He knows perfectly well-- [Interruption.]

Mr. Speaker : Order.

Mr. Clarke : This will be planned and brought in by the profession. The additional £2 million is extremely welcome to the profession and shows our good will to that development. We accept that more money will be required to finance medical audit when the profession has in place the mechanisms required to carry it out. We are talking about £2 million being spent on pump priming for that purpose this year.

Mr. Squire : Will my right hon. and learned Friend take all possible steps to implement the White Paper at the earliest opportunity so that my constituents, who are suffering excessive waiting lists in Barking, Havering and Brentwood, have the advantage of one of the White Paper's many proposals--that money should follow patients rather than some abstruse formula?

Mr. Clarke : I am grateful to my hon. Friend, and I reassure him that progress on preparation to implement the review is going steadily and very well at present. We seem well on target to deliver not only the review but, most important, its benefits to patients such as his constituents, who will experience a big improvement in how the service is delivered once the changes are in place.

Mr. Speaker : Order. It is difficult to hear questions against a background of discussion.


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