The Parliamentary Under-Secretary of State for Health (Mr. Stephen Dorrell) : Four districts reported no cancelled scheduled operating theatre sessions in 1988-89 and one reported just over 2,000 cancelled sessions.
Mr. Maples : I congratulate my hon. Friend on his appointment. Does he agree that the figures that he has just given show yet again that there are enormous discrepancies in the performances of different health authorities? Does he further agree that if only the less efficient could improve their performance, they could deliver far more health care for the same amount of money?
Mr. Dorrell : I am grateful to my hon. Friend for his good wishes. He made a good point. Both the National Audit Office and the Public Accounts Committee have pointed out the enormous discrepancy within health districts in the efficient use of operating theatres. The Bevan report shows that across the country the average utilisation is 70 per cent. If that were raised to 90 per cent., there would be a saving to the National Health Service of £100 million. The reforms that we intend to introduce next April will help to achieve that.
Rev. Martin Smyth : What steps are being taken to increase the average utilisation figure? Would improved information technology help, especially when patients do not turn up or when notes are not available to the surgeon carrying out the operation?
Mr. Dorrell : Improved technology certainly has a part to play and our response to the Bevan report recognises that. We are currently consulting on the lessons to be learnt from that report and we expect to issue guidance soon.
Dame Jill Knight : Was not there a recent case of an ophthalmic surgeon working in the Health Service carrying out more operations in one month than another ophthalmic surgeon carried out in six months? Do not
Column 492NHS patients have the right to expect unanimity of good service, wherever they may live? Is not that the most important reason for the review of the NHS?
Mr. Dorrell : During my three and a half weeks in the job, that specific case has not been drawn to my attention. However, the principle espoused by my hon. Friend is right. We are introducing reforms next April to try to achieve that unanimity of service throughout the country.
The Secretary of State for Health (Mr. Kenneth Clarke) : Local authorities are responsible for determining the use of the resources on matters for which they have policy responsibility and for which they are accountable. The House welcomed the Government's decision to make community care the prime responsibility of local government, and earmarked grants would be inconsistent with that decision.
Mr. Bell : I am sorry to hear the Secretary of State's response, although I am not surprised by it. Is he aware of the anxiety throughout social services departments that there will not be sufficient grant to meet the demand for community care? Is he further aware of the London Research Centre report, published in April, which suggested that there would be a shortfall of £100 million rising to £500 million by 1994? Will he consider specific grants to meet such shortfalls, should they arise?
Mr. Clarke : We have always made it clear that local authorities need, and will receive, adequate resources to carry out their new responsibilities. Those resources will be decided during the public expenditure round. It is rather premature to produce reports, from any source, about the inadequacy of resources before we have even decided what those resources will be.
One difficulty with earmarked grants is that it is impossible to separate that area of expenditure from what is already being spent on care in the community, which in large part is already a local authority responsibility. I remind the hon. Gentleman that while the Government have been in power total spending on care in the community has risen by 68 per cent. in real terms--that is more than half as much again as was being spent when we took office and before we introduced our popular arrangements.
Mr. Harry Barnes : On 6 December the former junior Minister made a speech of glowing support for community care when he addressed the annual general meeting of the National Schizophrenia Fellowship. Is not it a cruel deception of such bodies that there is a distinction between the Government's aims and the methods that they use? Does the right hon. and learned Gentleman accept that earmarked grants should be available to areas such as north Derbyshire so that they can meet the provisions referred to in Government statements?
Column 493Mr. Clarke : My junior Ministers move on to greater things so rapidly that I am not sure whether the hon. Gentleman is referring to a speech made by my hon. and learned Friend the Minister of State, Home Office or my hon. Friend the Minister for Public Transport, but if he was addressing the National Schizophrenia Fellowship I have no doubt that the reference was, above all, to the specific grant that we have made it clear that we shall be introducing to encourage community care for mentally ill people. A specific grant for that area is important because in the past it has not been given high enough priority by local authorities. Therefore, money aimed specifically at mental illness will be allocated to local authorities when they produce plans that are satisfactory to the health authorities.
Mr. Sims : Will my right hon. and learned Friend comfirm that, whether earmarked or not, grants given to local authorities from next April will represent the sums that hitherto would have been paid in social security benefits? Is he yet able to give the formula by which the figures will be calculated or an estimate of the sum involved? I am sure that he appreciates the difficulties of local authorities in making their plans from next April without knowing what resources will be available to them.
