|Previous Section||Home Page|
Column 559No money. No staff--consequence, I collapsed in July 1989 and Michael had to go into care, the one thing we had hoped would never happen."
He was moved 15 miles away from Wakefield to a private home near Goole.
Pat Frobisher then mentioned costs, saying that they are covered by the Department of Social Security and a small occupational pension, which gives them an income of £245.05 a week. The letter continues : "The fees at Greenacres are £245 pw, leaving Mike 5p per week spending money."
As a result, the family are having to sell their house in Wakefield to raise money to pay for the man's care, simply because domiciliary support is not available. I telephoned Mike Frobisher today to ask his permission to use the letter. He reminded me that we had met--when I spoke at a meeting to try to keep open the younger disabled unit at Pinderfields hospital at Wakefield because it was threatened with cuts by the Government whose performance we have heard praised by Conservative Members throughout the debate. What I have described is the reality of Government policy. People are being forced into institutional care because domiciliary provision has disappeared in many areas as a direct result of Government cuts.
The Bill's parentage is highly questionable. The motivation behind it is financial and ideological. It is a clear attempt to reduce Government spending. There is deep anxiety about the financial mess that has arisen because of the open-ended income support of private care. The Bill is a deliberate attempt to shift the burden of funding residential care away from the Department of Social Security to the backs of local authorities. The Government continue to regard community care as a cheap option. It is a disgrace that the Bill fails to finance the resource requirements that have been identified by many, including the Association of County Councils. Professional training and resourcing requirements are not being funded in the Bill.
The Bill is ideological because it attacks local authority provision and discriminates in favour of the voluntary and private sectors. That discrimination against local authority is indefensible. They will no longer be able to provide part III accommodation and residential care, which, as everyone knows, is a safety net for people whom the private sector reject.
I support the voluntary sector--I am aware of the many initiatives taken by voluntary groups--but it is patchy and uneven. The many representations that hon. Members receive from such organisations show that they do not want to play the role envisaged for them in the Bill.
There is deep anxiety about the implications of the market forces approach. Experiments in such an approach to private institutional care provide clear evidence that market forces do not lead to improved quality. Problems after problem in the private sector has forced the Government to bring forward the Registered Homes Act 1984 to tidy up the problems faced by people in private homes and the scandals that continue to occur in the private sector.
I find the issue of choice interesting. Genuine choice in residential care would mean leaving vacancies. How many
Column 560owners of private homes will say, "We believe in choice, so we will leave three or four vacancies"? The idea that choice can be provided in community care is a myth.
In the debate on the Queen's Speech, I said that competitive tendering for care was offensive, and irrelevant to the care that our welfare state should continue to provide.
My time is virtually up. Once again I am at the dog-end of the debate. I seem to manage to have this slot every time that I speak in the Chamber. In Committee, the Opposition will put forward radical alternatives to institutional provision. Let us get away from the legacy of the workhouse. Our alternatives will be to bring about an intensive domiciliary support service, to keep people out of institutional care rather than force them into private homes as the Government have done.
I am proud to boast that I have been personally involved in community care. The community care provisions in the Bill are clearly an afterthought, as was the Secretary of State's reference to it towards the end of his speech. The Bill is a dog's breakfast. It is inappropriate to say that it makes sensible provision for community care. It will compound, rather than correct, the appalling consequences of 10 years of Conservative policy in that area. 9.23 pm
My right hon. Friend the Member for Blaenau Gwent (Mr. Foot) said that he was here in 1948, when the original NHS Bill was introduced. We know from his speech that he has just had an operation, so he has sampled the NHS many years later. He congratulated my hon. Friend the Member for Livingston (Mr. Cook)--rightly, in the view of all hon. Members on this side--on his superb speech. He made many points, but he will agree with my right hon. Friend the Member for Blaenau Gwent that the Prime Minister wishes to twist the NHS into something else. As my right hon. Friend knows, the Bill is greatly disliked throughout the length and breadth of Wales. In an intervention, the hon. Member for Lancaster (Dame E. Kellett-Bowman) asked about lithotripters for the treatment of kidney stones. Why do the Government consider that it is permissible for Wales to be without those machines? Why should the people of Wales, who fall prey to kidney stones as much as any other people, not have that treatment? These machines are in Leeds, Sheffield, Bristol, Manchester and Scotland and there are two in London, but none in Wales. Will the Under-Secretary of State tell us whether the Bill will guarantee these long overdue machines for Wales?
