[Lords] Read the Third time, and passed, with amendments.
To be read the Third time.
Sir John Stokes : On a point of order, Mr. Speaker. I understand that a number of the names of those right hon. and hon. Members who wish to ask questions of the Prime Minister have been omitted at the end of the printed list.
The Minister for Health (Mrs. Virginia Bottomley) : We regularly meet local authorities, health authorities and voluntary organisations. They all have vital roles to play in the provision of community care.
Mr. Rogers : The Government, in their proposals, and in the answer that the Minister has just given, have rightly emphasised the part that the voluntary organisations can play in this sector. If that is the case, why do not the Government give adequate time to consult those organisations on the proposals contained in the Bill? Can
Column 724we have an assurance today that the Government will provide enough funds for voluntary organisations fully and properly to carry out their functions?
Mrs. Bottomley : The whole spirit of the proposals, leading on from the original Griffiths report, "Community Care : Agenda for Action", has been on the basis of consultation with voluntary organisations and local authority associations. About 280 representations were made on the original report. Since my right hon. and learned Friend's statement last July, about 100 further representations have been made. Since the publication of the Bill I have been involved with local authority associations and voluntary organisations in carrying forward these important plans. We have made it clear that adequate resources will be available.
Mr. Martlew : Had the Minister held discussions with voluntary organisations, perhaps the future role of hospices in community care would have been raised. Will she explain why hospices in Scotland are funded pound-for-pound by the Scottish Office, yet, despite repeated requests from my hon. Friends and me, the Minister steadfastly refuses to do the same for those in England and Wales? Will she explain to those involved with the Carlisle hospice appeal why they are working so hard to build a hospice in my constituency when nine miles up the road in Scotland the Government provide money? Is it not time that the Government stopped discriminating against the terminally ill in England and Wales?
Mrs. Bottomley : The hon. Gentleman may have been drawing attention to the way in which matters have developed in Scotland. One way in which we manage matters is to have some variation between different parts of the country. I thank the hon. Gentleman for giving me the opportunity publicly to pay tribute to the voluntary hospice movement which has been a major force for good. I draw his attention to the announcement that I made shortly before Christmas of a further £8 million for the voluntary hospice movement to be distributed by the regional health authorities. That will greatly add to the financial assistance that they already receive.
Mr. John Greenway : Does my hon. Friend agree that all organisations, with the exception of the Labour party, welcome the Government's proposals for community care, which are largely in line with the Griffiths recommendations? What discussions has my hon. Friend had with the Association of Directors of Social Services, particularly in respect of funding and the timetable for implementation?
Mrs. Bottomley : The proposals offer a major opportunity to improve care in the community, and many people have long looked forward to them. The key is now to make a reality of them. We have held discussions with local authority associations on the ways in which we can work together on projects and in giving guidance and training. I reiterate that we made it clear that adequate resources will be available, taking account of demographic factors. At present, many resources are misspent, without any proper assessment of the necessity, for example, for residential care. The proposals provide an opportunity to ensure that the frail and vulnerable are well cared for in the community.
Column 725SANE Concern or allied organisations about the over-rapid closure of pyschiatric hospitals and the placing of their former patients into the community when there are inadequate facilities, and an inadequate number of qualified persons, for looking after them? Sadly, those people are going off medication, sleeping under arches, and in some cases ending up in prison.
Mrs. Bottomley : My hon. Friend draws attention, rightly and properly, to a particularly vulnerable group. There is general recognition that the great swing to remove people from psychiatric hospitals--in which many of them were quite improperly incarcerated a generation ago--needs tempering. My hon. Friend the Under-Secretary of State for Health has presented proposals for dealing specifically with that needy group.
Mr. Ieuan Wyn Jones : Is the Minister aware that local authority social services departments are examining local plans for delivering community care? The hon. Lady will be aware of the concern expressed by many voluntary organisations that, in view of their increased responsibilities, local authorities are taking insufficient account of their views in the consultation process leading to publication of community care plans. What guidance are local authorities being given to consult voluntary organisations before publishing such plans?
