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Column 729privatisation of care, while effectively doing so for all but the severest of cases. As the House knows, the tendering is to be policed by the Secretary of State for Health who will "issue direction" and "give guidance", whatever that means, to authorities that do not seem to be doing their utmost to stimulate privatisation.
Will the Minister for Health spell out what powers she intends to take to ensure that local authorities comply with community care plans? How is it possible for local authorities to balance this form of compulsory tendering to the private sector with the requirement to retain facilities where needed? Obviously, the Government have in mind commercially unattractive areas of the market with what they term "challenging patterns of behaviour", which the private sector will not touch with a barge pole.
Private sector homes will probably concentrate their efforts on the 40 per cent. of the elderly who do not need financial assistance from the state. Others will be cared for in the community--or so the Government envisage. The White Paper called on local authorities to support unpaid carers, yet the Bill does not provide the means for them to do so. By encouraging private sector service provision, the Government believe that that vulnerable sector of society will benefit from the increase in choice, but, as with so many of the Government's ideas, that so-called choice exists only for those who can afford it.
How can the provision of home helps be both good business for the private sector and yet affordable to the average pensioner, without there being a lowering of carers' working conditions and wages? Why should the elderly and disabled be subjected to the risk of corner cutting and slipshod standards, which will almost certainly arise from accepting the lowest bids for private sector services? he legislation seeks to encourage the voluntary sector to play an even greater role in care provision, while failing yet again to provide the resources needed to fund such a change. I have discussed the Bill's proposals with many national and voluntary organisations, of which Crossroads is the largest. It provides direct services to the disabled and to informal carers and families in their homes. Crossroads can give voluntary help to 12,000 families, but it already has 7,000 on its waiting list. It has told me that it fears that funding will be insufficient to fulfil all the unmet needs that already exist in our constituencies and that voluntary funding is not a realistic option. It raises as many funds as possible, but it cannot possibly be expected to meet all the cost by voluntary donation. Many depend on joint finance and are worried that local authorities will not pick up the bill, should joint finance come to an end, as the legislation implies.
Crossroads has monitored a marked tendency among local authorities to focus dwindling resources on the highly dependent. If the legislation is implemented, even greater numbers of such people will be dependent on community care and local authorities will be forced to prioritise even further. Naturally, they will focus on the most dependent. That will leave carers, already a low priority group, even further out on a limb, increasingly burdened and possibly receiving poor standards of help.
My local borough of Tameside has informed me that it may well prove difficult to develop the voluntary sector as
Column 730the Government want. Despite good contacts with Age Concern and other organisations, a common voice is lacking and there is little tradition of these groups working together.
The Bill is a direct attack on the quality of life of many women in society, as women make up the vast majority of paid and unpaid carers. The provision on contracting out community care poses a threat to many jobs, especially among members of my sponsoring union NUPE. Those who manage to keep their jobs are likely to see pay and conditions deteriorate under the private sector. The legislation will lead to yet more women taking on the role of unpaid carer while receiving no extra financial help, at a time when the poll tax will add yet another heavy burden to their daily lives.
This commercialisation of community care has been described as a "charter for despair". How true that description is. It is hardly surprising, knowing the Government's record, that the old, the disabled and the mentally handicapped now have cause to feel as though they have a shelf life rather than that they deserve a life which can be both longer and of greater quality.
Mr. Kenneth Hind (Lancashire, West) : As my right hon. Friends have recognised, the National Health Service is not a sacred cow that is incapable of reform. The 1987 Conservative manifesto suggested reforms. Now we face the reality of the considerations to change and improve it. The emphasis is on patient care. The Bill is about improving the standards of care for patients. If we look at the Bill from that point of view, we are looking at the driving force behind it.
The new system is patient-led. It is based on demand and the needs of the patient. The money will follow the patient. We have tackled the problems connected with waiting lists and the closure of wards. Nobody has considered in the past where the demand really lies. With money following the patient, it will be made available where that demand exists. The demand is for hip replacements and cataract operations. They are among many of the items towards which Ministers have directed their waiting list initiative.