The Secretary of State for Wales will not take part in our debates on the Bill, yet this is the most important Second Reading debate in this Parliament. Why has he resolved not to speak? Perhaps he is ashamed of the Bill. Perhaps he dislikes the tinge of commerce that runs through it. Perhaps in Cabinet Committee he lost the fight against hospital trusts in Wales, but his name had to go on the Bill, or he could not stay in the Cabinet. That was the price of high office. This wretched Bill appears to be the
Column 561price that he had to pay to remain in office. It is regrettable that he is not even in the Chamber for this greatly important debate.
Wales comes at the bottom of too many tables of social indicators. We are the land of low wages. We tend to be at or near the top of any assessment of poverty, ill health and poor housing. Our anxiety is that the Bill overlooks the interests of the average family on low wages. Until now, that family has had the guarantee of a comprehensive Health Service, free at the point of use--a compensation, a buttress and an insurance for families who find it hard to make ends meet. In this Bill we see the first disturbing signs of the erosion of the concept of a comprehensive Health Service. The Bill raises doubts for the retired miner in Tymbl or Blaenavon, the quarryman's widow in a terraced house in Blaenau Ffestiniog and the unemployed steelman in Shotton.
The great Aneurin Bevan in Mr. Atlee's Administration bequeathed the NHS to our people. The NHS was conceived and nurtured in Wales, where in the different communities miners and quarrymen initially banded together to provide basic health care. Many will agree that the NHS has bound us together as a society. It represents the pursuit of a humane and social objective : that the sick should receive treatment of the highest possible quality because they are sick, not because they are rich.
The Bill is irrelevant for Wales. There are barely 13 general practices of the required size. So far, there is not one application for a hospital trust. The plans are deeply unpopular throughout the length and breadth of Wales. That partly explains our magnificent parliamentary election successes throughout 1989. We can say without a shadow of doubt that there is no mandate for the Bill in Wales--none whatever.
The Conservatives are a minority party in Wales. This Bill is a home counties solution to the Health Services problems. It is the socially divisive Cabinet politics of the south-east of Britain. Without a shred of support for it in Wales, it is yet another example of the north-south divide.
The Bill fails to address the problems of health inequalities. The Bill sees the model patient as a person in a health supermarket or in Marks and Spencer, with time and money to spend choosing health care from among the many goods on sale. That is not true of most people who use our health services. The Bill's proposals will make the Health Service less accessible to those most in need, especially the elderly, the disabled and those with mental health problems. The poor already have difficulty in getting the best out of the Health Service. All those people may need to see a doctor more often and receive more treatment in hospital than others.
In Wales we have areas of social and economic disadvantage that are among the worst in Britain. This decade, unemployment, poverty and industrial decay have increased enormously. Those social and economic disadvantages are shown in major health indicators--41 per cent. of Welsh people report long-standing illness, compared with 33 per cent. in England and 31 per cent. in Scotland. In Wales, child health is poorer than in the rest of Britain and there are 5.2 stillbirths per 1,000 live births. The mortality rate among children under one is much higher than in England or Scotland. Such health disadvantages are often a function of the Welsh industrial history. The death rate among men in Wales from bronchitis, emphysema and asthma are much higher than in Britain.
Column 562It is also true that Wales is a black spot for heart disease. The Welsh heart health survey, the most comprehensive survey of its kind, found that deaths from heart disease among women increased by 25 per cent. between the years 1970 and 1980. Heart disease accounted for half of all deaths in Wales in the survey year--something like 10,000 men and women. In the Rhondda valley, the mortality rate is 20 per cent. higher than the British average.