Mrs. Bottomley : Clearly, we want community care plans to be discussed with voluntary organisations and the users of services, and, above all, with carers--who have so often been overlooked and neglected in the past. We are giving local authorities precise guidance on the importance of preparing their plans properly, and I assure the hon. Gentleman that the role of voluntary bodies in community care is perceived to be enormously important. We want a mixed economy of voluntary organisation, local authority, and private and independent provision. We want choice and dignity for the vulnerable.
The Parliamentary Under-Secretary of State for Health (Mr. Roger Freeman) : The responsibility for providing psychiatric services forpeople who need them rests with district health authorities and local social services authorities. However, the Department is presently exploring what practical steps might be taken to assist such people who are homeless.
Mr. Day : My hon. Friend will be aware of the concern expressed in the House and outside. Will he confirm that Ministers will not approve the closure of any hospital for the mentally ill without first demonstrating that adequate alternative facilities exist? I cite as an example the £3 million project for a mental illness unit at Manchester royal infirmary, which is to start this year.
Mr. Freeman : I confirm my hon. Friend's remarks about the facilities at Manchester royal infirmary, which I visited recently, and which has excellent plans to meet the needs of patients from Cheadle hospital. I confirm that no
Column 726hospital for long-stay psychiatric patients will be allowed to close until the National Health Service is satisfied that proper facilities exist in the community.
Mr. Frank Field : Although the House welcomes the Minister's last statement, does he accept that over the past 10 years, more than 40, 000 long-stay patients have been dumped in the community with nowhere to go? Is he aware that many of them are homeless and are wandering the streets? While we are grateful for the Government's concern, at least as expressed in words, how much new money is being put up front?
Mr. Freeman : There is no question but that some discharge policies by some hospitals were ill-advised by present standards. The hon. Gentleman is right in saying that it is of concern to the House, and to the Government, that some people are now homeless or roofless. We have outlined specific policies so that no one should be discharged from any psychiatric hospital unless a care programme is agreed for the individual. We have also made provision for the year 1991-92 for a specific mental illness grant, to be distributed through the regional health authorities, to help local authorities to improve the quality of social care in the community.
Dame Jill Knight : The House will be pleased to learn of the sums of money that have been allocated to deal with this problem, and to know that specific instructions are being sent to local authorities to deal with the issue. How long will it take before those plans reach the point where they are helping people who have been released from hospital?
Mr. Freeman : My hon. Friend refers to district and regional health authorities' responsibilities, and those are separate from the responsibility of the consultant and the authority in charge of the hospital. I have stressed that no patient should now be discharged without a proper care programme. By April 1991, every district health authority should have a proper care programme for all patients who have been discharged or will be discharged. We will provide additional funds for local authorities to enable them to improve the quality of social care.
"like feral children scavenging for food"?
Is not that a bitter criticism of the Government's community care policy at a time when The Sunday Times has shown--I speak as a trustee of Crisis at Christmas--that there is massive public backing for more humane provision? Is there not now an urgent and compelling case for full implementation of the Disabled Persons (Services, Consultation and Representation) Act 1986?
Mr. Freeman : I read the article in The Lancet, but I think that, unfortunately, it was written too early to take account of the Government's new proposals on care for the mentally ill. As for roofless people in our cities who have a history of mental illness, the Government recognise that that is a problem and hope to bring forward proposals to deal with it in due course.
Sir William Clark : Is my hon. Friend aware that mentally ill people in my constituency have been discharged from Cane Hill hospital and put in bed and breakfast accommodation by the local authorities? They
Column 727are walking the streets. It is all very well for my hon. Friend to say that that will be fixed in 1991, but what will happen to them between now and then?