There was a real need to tackle the problems in the National Health Service. Two years ago there were articles in the press and letters from our constituents suggesting that the NHS needed to be reformed. We have now devised a solution. It may not be acceptable to the Opposition, for the simple reason that we have not followed the old formula of throwing money at the problem and hoping that money will solve it. Money has to be adequately and efficiently spent if we are to provide maximum care for the patient.
The Opposition can tell us nothing about care. In the 1970s when the Labour Government were in office there was a cut of one third in the hospital capital building programme. That is why so many people have had to wait for a very long time for new hospitals. Waiting lists increased by 250,000 and nurses' pay decreased by a fifth. There was a 3 per cent. cut in real terms in the National Health Service budget for 1977-78. The Opposition cannot, I repeat, tell us anything and they have offered no solutions in the debate. The public will judge them on their record. When the Bill is considered in Committee, the
Column 731Opposition will have to table amendments, which presumably will be based on the Opposition's ideas. We shall then be able to judge them.
Various criticisms have been levelled at the Bill, including GP budgets. They do not exist ; there is simply a guide for GPs as to the money available to them. Information about the treatments that a general practitioner has prescribed over the past three years can be fed into a computer. That will include the background and the age profile of the GP's panel. It can be allied to the panel's prescription patterns. It enables one to find out what the general practitioner is likely to spend on his patients in the forthcoming year. That is a sensible approach. We need to know what will be spent on patient care. The system is based on technology.
If my constituents believe that the Government are imposing a cash limit on the budget for GP treatment, or the drugs that are prescribed, ignoring the fact that a doctor may have heart bypass patients, or AIDS patients, or people suffering from influenza, they must think that we are well and truly off our trolleys. The system has been devised to give guidance on how much money is spent, and that is all.
The funding of the National Health Service has not changed. It is paid for by taxation and it is free at the point of delivery. All that has changed is the organisation of the funding, and the public should have no fears.
On drugs and practice budgets, who will decide whether prescribing practice is adequate for modern treatments? That will not be decided by officials or Members of Parliament. Doctors will examine the practice of their fellow doctors. They will decide whether, in certain circumstances, it is reasonable to prescribe a certain drug, or whether there is an adequate generic substitute. Judgments will be made by one doctor about other doctors. Clinical decisions will not be made by those who are not qualified to make them. Doctors will make them.
It has been suggested that because the money will follow the patient, he will be sent to the hospital that can provide the cheapest treatment and that he may have to travel a very long way for it. Today, 80 per cent. of patients are treated in their local hospitals. That pattern will, I am sure, continue. The hospital in my area is small and relies for certain essential services on hospitals in Liverpool, Manchester and Wigan. It will continue to rely on them for those services. If, however, there is a waiting list in a certain area, the patient will be able to say to his GP, "I need care urgently : can you look, using the new technology, for a bed somewhere else so that I can get help quickly?" No patient will be obliged to go to the hospital with which the GP has an arrangement. He will be able to choose his GP, the hospital and the consultant. My right hon. and learned Friend the Secretary of State for Scotland said that there will be a fund for those cases.
The role of the district health authority will be crucial. People have asked how the provision of health care for particular groups will be protected under the new system. It will be protected because of the obligation on the district health authority to provide a full range of health care for the people in its area. In the vast majority of cases, people will follow the pattern of the past and go to their local hospital. For my constituents, for example, I expect some treatments to be available in Wigan, Manchester and Liverpool, but it will be for the DHA to ensure proper provision for their health care is made.
Column 732Hospitals, it is claimed, will be able to opt out. That is nonsense. They will be NHS hospitals, controlled by the NHS and funded by central Government. The Government have provided a 45 per cent. increase in real terms in health care. It has tripled since 1979--
Mr. Doug Hoyle (Warrington, North) : As the joint president of the Manufacturing, Science and Finance Union I do not intend to refer to matters that have already been discussed. I intend to refer to the forgotten people, the 40,000 members, apart from junior hospital doctors, whom MSF represents. Most of them are speech therapists, clinical psychologists, medical laboratory scientific officers and hospital pharmacists.