Comprehensive health services, within easy reach of all, are absolutely vital to the Welsh people. The proposals in the Bill will not provide those services. Local accountability of the Health Service will also be reduced by the Bill. The number of community health councils in Wales will be reduced from 22 to nine, but the changes to the Health Service will make those councils more not less important. The proposals mean, however, that patients will be more remote from health care. If there are fewer community health officers, there will be less local representation and less local accessibility to the Health Service.
The chairman of the Society of Community Health Council Secretaries in Wales, Mr. Ivor Roberts, has told me that the proposals are incompatible with the supposedly "consumer-orientated" aims of the Bill.
The changes are unwelcome. We know that the aim of community health councils in Wales is to enable people to participate in the planning and running of the Health Service. The proposal to reduce the number of such councils from 22 to nine is a retrograde one. It will mean that the Health Service is less accessible--more distant from, and less responsive to the needs of, the communities that it seeks to serve.
A number of hon. Members have already expressed great concern about community care. The provision of the highest quality community care to our elderly and mentally and physically handicapped is of the utmost importance. Wales has the second highest proportion of elderly people of any part of Britain. Wales has a higher proportion of elderly people in local authority residential homes than the United Kingdom average. The number of severely handicapped adults in Wales is more than double that for Britain as a whole. The Bill's proposals are just not good enough to meet the challenge.
If the Bill is enacted, there will be a problem with travel and access. People may be expected to travel to hospitals in other areas to avoid waiting. However, for those with mobility problems--the elderly, the disabled and the poor--this may be impossible. For everyone, it will be harder for families and friends throughout Wales to visit. The problem will be particularly great in rural areas, where patients already experience longer travelling times than people in other areas. Bus and train services are not as good as they were 10 years ago.
For women, the great users of health services, travel can be a particular hardship in Wales. Difficult and expensive journeys may deter some women from attending clinics for antenatal and post-natal care. Increased travelling costs to more distant maternity units could create financial pressures for those with incomes just above the level of eligibility for financial help for travel. The problems are even greater for parents with sick or handicapped children who need to remain in hospital or return there regularly.
It is no exaggeration to tell the House on behalf of the people of Wales that this measure is of great concern to people with children in hospital, to people who are in great pain who are in hospital for a long time, and to the
Column 563terminally ill. Modern hospitals' care of children relies heavily on the participation of parents. How will that be possible if the hospital is distant from home?
I want to pose some questions which I hope will be answered by the Under- Secretary of State. Has the Bill been costed? What do the changes mean in real terms? Will there be the manpower with sufficient skills to implement the proposed changes? If these supposedly massive amounts of money are available, the nurses in Wales ask this question : why cannot the money be given now for patients' care?
There are no proposals for ballots. The changes will occur over very short time scales. It looks as though there will be greater centralisation of the control of the Health Service in Wales. It is a cheek to push the Bill in Wales. Waiting lists are already a disgrace. We have seen hospitals and wards close and the loss of many beds. The Government have imposed eye test charges. They are increasing the cost of dental examinations. The Government have given well-off older citizens tax relief, should they go for private treatment. Many hon. Members have said what must be the truth-- the morale of those who work in the service is very low.
It is no exaggeration to say that in Wales the Health Service is the people's health service. Now, it is free and accessible to all, but the Bill has no support in Wales. No Conservative Back Bencher from Wales will say that it has support. I challenge any of them to say that they will support it. There are no such Back Benchers here tonight. The Secretary of State for Wales is not here. They have run away. They are afraid, and know that there is no support for the Bill. In the Vale of Glamorgan parliamentary by-election, the proposals on the Health Service constituted one reason why the seat was gained by Labour from the Conservatives. We had a great deal of help from the Secretary of State for Health, too. His proposals helped us to win the seat.
The people of Wales are not behind this Bill ; those who work in the Health Service will have none of it ; the community health councils are critical ; patients and voluntary groups are almost universally opposed. Opinion in our country of Wales is that the humane and magnificent aims of the Health Service are under threat and that the Government are up to no good. We all believe in Wales that we shall lose if Government Whips push this measure through against the interests of our people.