Mr. Freeman : We must be careful to distinguish patients who are discharged from hospital properly, because they are psychiatrically and medically cured and have the same rights as other people. I share my hon. Friend's concern about the past discharge policies. We have given all district health authorities due notice that they must make progress within 12 months. It is not possible to reform procedures overnight. We have made substantial progress, and I shall study the example that my hon. Friend has cited and write to him.
Mr. Freeman : Stockport district health authority will benefit from the increased cash resources announced by my right hon. and learned Friend the Secretry of State for Health on 14 December last year for the North Western region amounting to £77.8 million, representing a cash increase in resources amounting to 7.21 per cent.
Mr. Bennett : Exactly how much will be received by Stockport, as opposed to North Western region? Is the Minister aware that since 1984 Stockport has lost £1.6 million in real terms, and is now being asked by the region to make cuts of £1.1 million? It has also lost out in capital terms, and the people of Stockport want to know why their health service is doing so badly under the present Government.
Mr. Freeman : I do not agree that Stockport health authority is doing badly under the present Government. North Western regional health authority will shortly make allocations to all the districts, including Stockport, although they have not been announced yet. My right hon. and learned Friend the Secretary of State for Health has enabled the region to experience a real growth in resouces this year, especially when we take account of cost-improvement programmes and income generation, and I am sure that that welcome increase will be reflected in the allocation to Stockport.
Mr. Favell : Is my hon. Friend aware of Stockport's application to have its general hospital on one site? Am I right in thinking that what should have been a first-class application has been bungled, and that Stockport should have had a share of the £300 million that is to be used for capital projects over the next three years? Will my hon. Friend come and see the position in Stockport for himself, and will he take it from me that, having done so, he will agree that the hospital should be on one site, not only to prevent inconvenience but to save money and lives?
Mr. Freeman : Owing to sustained pressure from my hon. Friend for me to visit Stockport, I can now tell him that I shall be going there on 30 March. As for the specific project that he mentions, all is not lost. I understand that discussions are continuing between the district and the region, and that the region will have a chance to reconsider later in the year further construction at Stepping Hill hospital for 1993-94.
Mr. Freeman : There are no firm proposals at present to close Park hospital, which is a mental illness hospital. The Liverpool health authority is considering how some of the patients at the hospital may be better cared for at the new acute unit at Broadgreen and other hospitals, and, of course, in the community.
Mr. Parry : Is the Minister aware that Liverpool health authority is currently being lobbied by a committee consisting of women and relatives of patients and all the NHS trade unions? Is he aware that Park hospital has been declared a centre of excellence by the Mental Health Act Commission, and that £2.5 million has recently been spent on it? Selling off such a priceless asset would be a crime against humanity.
Mr. Freeman : I have already said that there are no plans to close Park hospital. As the hon. Gentleman and many of his hon. Friends will know, a formal procedure takes place before the closure of any hospital, or indeed any significant change in the service. In the event of sustained opposition from the community health council, the proposal ultimately comes to Ministers, but in this instance, that has not happened.
Mr. Terry Fields : Surely the Minister must come up to Liverpool, visit Park hospital and see the reality for himself. Staff have been told that four of the seven wards are to close. Some patients will be shunted to Rathbone hospital ; others will be dealt with in the private sector and by charities. The least able members of society will be left to fend for themselves, and psychiatric patients will be forced to wander the streets of Liverpool. Despite the nonsense talked by the Minister about there being no diminution of care in the community, old people will clearly be treated despicably by the Government.
No patients, elderly or otherwise, will be wandering the streets. I am sure that the hon. Gentleman will agree that those patients--and that does not mean all--who can be cared for better in the community, which may mean hostels or their own homes, should be cared for in that way ; it is correct and the humanitarian way.
The Secretary of State for Health (Mr. Kenneth Clarke) : I last met representatives of the British Medical Association formally on 18 October 1989 when we had a friendly and constructive discussion about the implementation of our proposals in the White Paper "Working for Patients".