I know that the House has a great deal of goodwill towards speech therapists. An early-day motion signed by 96 hon. Members recognises that speech therapists in the Health Service are being treated most unfairly. Despite being highly skilled professionals, they are badly paid because it is almost entirely a female profession. Speech therapists are badly paid compared with other professions in the Health Service. We in MSF consider that they should be comparable with other professions such as clinical psychologists and hospital pharmacists. We are waiting for a review tribunal to look into the matter. Meanwhile, speech therapists have been offered an increase of only 6.5 per cent. and that is causing a great deal of concern. I received a letter from a speech therapist who has been qualified for 33 years, yet her salary is only £10,947. Will the Minister who replies to the debate say what the Bill offers speech therapists as a profession?
Clinical psychologists are also highly qualified but they are leaving the Health Service in droves because the pay in the Health Service does not compare with that in the private sector. In the private sector they are used in top management and would not receive below £30,000 but at the top grade in the Health Service they receive just over £28,000. The Department of Health commissioned management consultants MAS for advice on clinical psychologists. There are rumours that the advice was that the conditions and salaries of clinical psychologists should be compared with those of consultants. Can the Minister confirm whether that is true?
Hospital pharmacists are also on the front line. The Bill is the thin end of the wedge for privatisation. It has started in Greater Glasgow health board which is the largest regional health service in Britain. It was caught out because it placed a notice in the official journal of the European Community asking for private companies to tender for pharmacy and laboratory work. Studies are still being undertaken but there is no doubt whatsoever about its intentions. There are two major objections to the privatisation of hospital pharmacies. First, a private company would be looking to maximise profit. Hospital pharmacies will simply offer drugs over the counter, but at present they do far more than that. They give clinical advice to doctors and nurses about the correct drugs to use and that service will be lost. Secondly, an even more serious consequence is that many companies that retail drugs also manufacture them. There is a danger of double standards as those companies which obtain tenders will be pushing their own drugs in the
Column 733hospital pharmacy and there could be a conflict of interests. Far from reducing costs, that tendency might increase costs.
Medical laboratory scientific officers are also in the forefront of privatisation because in certain areas laboratories will be privatised. Before we privatise the laboratory service we should consider what happens in north America where the service is privatised. In north America the staff are poorly trained and the laboratory equipment is old because of the need to maximise profits. Some doctors look at the samples themselves and the errors in diagnosis are as high as 27 per cent.
Inaccurate tests have led to fatal consequences and many women have died of cervical cancer because they received a negative smear test and the error was discovered far too late. Financial compensation is not much good when lives are lost. The reverse also occurs when people receive a positive result instead of a negative one and again lives are lost. The staff maximise the number of tests. They even take work home. Because they are poorly paid they work long hours for overtime and they are not properly qualified. Laboratory staff are spending seconds on difficult tests which should take quite some time. That is because poorly qualified laboratory staff are working with outdated equipment and private laboratories are reluctant to install new equipment. That is what could result from the privatisation of the National Health Service. Instead of being a professional service, it will be concerned more about profit than about patients' needs. We should be very wary of the lessons to be drawn from north America.
The Secretary of State will become the Arthur Daley of the Health Service and we all know who " 'er indoors " is. The Government would flog off anything and this is only the beginning. The public should be warned because, although there will be a little privatisation before the general election, if the Government are returned to office, there will be wholesale privatisation of the National Health Service. I conclude by applying the words of Lady Macbeth to the Secretary of State :
"Stand not upon the order of your going
But go at once."--
and take the Prime Minister with you.
Mr. Nicholas Bennett (Pembroke) : The speech by the hon. Member for Warrington, North (Mr. Hoyle) bore very little relation to the National Health Service and Community Care Bill. He sounded like a trade union spokesman making a bid for the next wage round. There is nothing in the Bill about privatisation and his speech was yet another example of the scare tactics that the Opposition have used in the past year. It is despicable that they should do that ; they have managed to scare many ordinary people into believing that the Government would produce a totally different Bill.
I support the Bill because it is important to examine what should be improved in the National Health Service after 41 years of existence and praise its qualities. I and my family have always used the National Health Service and I believe that it is the best health service in the world. But that does not mean that I do not recognise that it has many grave faults which could be corrected. I believe that the Bill will do that.