The Government have a clear choice : they can abandon dogma or face the loss of parliamentary seats throughout Wales. Even if they will not listen to public opinion, perhaps they will at last listen to their own voters. This Bill should be dropped and Wales should be exempted. I am sure that we shall vote against it next week. 9.41 pm
The Parliamentary Under-Secretary of State for Wales (Mr. Ian Grist) : That was a miserable speech, but it was in line with what one usually hears from the hon. Member for Alyn and Deeside (Mr. Jones). I shall be going to his county tomorrow to see the great new hospitals that have been built there under this Government--Maelor Wrecsam and Ysbyty Glan Clwyd. I hope to learn there of the support that we have gained for building the hospitals
Column 564that the hon. Gentleman so signally failed to build when serving in my position for five years under the Labour Government.
When the Labour Government were in power, expenditure on the Health Service rose by only 6.6 per cent. in real terms, whereas I am delighted to say that, in the district health authority serving Alyn and Deeside, it has risen under this Government by no less than 46 per cent. in real terms. That is the measure of the difference between the Conservative record and Labour promises.
It is remarkable to hear the hon. Member for Alyn and Deeside talking about waiting lists, doctors and nurses and the need for greater resources. When he was in power, nurses' pay fell by 20 per cent. in real terms. Hon. Members who were in Parliament then will remember nurses complaining to them. The same applies to the right hon. Member for Blaenau Gwent (Mr. Foot), who made a heartrending speech about the Health Service, claiming that it was Socialism in action. We do not accept that ; nor do the people who worked in the service and suffered under the Labour Government.
Of course we are sorry about the disputes in the service, but they are as nothing compared with the industrial action in the Health Service in the last months of the Labour Government. It is no wonder that the hon. Member for Alyn and Deeside and the right hon. Member for Blaenau Gwent feel guilty when they reflect that, if we had continued nurses' pay at the level at which it stood when we came to office, it would be worth £68 per week less, than it now is. Consultants would be paid £63 per week less and the average remuneration of GPs in Wales would have to fall by £94 per week to bring it to a level comparable with that in the last year of the Labour Government. When the hon. Gentleman had the power to act, he paid nurses, doctors and consultants miserable sums. There was no capital expenditure, there were 7,000 fewer front-line staff in Wales--including nurses and doctors--and the hospital service was treating 400,000 fewer patients every year.
Practice funds have been discussed in today's debate. They will give GPs much greater freedom to be masters and mistresses in their own houses and to deploy their resources in such a way as to enable them to provide patients with the high quality care that they want and need. Hospitals will become more responsive to the needs of GPs and their patients, as GPs will obviously choose those which offer the best quality services with the shortest waiting lists. Practice fund holders will also be able to transfer funds between different elements of their budget. That will provide them with greater flexibility in meeting the needs of their patients. Greater freedom in managing budgets will also enhance their clinical freedom and they will be able to make savings from the fund which can be used to provide improved patient care.
As with National Health Service trusts, we want GPs to be attracted and not compelled towards becoming fund holders. If GPs consider that funds are not in the best interests of their patients, no pressure whatever will be placed on them to accept funds against their better judgment. In addition, before any practice is allowed to hold funds, the Secretary of State will have to be satisfied that the practice has the capacity to manage them efficiently and in the best interests of patient care.
Full discussions will be held with a practice which applies to hold funds so as to take account of its particular circumstances and the composition of its practice lists.
Column 565There will be safeguards to ensure that any unforeseen circumstances leading to a need for additional expenditure on patient care can be accommodated. In short, funds will be set up and run in such a way that patients will receive all the care that they need within a structure which provides much more directly for the GP taking into account the wishes of the patient to ensure the best quality care.
The Bill also provides a framework for more effective prescribing by GPs through our proposals for indicative drug budgets, to which several hon. Members have referred. Doctors will be given an indication of what their expenditure on medicines should be, based on the age and range of patients treated. If they spend more, as they may, they will be expected to show that there were good medical reasons for so doing. If they can show such reasons, that will be the end of the matter. Any necessary follow-up on GPs who appear to be prescribing irresponsibly--and irresponsible prescribing damages patients--will be undertaken by senior and experienced doctors whose aim will be to help GPs maximise patient care.