Column 729are already beginning to strike off their lists patients whom they regard as potentially uneconomic so that far from choice for patients being increased, some patients are losing the choice even to remain with their existing GPs? I know that the Secretary of State does not keep such information, but will he now undertake to do so in order that he can monitor any such changes in GPs' lists and the fate of those patients affected?
Mr. Clarke : I personally have seen no evidence whatever that any such practice is taking place. If any GPs were striking off their lists elderly or chronically sick patients, they would be doing so on a mistaken interpretation of the contract. If they study the new contract for GPs and the proposals in the White Paper, they will see that there is no financial or other incentive to any GP to refuse to accept an elderly or chronically sick patient.
Mr. Viggers : Does my right hon. and learned Friend agree that many patients, especially elderly people, have been frightened by comments made by some doctors which have fallen short of the level of objectivity and accuracy that one would expect from the profession? Can my right hon. and learned Friend confirm that no patients will be deprived of the medicines they need and that in particular, the indicative drug budgets are likely to be very helpful in encouraging doctors to prescribe well?
Mr. Clarke : I am sure that my hon. Friend agrees that we welcome the end to such campaigning over recent months. There was certainly no such suggestion at my last meeting with the BMA. It is extremely unfortunate that last summer a great deal of effort was put into concocting inventions about our proposals and then publicising them to patients. I hope that now we can put behind us some of the damage that did to doctor-patient relationships.
Ms. Harman : Will the Secretary of State look into the case of Mrs. Jackson who arrived home from hospital to find on her doormat a letter from the Hillingdon FPC saying that she had been struck off her GP's list because she would require too many expensive night visits? Will the Secretary of State together with the BMA now monitor the growing number of so-called uneconomic patients who, because of the GP contract and the changes in the forthcoming National Health Service and Community Care Bill, are losing the right to stay with their own GPs?
Mr. Clarke : I shall certainly look into that case. I should be extremely grateful if the hon. Lady would pass on to me the evidence that she has to support it. I would strongly disapprove of anybody being struck off on that ground or any other. The only change that the new GPs' contract is making is that doctors who carry out their own night visits, or send a doctor from their own practice, or one who is likely to be known to the patient, will be paid three times as much for those visits as one who uses a deputising service. That encourages a welcome improvement in patient services. If the hon. Lady's allegation turns out to be true, I shall certainly investigate it most closely.
Mrs. Virginia Bottomley : Over the past three years for which figures are available, spending for family planning purposes in England has increased from £76.7 million in 1985-86 to £84.2 million in 1987- 88. Family planning is an important preventive service which contributes to better maternal and child health and to the stability of family life.
Mr. Stevens : I am grateful to my hon. Friend for that reply. I am sure we all welcome the increased expenditure on that most important service. Does she agree that family planning plays a vital role in health care? Do the Government intend to continue their financial support for the outstanding Margaret Pyke family planning centre in London?
Mrs. Bottomley : I assure my hon. Friend that we continue to give priority to family planning services and that funding for the Margaret Pyke family planning centre will continue. It is a national centre of training in family planning, training something like 850 doctors and 60 nurses a year. It also does very important work in the prevention of AIDS.
Mrs. Mahon : Will the Minister come clean and tell British women that family planning will suffer under the Bill as health authorities will have an incentive to close clinics, and women will be left with no choice other than their GPs and a much reduced service?
Mrs. Bottomley : The key point about family planning services is that women and men should have a choice of services. Whether they are provided through the family health service, the family practitioner or the district health authority is a decision to be made locally. In recent years, many women have demonstrated that they would rather receive family planning advice from their practitioner than from family planning clinics. That must be a matter for them rather than a diktat from on high.
Mr. Kenneth Clarke : The National Health Service and Community Care Bill currently before the House provides for GP practices which volunteer to do so, and which meet the eligibility criteria, to run their own practice funds. This will give them additional freedom to decide how funds are best used in the interests of their patients and, in particular, to influence the way in which hospital treatment is provided. In December I issued a programme to all GPs in England for the scheme, inviting expressions of interest to regional health authorities. I am pleased that there has already been a very encouraging response.