Mr. Clarke : We are firmly committed to transferring from the Department of Social Security vote to our vote and to local government the sum of money that would have been spent by the Department of Social Security under the old policy of making provision through income support for people in residential care. We also have to make a calculation for growth and a calculation of what is available for this year, and we shall do that when we make the decision on the revenue support grant for local government. I appreciate the difficulties for local government in having to make plans when final decisions have not been reached on exactly how much will be available next year, but that is inescapable in the system of annual financial planning that we have always had. It is true of the whole range of government, under this Government or any other, that we have to wait for the autumn spending round before we know exactly how much we have for the next year. Neither the Treasury and Civil Service Committee nor anybody else has yet come up with a better way of doing it.
Mr. Andrew Mitchell : Has my right hon. and learned Friend had a chance to consider the sad and moving story that appeared in the Nottingham Evening Post last Friday about Colin Jago, a schizophrenia sufferer, who slipped so tragically through the community care net? Will he have a look at that story to see whether any lessons can be learnt for our policy on care in the community?
Mr. Clarke : I agree that the story of Colin Jago is tragic. It shows what a dreadful way of life he led as a result of suffering from schizophrenia. I shall ask the chairman of the district health authority to let me have a report on his case to see whether there are any lessons to be learnt.
I should point out to my hon. Friend the Member for Gedling (Mr. Mitchell) that Colin Jago was examined and interviewed by a doctor at Mapperley hospital, who decided that it was not necessary to admit him to hospital for treatment. However, we must discover the full facts to see whether there are any lessons to be learnt from Mr. Jago's sad death.
Mr. Robin Cook : Will the Secretary of State acknowledge that Sir Roy Griffiths recommended an earmarked grant, that the local authorities, including the Conservative ones, want an earmarked grant, and that now the other place has voted for it? Even flagship Wandsworth has made representations to the Secretary of State supporting the case for a ring- fenced grant. Why does he disagree with everybody else if it is not that he is afraid that an earmarked grant will make it only too plain that he cannot come up with the cash that the councils need to make care in the community work?
Mr. Clarke : Because good government depends on clear responsibility and accountability, and I have not been persuaded that it is right to give responsibility for this matter to local government and then for the House or any Government to try to keep to themselves part of the responsibility for determining the level of resources. No one in Wandsworth or anywhere else would want the Government to determine the total level of resources available. There is also a practical problem with an earmarked grant. I do not understand how it is proposed to distinguish the earmarked grant, made with whatever new money we might make available, from all the moneys already being spent on care in the community by local government, which already provides home helps, meals on wheels, and so on. I do not believe that it is practicable and nor, for the reasons that I have given, am I persuaded that it is desirable.
Mr. Worthington : Did the Minister hear the Prime Minister praising the work of child helplines the other day, when she said that we must make sure that enough telephones are provided and that sufficient volunteers are available to man them? Is not it a little hypocritical of the Prime Minister to make that remark when the Central Council for Education and Training in Social Work states that an extra 800 social workers need to be trained each year to maintain the present level of services?
Column 495Mrs. Bottomley : My right hon. Friend the Prime Minister was praising the work of Childline, which uses volunteers and provides an excellent service. We pay £300,000 towards the cost of that service. The CCETSW has responsibility for training, and we have substantially increased its funding. There are significantly more people-- about 4.5 per cent. more--joining the profession each year than leaving it. Of course, we continue to have discussions with employers and with the CCETSW to ensure that there is an adequate supply of social workers to undertake important tasks, in addition to the volunteers to whom the hon. Gentleman referred.
Mr. Dickens : Does my hon. Friend agree that social services recruits not only need university degrees or to be armed with diplomas in humanities but should be streetwise? Would not it be a good idea to recruit mothers whose children have grown up--and perhaps even younger grandmothers --because such women have raised families, are streetwise, and are not as green as grass?
Mrs. Bottomley : I entirely support my hon. Friend. In my view, streetwise grandmothers are precisely the people who should be undertaking work with young families. The work that we do in training social workers ensures broad entry. It is not the case that it is only 18 or 19-year-old undergraduates whom we want to attract. We seek to recruit also the mature woman who has experience. I shall certainly bear in mind my hon. Friend's words when I next meet those responsible.
Mr. Allen : Is the Minister aware that there is great concern at Strelley and other health centres about the Government's policy on preventive medicine? Is he further aware that 2.5 million fewer people have received free eye tests than in the previous year? Eye tests can detect serious illnesses such as cancer and kidney disease, and other conditions. Will the Minister admit at the Dispatch Box, on his first day in the job, that it was a terrible mistake to charge people for eye tests that were previously free?