The proposals for indicative drug budgets have been the subject of dreadful misrepresentation. I emphasise that they will be indicative, exactly as they are described. They will not in any way infringe the right of medical practitioners to prescribe all the drugs that their patients need. The scheme will provide GPs with an incentive to examine critically their prescribing patterns and costs. Every patient being cared for by a general practitioner will, of course, always be able to get the drugs that he or she needs, including high-cost medicines, for as long as they are needed. I hope that that meets the fears of my hon. Friend the Member for Newbury (Sir M. McNair-Wilson) who spoke so feelingly.
Mr. Alun Michael (Cardiff, South and Penarth) rose
Mr. Grist : I am sorry, but I will not give way at this stage. Indicative budgets are not cash-limited and the Bill exactly replicates existing provision about cash-limiting expenditure in the family practitioner services.
I come next to the part of the Bill which provides the necessary framework to carry forward our proposals for community care, about which many hon. Members were extremely interested. Details were set out in the White Paper "Caring for People". The broad thrust of the proposals has been welcomed by many people, including those whom I met on Monday at a meeting with the social services chairmen and directors in Wales. The proposals place a clear responsibility on local social service authorities in co-operation with medical, nursing and other interests, to assess the social care needs of their population and to design and make arrangements for the delivery of appropriate packages of care that will meet the needs of individuals.
Mr. Nicholas Winterton rose--
Many people have benefited from the expansion of the independent sector, about which the hon. Member for Wakefield (Mr. Hinchliffe) spoke, and nursing home care which has been made possible by massive new expenditure through the social security system. In Wales alone, the numbers have quadrupled, to about 12,000 during the
Column 566Government's period of office. As the hon. Member for Wakefield said, that care has not always been the most appropriate for individuals.
The present funding arrangements that have created the incentive to place people in private residential or nursing homes, irrespective of whether that was the type of care that they wanted or needed, will end. From April 1991, there will be a phased transfer from central Government to local authorities of resources to enable them to carry out their new role. The details of the resources involved will be determined in next year's public expenditure deliberations. It was extraordinary to hear the champions of local authorities sound off so suspiciously about their colleagues in local government who they suspect will misuse those funds. I include in that my hon. Friend the Member for Macclesfield (Mr. Winterton), who was not too friendly last night either.
In Wales, the new arrangements will build upon the strategies and initiatives that we have embarked upon already in respect of services for those with mental handicap and mental illness, as well as services for the elderly, which have been widely praised by many, including Opposition Members. For example, I think that the hon. Member for Ynys Mo n (Mr. Jones) has praised the efforts that have been made under our mental illness and handicap strategy. I do not think that I would be going too far if I suggested that the Government's approach to future arrangements for community care for the whole of Great Britain may owe something to our pioneering initiatives in Wales. I sincerely believe that they provide the opportunity to develop quality services that will sustain local communities and maximise the independence of individuals. It is the framework that we need to meet the demographic and social changes that we face over the next decade.
I had hoped that the contributions of Opposition Members would have been rather more constructive than they have proved to be. There are objectives underpinning our proposals which I hoped we could all share. The Opposition are making a serious error of judgment in the way that they express total opposition to our proposals. As the debate unfolds during the passage of the Bill, more and more people will understand that the increased pressures to improve services that will be placed on the NHS in the next decade and beyond as a result of increasing numbers of elderly people and other social changes, as well as from the continuing advance of medical science and the growth of available treatments, can be met only by the programme of reform which the Government propose.