Mr. Walker : I thank my right hon. and learned Friend for that reply. Can he confirm that GP practices that decide to set up their own budgets will have access to up to £32,000 of the management charge? Does not this make nonsense of all the stories that we have heard about GPs having to spend more time on paperwork than with patients?
Mr. Clarke : There will be £32,000 available to reimburse GPs for expenditure that they incur on the management of the practice budgets. They will use that money to obtain information technology, including
Column 731software, as well as the staff that they need to make sure that the budget can be run effectively without intrusion on their clinical duties.
Mr. Pike : Will the Secretary of State recognise doctors' genuine worries and patients' concerns about the changes in the Health Service? Today I received from a Mr. Bramald a letter enclosing a letter from his doctor, Dr. Durkin, stating that the change in payment for doctors means that they can no longer afford to keep on their lists people who require more active night calls and weekend calls, and saying that Mr. Bramald and his family were being given 10 days in which to find another doctor. Does this not show the problem, and will the Secretary of State take action to rectify it?
Mr. Clarke : I understand that there are uncertainties among doctors at a time of change, but it is my experience, and that of everybody in the National Health Service, that those uncertainties are diminishing rapidly. GP practice budgets are entirely voluntary, and only GPs who want to take advantage of them will apply to do so. I think that the vast majority of eligible practices will apply. I will have a look at the letter from Dr. Durkin to which the hon. Gentleman referred, but on the basis of the hon. Gentleman's account I can only say that, under the contract that the doctor has been given, he has no justification for making such statements. I suspect that he is yet another doctor who has been misled by some of the rather over-the-top campaigning that went on last summer about the contract, and that if he looks more closely at the contract he will see that it gives him no encouragement to take such steps against his patients.
Mr. Michael Morris : As all GPs have tight budgets, and inevitably always will do, will my right hon. and learned Friend consider GP practice leaflets? GPs are not allowed to use ordnance survey maps unless, as I understand it, they negotiate directly with the Ordnance Survey. Is not this a case in which my right hon. and learned Friend should knock a few heads together and encourage direct negotiations between the Department of Health and the Ordnance Survey so that GPs may use those maps?
Mr. Clark : GPs must have reasonably tight budgets for their premises and practice expenses, but, as my hon. Friend will know, the amount that has been spent, under this Government, on the improvement of premises and on practices has increased enormously with the huge expansion in the practice staff that GPs employ. I am grateful to my hon. Friend for drawing attention to this problem. I understand the desire of the Ordnance Survey to protect its copyright, but I will look into the possibility of my Department's being able to help to sort out the problem.
Mr. Kennedy : Has the Secretary of State recognised the genuine and legitimate anxiety of patients and general practitioners arising from the changes to the GP service that, in the shape of legislation and contracts, he has forced through this House?
Can he not see that there continues to be legitimate anxiety arising from the peer audit to which GPs are subject, particularly on spending? It makes sense, from the point of view of the Department of Health, only if punitive action is likely to follow supposed or alleged overspending. The injection of that cash element between the family
Column 732doctor and the patient at the coal face of the Health Service is utter poison for what are supposed to be the principles of the National Health Service.
Mr. Clarke : The hon. Gentleman is muddling a variety of aspects of general practitioners' work. The general practitioners' contract, for which a majority was obtained in the House, will reward general practitioners better than in the past for heavy workload and good performance. That is the point of the contract. The hon. Gentleman is referring to indicative budgets for drugs and prescribing costs, and we have repeatedly made it clear that every patient will be entitled to the drugs which, in the general practitioner's opinion, the patient requires. General practitioners will be subject to penalties under the contract only if they deliberately continue to overprescribe in the face of professional advice that points out their wasteful practices. That is not a serious intrusion into the care of patients.