Mr. Dorrell : No, I am unaware of any of those things. The hon. Gentleman will have an opportunity to represent his arguments in tomorrow's debate. I have not the slightest doubt that my hon. Friend the Minister for Health, who is replying to that debate, will be able to knock the hon. Gentleman out of the water.
Mr. Brandon-Bravo : My hon. Friend the Member for Loughborough (Mr. Dorrell) is almost the local Member of Parliament concerned, and I am sure that he agrees that his constituents and mine receive excellent service under the National Health Service provision in the city of Nottingham. Does my hon. Friend the Minister agree that health centres are growing not only in number but in excellence? I ask him to join in paying tribute to the chairman of the district health authority, Mr. David White, and to all those involved in Health Service provision in the city of Nottingham.
Mr. Dorrell : I join my hon. Friend in congratulating Mr. White. As he said, my constituents also benefit from the considerable improvement in health care made over the past few years in Nottingham. The city has two major general hospitals, and has seen a 9.2 per cent. increase in direct care staff in the Health Service over the past five years. It has also seen a 22 per cent. increase in in-patient cases and a 22 per cent. fall in the average general practitioners' list. That is an enormous improvement in health care in Nottingham, from which my constituents, among others, benefit.
Mr. Hood : Has the Minister read the leaked letter--published in the National Union of Public Employees journal recently--from the Secretary of State for Social Security, which showed that the answer given to the House is not as accurate as suggested? The letter states that it is the Government's intention to do away with the right of community health councils to complain about such things as hospitals opting out. If that is the case, will the Minister admit it, and if it is not, will he officially deny it? Consumers of health care are getting sick of their democratic rights being taken away.
Mr. Dorrell : I am afraid that I am not an avid reader of the NUPE journal, but I can confirm that no change is envisaged for the role of the community health council when a district health authority proposes the closure of a hospital.
Mr. Nelson : I welcome the reassurance that my hon. Friend has given, but will he reflect on the fact that while community health councils can be a useful sound-board for local opinion on the health services that are provided, it is the membership of the health authority that has executive control over local allocation of resources? A key issue in future is to try to ensure that the range of authority members and their responsiveness to local opinion is such that they can bring influence to bear and reflect public opinion in the provision of health services.
Mr. Dorrell : My hon. Friend is right to say that the changes that will be introduced next April are intended to emphasise the executive nature of health authorities. That leaves an important role for the community health councils. In many ways it will be an enhanced role after April. It creates the opportunity for them to become more concerned with the development of the service in the area for which they are responsible.
Ms. Harman : Will the Minister publish for the relevant community health council any draft business plan that has been submitted to his Department or any draft application for self-governing trust status? Will he also publish for the relevant community health council a copy of his Department's response to any such draft papers, to ensure that the council is effectively able to represent local opinion when a hospital in its area is deciding whether to opt out?
Column 497Mr. Dorrell : I shall not undertake to publish draft business plans, but I give the undertaking, which my right hon. and learned Friend has given many times, that the community health councils will be fully consulted on any proposal to establish a self- governing trust.
Mr. Conway : Will community health councils be able to do much that Members of Parliament who are active in their constituencies cannot do? Given that circumstance, does my hon. Friend think that if the councils did not exist at this time tomorrow, they would be missed, or that they are much loved?
Mr. Dorrell : My hon. Friend is an active Member of Parliament. If everyone was as active as him, he might have a point. Community health councils have a significant part to play in the future of the Health Service, by representing proper concerns when major changes are envisaged and as a consultee in the future development of the Health Service. I hope that in future the councils, in the same way as other bodies are concerned with health issues, will be more interested in output by the Health Service than in input.
6. Mrs. Margaret Ewing : To ask the Secretary of State for Health what information he has on how many ballots have been held in hospitals which are considering opting out ; and whether any of these have shown a majority in favour of such a course of action.
Mr. Kenneth Clarke : No Government have ever thought it sensible for changes in management of NHS services to be subject to ballots. Applications for NHS trust status will not be invited until Parliament has approved the necessary legislation. Staff and members of the public will then have an opportunity to express their views on individual proposals before any decisions are taken. I prefer the usual process of consultation rather than public referendum on such complicated and specialist issues.
A total of 195 units have so far expressed an interest in NHS trust status, with some 80 stating that they may seek trust status in 1991. That demonstrates the keen interest with which senior NHS staff, including members of the medical and nursing profession, view the prospect of establishing NHS trusts.