They will see, as many see already, that the Opposition are bankrupt of real ideas for improving the Health Service. Hon. Members who represent Welsh constituencies had a good chance to speak about these matters in the Welsh Grand Committee about three weeks ago. Mr. Morgan rose--
Column 567it is that, in advance of the Bill becoming law, he and his boss have decided already to implement part of it in my constituency since December--
Opposition Members have gone on about expenditure. If that alone were the answer, we should not have a problem today. Since 1978, spending on the Health Service in the United Kingdom has increased massively from £8 billion to £26 billion in 1989. I have no doubt that the hon. Member for Alyn and Deeside will remember with satisfaction that when he was a member of the Labour Government and a Minister with responsibilities for health, he cut expenditure on the NHS by no less than 23 per cent. in one year. That must be compared with the growth of over 25 per cent. that we have provided in Wales alone this year. As my hon. Friend the Member for Bournemouth, East (Mr. Atkinson) said, his spanking new hospital was delayed for 10 years.
Mr. Grist : Indeed, many of us can say the same thing. It is the reversal of the position which prevailed under the previous Labour Government, which explains why the hon. Member for Crewe and Nantwich (Mrs. Dunwoody) finds it so difficult to understand where all the money has gone. It has gone on new hospitals, new units, new drugs and a vastly increased work force in the Health Service.
I suppose that it is just possible for the Opposition to fool some people about their intentions and their earnestness, but I doubt whether they will ever be able to convince the public that they could manage the economy well enough to create the resources that are needed for the NHS. Even if they were able to do so, would they convince anyone that they would not fritter the money away on the pay of those employees in the NHS who threaten the loudest?
In another sense, resources lie at the heart of the matter. I hope that we can all share the objective or overriding aim of ensuring that we derive maximum benefit from the massive resources that we are investing in the NHS so that we can be sure that every pound purchases the greatest possible amount of direct patient care. We have been accused of pursuing market ideology, but Opposition Members are the ideologues. They are hidebound in the way in which the cling to a structure and an organisation which is monolithic, over-bureaucratic and corporatist. It is too distant from those whom it is meant to serve.
The fundamental aim of our proposals is to make the Health Service more responsive to the needs of patients and to provide a widening choice. We shall do that be delegating responsibility to local level, by developing more patient-centred treatment and care and by increasing the accountability of those in the front line who deliver the patient care and the managers in the authorities providing the conditions in which front- line staff work.
Column 568Opponents of our proposals have consistently failed to recognise the crucial and strengthened role of the district health authorities. For the first time, the authorities will be funded on the basis of their resident population. They will have a clear duty to ensure that the health needs of that local population are properly met. Each health authority will need to carry out a systematic assessment of the health status and needs of its local population. The director of public health medicine in each district will be responsible for carrying out that assessment, in consultation with clinicians in hospitals, with general practitioners and with other interests. Their task will be to identify local needs and priorities and to ensure that people have access to a comprehensive range of high quality, value-for-money services from the hospitals and units judged best able to deliver them.
Complementary to that will be the duty that we intend to place on social service authorities to produce social service plans in collaboration with health authorities, voluntary bodies and the users of services and their representatives. They must set out how they intend to ensure the provision of quality social care for people in their homes and their communities. Taken together, our proposals will lead to a systematic assessment of people's health and social needs and the planning of comprehensive services to meet those needs. Central to our approach is the need to devolve responsibility for the day-to-day provision of services to local unit level, thereby freeing district health authorities to concentrate on their principal task of assessing the needs of those for whom they are responsible and ensuring that those needs are met by service providers-- [Interruption.]
Mr. Grist : That does not matter--I have plenty of brief. Our approach builds on the acknowledged success of the progressive introduction of general management at all levels of the NHS--which, of course, Opposition Members resisted so bitterly. Our proposals for new, streamlined health authorities will make them far better equipped to perform those functions. Listening to our opponents' views, I fail to understand what can be so terribly wrong with a system of which the overall objective is to achieve better value for money so that more resources can be released for direct patient care. Our opponents do not like that approach--
Column 569Mr. Powell rose --
Mr. Powell : The hon. Gentleman should withdraw. I would not call him a cheat. If it were anyone else, Mr. Speaker, you would ask him to withdraw. He referred to me as a cheat. I ask you to use your authority to ask him to withdraw his remark. Otherwise, I shall have to take the matter further.
Mr. Barry Jones rose--