Mr. Boswell : Has it occurred to my right hon. and learned Friend that the minimum size for practice lists is approximately four or five times the size of the sample drawn by opinion pollsters to represent the population as a whole, so it is highly likely that practice lists will be representative? Will he assure the House that in the event of there being an unusual patient profile, the system will be sufficiently flexible to ensure that general practitioners do not lose out as a result of their introduction?
Mr. Clarke : I can certainly give my hon. Friend that assurance. The funds placed at the disposal of each practice will reflect the make up of its patient list. If general practitioners are not satisfied with the sum provided by the regional health authority, they can refuse to proceed with their application for a practice budget.
Mr. Freeman : We have always made it clear that implementation of the Act depended on identifying and making available the necessary resources without damage to other priority social services. We have already implemented six sections, which include imposing duties on local authorities to assess on request the needs of disabled people, while taking into account the abilities of their carers.
Mr. Howarth : Does the Minister accept that if the consumer control provisions are to have any meaning at all, sections 1, 2 and 3 of the Act should be implemented at the same time as the National Health Service and Community Care Bill?
Mr. Freeman : It would be irresponsible to consider only the administrative costs of implementing sections 1, 2 and 3. We must also look at the underlying resource assumptions for providing the services. We shall be commencing formal consultations with local authorities
Column 733on the implications of implementing sections 1, 2 and 3, and other sections not yet implemented, within the next few weeks.
Mr. Loyden : The Minister's answer falls short of giving satisfaction. Is he aware that 40 per cent. of local authorities are not making provision for wheelchair access into rooms and buildings from which disabled people can obtain information, including council agendas, so that they can be treated as citizens equal to non-disabled people? Is it not a disgrace that so long after the Act was passed, disabled people are still being treated by local authorities, encouraged by the Government, as second -class citizens?
Mr. Freeman : The sections of the Act already implemented are clear on the obligations placed on local authorities. They have to provide services within their resources. In the coming financial year, 1990-91, we will provide £31 million through the rate support grant to help local authorities to provide services under the sections of the Act that we have already implemented.
Mr. Hannam : I thank my hon. Friend for the £24 million already allocated this year for the implementation of the Act, but does he accept that if disabled people are to have a reasonable standard of care in the community they should have access to the assessment procedures and the right of appeal? Therefore, will he expedite the implementation of sections 1, 2 and 3?
Mr. Freeman : I assure my hon. Friend that we shall proceed as quickly as possible in our review of sections 1, 2 and 3. The social services inspectorate will be reporting shortly on the success so far in the implementation of the Act.
Miss Emma Nicholson : I welcome my hon. Friend's commitment to early implementation of the sections of the Act that have not yet been implemented, and I am delighted that he is already consulting local government. Does he agree that it is important to rest on a consistent national framework so that all individuals who depend on community care have the same treatment?
Mr. Freeman : I agree with that. The report of the social services inspectorate, which I hope will be published next month, will make that point and comment on the differences in the standards of treatment and, ultimately, their elimination.
Mr Tom Clarke : If the Government are genuinely committed to community care, is it not odd that they do not see this important Act as a framework for involving-- [Interruption.] --disabled people, their carers and advocates in contributing to the formulation of policy which is important to them? Despite the Government's rhetoric, they have not lifted a finger to implement the remaining sections of the Act since April 1987.
Is the Minister aware that that is being seen not simply as a scandal, but as one of the Government's greatest failures and most mean-minded acts of lethargy, if that is possible, in this Parliament?
Mr. Freeman : It is not mean minded. We have implemented six sections of the Act, as the hon. Gentleman knows, and I have given a commitment about the consultation procedure on the remaining three sections. I share his view that they are important. It would
Column 734be irresponsible to consider only the administrative costs of implementation and not to make sure that the underlying service provision increases. That requires real resources-- [Interruption.]