Column 734It is interesting that after two days of debate the Opposition have not yet addressed themselves to the many problems that have come to light. General practitioners' referral rates differ greatly. Some GPs refer 25 times as many patients to hospitals as do others and some GPs prescribe twice as many drugs as do others. Operating costs can vary by 100 per cent. between different hospitals in the same district for the same operation. Operations per session can vary greatly between different hospitals, and accident and emergency departments continually complain that most of the vast numbers of people they see are there for entirely the wrong reasons. They clog up casualty departments. Statistics show the difference in the use of the National Health Service from district to district and hospital to hospital. We are entitled to ask why there are such marked divergences in spending and use.
We must ensure that the expenditure on our Health Service--£28 billion at the last count--is spent properly. That is what I wish to discuss. It is not new for the Health Service to have problems with its budgets and spending. I recently read John Campbell's biography of Aneurin Bevan. On page 177, he says that in 1949
"there was inadequate financial discipline"
of the National Health Service. A year after the National Health Service came into operation, Aneurin Bevan, speaking at a meeting in London on 15 November 1949, warned :
"Now that we have got the National Health Service based on free prescriptions I shudder to think of the cascade of medicine that is pouring down British throats at the present time. I wish that I could believe that sufficiency was equal to the credulity with which it is being swallowed."
These problems with Health Service spending and ensuring that resources are properly used have not disappeared.
It is interesting to read the works of academics who support the National Health Service and want it to be improved. Alan Maynard, writing in the Health Service Journal on 10 September 1987, said : "At present the majority of healthcare treatments cannot be demonstrated to be good value for money because their costs are uncertain and their outcomes largely unmeasured. Unless GPs and consultants can demonstrate the superiority of the costs and benefits of their activities, the economic case for financing these activities is absent.
Consequently the argument that the NHS is underfinanced is seriously flawed. It may be--and only an evaluation of practices will demonstrate it- -that the NHS is overfinanced and the existing improvements in health status, or benefits, could be achieved by a budget less than that currently available to the NHS."
He further said that it is important, if we are to spend more on the Health Service, to ensure that resources are spent properly, that we know the outcomes of operations and that we know that resources have been targeted on the right sectors and operations.
It was interesting to read shortly after that an article in the British Medical Journal entitled "Mr Q the surgeon", "Conversations with Consultants" by Tony Smith. The consultant said that his hospital formed an economy committee to consider the use of intravenous needles and other disposable materials by the National Health Service. It discovered that it could save £80,000 or £90,000 a year by changing the brand of needles, catheters, bags and other disposable items. Suddenly, there was a National Union of Public Employees strike, and overnight the hospital lost over £250,000 because it was not allowed to
Column 735use its pay beds. He asked what was the purpose of saving that money if the union can lose £250,000 in the next week simply by strike action? He says :
"If you asked me what can we do about"
resources in the National Health Service,
"I would answer that we must stop the terrific wastage in the NHS. The reason for the wastage is that there is virtually no incentive to save in an enormous organisation like this. In your home you are paying the electricity bill and you turn off the lights as you walk out of the room, but in a hospital you don't. Even though many of us may turn out the lights as we walk out of the department in the evening when we come back in the morning every single light is back on. The cleaners have been in in the night and left them all on." The consultant argued that the National Health Service would happily save money if it was told that for every pound that it saved by being careful with disposables, being more efficient, watching electricity, turning the lights off in the evening and the other things that people in the Health Service could do, it could be given back the 10p or 15p in the pound that it saved towards its research funds.
What surprises me about Labour Members is that whenever we talk about budgets or finance, they say, "We do not want to hear about that ; we do not want to hear about accountancy." But we all know that they are very careful with their own money. They somehow assume that there is an unending supply of public money that does not need to be monitored. I only wish that, like the rest of us, Labour Members would treat public money in the same way as they treat their private resources.
Ms. Diane Abbott (Hackney, North and Stoke Newington) : Is the hon. Member aware that we have one of the most cost-effective health services in the world? It is four times more cost-effective than that in the United States, and we spend less per head on the Health Service than any other industrialised nation. Will the hon. Gentleman withdraw the slur that the National Health Service wastes money?
Mr. Bennett : The hon. Lady's assertion is incorrect. Italy spends less than us. She should consider the figures for the amount of gross domestic product spent on health services in different countries. It is interesting that although Britain spends less of its GDP on health than other countries in Europe, it is largely because many of those countries have a far larger private sector. Much depends on the size of a country's GDP, and Britain has seen the largest increase in GDP over the past two years of any country in the European Community. We should bear in mind the fact that health spending has increased under this Government because we have had the resources to make increases and because we have increased prosperity so much since 1979. It is interesting to note the Labour party's policies, or the lack of them. I have read the debate of the first day, and I was present for the speech of the hon. Member for Livingston (Mr. Cook) and on the Welsh Grand Committee when the hon. Member for Alyn and Deeside (Mr. Jones) led for the Labour party in a debate on the National Health Service. What are its policies? We have not heard how it would improve the National Health Service.
Column 736so, it has a duty to tell the public how it would spend the Health Service budget of £28 billion and ensure that the service was improved.
Mr. Bennett : The hon. Gentleman knows that every Queen's Speech says "Other measures will be laid before you", of which this is one. The Labour party believes that we should do nothing to the Health Service and leave it as it is. Let us consider its policies. When the Labour Government were in power between 1974 and 1979, they did not increase spending on the Health Service, as this Government have done, but cut it by 3 per cent. in real terms in 1977-78. They cut the hospital building programme by 30 per cent. in 1976, and hospital closures were 50 per cent. higher under the Labour Government than under this Government. Nurses' pay went down in real terms by 21 per cent. and GP's pay was cut by 16 per cent. The trouble is that the Labour party's policy is predicated not on what the people want but on what NUPE and the Confederation of Health Service Employees want. They want a Health Service run by NUPE and COHSE for the benefit of NUPE and COHSE, not for the benefit of the people of this country. I shall conclude by asking three questions, to which I hope my hon. Friend the Minister will reply. The first concerns the definition of "resident" in the Bill. I represent a health authority that, in the summer, covers three times as many people as it does in the winter because of holidaymakers visiting our beautiful county. Can we be assured that we shall be given the resources to deal with those holidaymakers and that they will be defined as being "resident" during that time?
Secondly, what will happen when someone has been referred to another health district for an operation but it is not done properly and remedial work becomes necessary? Can we be assured that the health district which did the operation will pay for the remedial work and not the health district that sent the patient to the operating district? That is important because it would be unfortunate if the health district that sent the patient had to pick up the bill for unsuccessful operations.
Thirdly, the family practitioner service authorities should have GP representatives who are elected locally by GPs in their areas. I hope that the Government will consider that carefully when we debate the clauses dealing with FPSAs, because it is an important worry of some GPs and it is worth considering further.
I draw attention to my health authority, because it is important to talk from the experience of what happens in our districts. I have been immensely impressed by the fact that since Pembrokeshire health authority came into operation in 1982 it has managed to spend resources properly and carefully. It has managed to increase outpatient attendances by 34 per cent., radiology attendances by 24 per cent., occupational therapy attendances by 90 per cent. and operations by 153 per cent. It has managed to save £340,000 by tendering out some services within the hospital, and that money has been reallocated to other services carried out by the health
Column 737authority. The authority has been able to employ 80 more staff this year and the unit of work costs in the DHA are the lowest for all the Welsh authorities.
It is therefore no surprise to me or my constituents that this year Withybush hospital in the Pembrokeshire health authority region has won an award from The Sunday Times for being the best district hospital in the United Kingdom. That is what can be done if resources are spent properly. The Bill is about making sure that that happens, and I commend it to the House.
Mr. Ian McCartney (Makerfield) : As a member of the Select Committee on Social Services, which for 12 months has been carrying out a review of the Government's proposals and the deliberate underfunding of the Health Service, it was my original intention to discuss the amendments which have been tabled in the name of my hon. Friend the Member for Birkenhead (Mr. Field). If my hon. Friend is not in his place, I intend to move those amendments formally at 10 o'clock.
I should like to discuss the implications of the review for my constituency. Because of the proposals and the Government's preparation for the reorganisation of the Health Service, my constituents in the Wigan metropolitan borough find themselves in an incredible position. The health authority has proposed the closure of five hospitals which cover not only my constituency but those of my hon. Friends the Members for Wigan (Mr. Scott) and for Leigh (Mr. Cunliffe) and the hon. Member for Lancashire, West (Mr. Hind). This summer, I wrote to the Under-Secretary of State about the way in which the matter was approached by senior officers and the chair of the health authority and in general about the cavalier attitude towards the proposals, in that no proper consultation was taking place with the community health council, Members of Parliament or the local authority.
At a meeting held in private, on the ground that it was not an issue that involved the public interest, the Wigan health authority decided to employ Amec consultants, an American company which owns Fairclough Construction and Fairclough Homes. The company was offered the use of public money to come forward with proposals to reorganise the health service in Wigan, in view of the Government's proposals in the White Paper and the need for the local authority to take account of the market-based economy which would thereafter operate both within the health authority and in terms of its relationship with other health authorities in the north-west.
The contract was awarded without public scrutiny. People were not able to make submissions and there was no proper check on funding for the contract. Amec proposed that the health authority close all five hospitals--Billinge, a maternity and general hospital in my constituency, which has a large section for the mentally ill, Atherleigh, a hospital for the frail elderly and those with senile dementia, the Wigan Royal Albert Edward infirmary, an accident and emergency unit and general hospital, Leigh hospital, an accident and emergency unit and a general hospital with a new section for the mentally ill, and Astley general hospital.
The proposal was to close the hospitals and to sell the land, without tender, to Fairclough Homes and
Column 738Fairclough Construction. Subsequently, the health authority decided to close all five hospitals and to approach the regional health authority to fund a new single-site hospital, which was to be built by Fairclough Construction without going to public tender. I wrote to the Minister asking him to intervene, taking account not only of any public impropriety but of the view of my constituents, the local authority and the community health council, which opposed the way in which the matter had been handled. The Minister not only rejected my appeal but wrote a letter supporting the idea.
Four weeks ago, the situation changed for the worse. The health authority-- because of Amec's recommendations--withdrew a request for funding for the reorganisation of Leigh hospital and its redevelopment phase. Two weeks ago, the North Western regional health authority advised the Wigan health authority that the Government had not made available a single penny of capital resources for construction of a new hospital. My health authority is going ahead with the programme of closure of five hospitals, with no plan for alternatives. That is happening because of the Minister's encouragement.
This action is unhealthy and is a gross dereliction of duty by the health authority and the Under-Secretary of State, who could have intervened this summer but refused to do so because of his ideology on the review of the NHS. The hon. Member for Lancashire, West, who has left the Chamber, shares a constituency boundary with me. He should tell his constituents--in Up Holland--what will happen to the maternity unit at Billinge hospital, which covers the south-east of his constituency. He should tell them what is happening in terms of patients following money at the Wigan Royal Albert Edward infirmary. There will be no hospital to follow. What will prevent the health authority from implementing hospital closures? The Secretary of State has refused to provide the regional health authority with funding for construction of a single unit to replace the five hospitals. The Minister refused to intervene this summer when I wrote to him about Atherleigh hospital. With 24 hours' notice, the health authority was decanting patients into the private sector without consultation with the community health council, the social services department, patients their relatives, or their representatives--a huge proportion of the residents of Atherleigh- -on the ground that the authority's financial position was so serious. A confidential report, which was leaked to the four Members of Parliament affected, showed that provision has already been made for the hospital to close and for the private sector to receive from Wigan health authority over 124 additional places for the frail elderly.
A private sector nursing home in my constituency recently submitted a planning application to extend its premises, on the ground that the local health authority would provide additional patients because of the closure programme. To do that, the nursing home sought an amendment to a previous planning application to get rid of the physiotherapy unit, recreation area and the hydro-pool facility. Those facilities are important to the environment of people living in public or private sector homes and needing long-term care. Because of my health authority's decision, the home was prepared to get rid of those facilities to provide additional beds, at a cost to the taxpayer.
The Minister owes us not just a scanty explanation. He failed to answer my points on the three occasions that I
Column 739raised them. He cannot do that now. He will have to sit down with the four Members of Parliament concerned and tell us and our constituents what we are to do about the crisis.
The health authority is embarking on a programme of closure of our facilities, but with no alternative facilities with which to replace them. The Minister cannot simply hide behind the claim that it is a matter for the district general manager and the health authority. He positively encouraged the authority to go down that road. Nor can he hide behind the fact that the health authority needs to take account of changing circumstances.
What would his position be if he were Under-Secretary of State for the Environment and a Labour or Conservative local authority sold off, without tender, large-scale public assets or became involved with a private sector developer in the wholesale disposal of public assets at a knock-down price? He would be the first person to bring in the district auditor to examine the way in which that local authority was operating, yet he, as a result of his inability or unwillingness to act in the matter over the summer months, has been a party to the asset stripping of resources in my constituency.
He owes it to me and to my constituents to meet us at the earliest opportunity to resolve the issue.
The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : Before the hon. Gentleman sits down, I must point out tha as he probably knows, I shall not be replying to the debate. My hon. Friend the Minister for Health will be replying. However, I and my officials will read the record of what he has said because he has made a number of allegations about me personally. As I shall not have the opportunity to reply in this debate, I shall write to him and send copies to the hon. Members who are affected.
Again as a result of the cut in resources, nurses leaving the training school in the hospital in my constituency this month have been informed that there is no placement for them in the health authority. That has happened at a time when the Government are, supposedly, spending £4 million on advertisements to encourage people to join the nursing service. At the end of this month, my local trainee nurses will be receiving in one hand a certificate saying that they are trained nurses and in the other hand a redundancy notice.
What will the Secretary of State do about that? Is he prepared for public money to be wasted in that way? Is he prepared to see nurses going through a full training scheme and at the end of it being told that neither the health authority in Wigan nor nearby health authorities are able to give them a position as a result of cuts in their budget for this and next financial year? Those trained nurses will have to sign on the dole in January 1990. The reality of the Government's policy of public expenditure cuts is reductions in services, a reduction in the overall money spent on nurse training and the asset stripping of the resources of local district health authorities.
Mrs. Mahon : Will my hon. Friend take on board what is happening to enrolled nurses? A scandal is being allowed to happen. The 150,000 enrolled nurses are the backbone of our nursing profession. Fifty thousand of them have
Column 740applied for conversion courses, but there are only 1,000 places. It will be well into the next century before even one quarter of those nurses are retrained under the Government's own training programme.
Mr. McCartney : My hon. Friend is right. The Select Committee on Social Services, in an earlier report this year, pointed out to the Government their failure in trying to provide resources for training in other aspects of the Health Service. The Government are already damaging the Health Service at local level. The Bill will do nothing other than further damage it and that is the all-party view of the Select Committee, which has examined the matter in great detail not over just a few months, but over a lengthy period. The Committee's report on the way in which the Government have handled the issue has the support of both Conservative and Labour Members.
Mr. Mark Wolfson (Sevenoaks) : I welcome the clear confirmation that was given, once again, by the Secretary of State in the debate last Thursday that the fundamental principle on which the Health Service reforms are based is that free medical treatment should be provided regardless of means and financed largely by general taxation. I also welcome the undoubted fact that the resources that are being made available to the Health Service by this Government have been increased steadily and that the past two public spending rounds have themselves raised the available cash by more than 20 per cent. I am also aware of the essential need to make the best use of every penny of those resources. That requires a public Health Service that is efficient and where waste is minimised. Many of those who now work in the Service, dedicated and effective as they are, are not at all satisfied that the National Health Service today uses its resources as carefully or effectively as it should. They too want reform and they too look for improvement, even though they may disagree with some--or in some cases all--of the proposals. It is of key importance that the decision- making process in the Health Service and the objectives of each unit and department in it be clarified and improved, and that the opportunity for local leadership and more localised decision-making be increased. The Bill aims to do this and addresses the issues that can enable that to happen.
During my 10 years as a Member of Parliament, my experience is that complaints against the quality of care that is given by the Health Service are very few and that, in the main, they refer to the length of the waiting list for consultation and for treatment in specific areas of difficulty. These are the orthopaedic and ear, nose and throat specialisations. There is also a continuing problem of providing adequate care for the elderly and infirm, and for those most vulnerable groups in our society--the mentally ill and handicapped. I accept that the provisions are designed to deal with those issues, but however good the intentions, they will not be realised unless the available resources are increased continually, as well as the organisation being improved to deliver the service as efficiently as possible.
I am concerned, as other colleagues have already said that they are, about resources. The overall funding of the Health Service makes no provision for pay alone. A centrally-assessed allowance is included which is meant to cover pay and general price increases, and it is left to individual authorities to use that sum to suit best their own
Column 741circumstances. The point at issue is the overall adequacy of that allowance. For some years now, the level of inflation that has been experienced by the health authorities outside their control has exceeded the national provision. I know that extra resources have been given, especially for pay review body awards, but they have not covered the true additional costs.
We are all aware that the Health Service is highly labour intensive and that any underfunding on pay is critical. It is a fact that there is a considerable difference between the index increases that the central allowance takes into account and the actual inflation in wage costs that the health authorities have had to pay. The result is that despite the necessary additional finance, which is welcome, health authorities have had to supplement their provision for inflation from their existing resources. I agree that that pressure has led to increased efficiency, a better use of resources and a more streamlined and cost-effective system, but there is a limit to the savings that can be achieved in that way. The squeeze has, in many cases, made the pips squeak, but when the pips themselves are dry the service will suffer and the level of care will decline.
I accept that the demands on the Health Service are continuing to increase. That is for good reason. The benefits of medical advances keep people alive and well for longer and the expectation of a full life into old age is vastly greater than it was even 20 years ago. But that means that to fulfil its proper role the service must be adequately staffed on a cost-effective basis.
In my health authority area the use of agency staff has been growing rapidly. Low rates of pay and a high level of local employment are making recruitment more and more difficult. Agency staff are required and must be used in all disciplines. The premiums paid to agencies represent a loss of purchasing power to the health authority, and the presence of such agency staff, often on higher pay rates and sometimes with less commitment to the unit in question, creates problems with staff morale.
I highlight the problem of resources not as criticism of the Bill, which I support in principle and which I believe will provide the opportunity to deal with the issue of local wage rates more effectively, but because it is necessary continually to remind Ministers of local pressures and the problems on the ground. I now turn to community care, for which the proposals in the Bill are positive. They tackle the problem that has bedevilled community care for years--the split responsibility between local authority and health service--thus providing a better base for dealing with what is bound to be a mounting social and financial responsibility in the years ahead.
I have important reservations, however, which I want to air. The first is that central funds for local authorities to cover community care should be ringfenced. I am not confident that without this local authorities will continue to direct those funds to the main purpose for which they are intended.
Secondly, I want to emphasise that removal of patients from mental hospitals must be strictly limited from now on to equate exactly with the provision of alternative facilities in the community. Those new facilities require buildings and adequate staff ; until now, the arrangements have too
Column 742often been the wrong way around--closing existing facilities before new ones are ready. I welcome the fact that recent ministerial statements have dealt with this important issue but we now expect to see the policy followed in practice. As I am sure the Minister of State knows, many professionals in the field exactly predicted the problems that have arisen when the wholesale closure was first mooted.
Finally, I ask my right hon. and learned Friend to do his level best during the passage of this important Bill through both Houses to listen and respond to the continuing anxieties of many who work in the Health Service and in the service of community care. Some of those concerns are not necessarily politically motivated. They are genuinely based on professional knowledge and a wish to see the Health Service improve. I accept that the BMA's propaganda got it badly wrong.
I shall support the Bill tonight, but with some reservations and with the firm expectation that a well-intentioned Bill can be improved during its passage through the House, provided that the Secretary of State is prepared to show flexibility and to respect views that may differ from his own. That is what well-respected doctors, highly qualified and thoughtful paramedics and sensible staff at all levels of the service in my constituency want, and I support their view.