Mrs. Ewing : In the light of that response, will the Secretary of State tell us the definition of the electorate when such decisions are reached? Surely all categories of staff and existing, past and potential patients must be involved in the decisions as well as the community health councils, which have already been referred to. Has he established any criteria on which he will say no?
Mr. Clarke : Of course, the staff of the National Health Service are a key part of it. They deliver the service and we depend on their dedication. However, we have never operated any type of worker control and the public have an interest in those matters as well. The founding of the National Health Service was not made subject to local
Column 498ballots and I can recall no change in the 40 years since then that has been made in that way. We shall have a full process of consultation and I will refuse applications unless I am satisfied from all the information that comes in from the consultation that, if granted, a particular application will lead to a better quality of service for patients in that hospital and better value for money for all those interested in the National Health Service.
Mr. McAllion : Is the Secretary of State aware that in ballots held across the country, huge majorities have been returned that are opposed to hospitals opting out of the National Health Service? Is he further aware that almost every organisation connected with the National Health Service-- the Health Service trade unions, the community health councils, Health Service charities and voluntary organisations--is equally opposed to hospitals being allowed to opt out of the National Health Service? As the Health Service belongs to the people, why does not the Minister let the people decide by ensuring that there are ballots in every area affected before any hospital is allowed to opt out of the Health Service?
Mr. Clarke : I am against any hospital opting out of the National Health Service. If people go round asking daft questions, they get daft answers, which is not a very positive contribution to running a better National Health Service. We shall have a full process of public consultation on what local people are proposing in the places that go ahead with an application for NHS trust status. The Labour party is bereft of any serious contributions. Instead of putting forward its own ideas on how we might go back to more local discretion and control in running the Health Service, it leaves the whole matter to the ridiculous local ballots being run by councils, unions and other people.
Mr. Nicholas Winterton : Will my right hon. and learned Friend admit to the House that the drive for NHS self-governing status comes from his Department through the chairmen of the regions and the chairmen of the districts, all of whom are party political appointments? Will he state genuinely to the House that if it is the view of local people, and especially if it is the view of consultants, doctors, nurses and paramedics working in a hospital, that they do not wish to go for self-governing status, he will refuse that application?
Mr. Clarke : If the appointments were party political, I should have complaints from the Opposition about them. The applications for self- governing status are coming from people concerned with the hospitals and units themselves. It is rather absurd that when, in effect, we go back to a system very similar to the old hospital management boards, which gives back far more local control at the sharp end of delivery over how the Service is run, we are opposed in this way. I well remember the Labour party fiercely fighting the establishment of the district health authorities and the regional health authorities, which it now says should run the Service. Eighteen years ago, the Labour party argued vehemently that it was wrong to take away local control of hospitals. I have undergone a
Column 499conversion in those 18 years and I am inclined to think that the Labour party was right. The trouble is that the Labour party just opposes any change at any moment.
Mr. Dykes : On a calmer note, does my right hon. and learned Friend agree that if there is a proposal for a management area change and then the idea of a self-governing trust, it could cause extra delays, and that, if there is an erosion of services and facilities, as at the Royal National Orthopaedic hospital, there is a danger of that hospital's future being severely threatened? Will my right hon. and learned Friend pay attention to that and say what he intends to do about it and when our colleague the Minister for Health will visit the hospital?
Mr. Clarke : I have visited that hospital and I certainly recommend my hon. Friend the Minister for Health to visit it if she has the opportunity. I understand the need to resolve some of the uncertainties surrounding the future of the Royal National Orthopaedic hospital. I shall certainly ensure, and I am sure that my hon. Friend the Minister of Health will too, that nothing connected with NHS reforms causes further delay or creates fresh difficulties for all those who work in that excellent hospital.
Mr. Robin Cook : Does not the Secretary of State recognise that he could sidestep all questions on local ballots if he would simply agree to a timetable that first put the proposals to the general electorate so that electors who had no opportunity to comment in the last election will have an opportunity to vote on them in the next one? I warn the Secretary of State that, if he persists in bulldozing through the proposals for opt-out without giving local people any voice, the next Labour Government will take back all those hospitals into local health authority control.
Mr. Clarke : I have had a look at the draft manifesto that the Labour party prepared for the next election. It seems to be so vague on management issues that I came to the view that it was voting to make no changes in particular to whatever it inherited if and when it got back into power. I am absolutely astonished that the hon. Gentleman is now committing himself to making no changes to the way in which the National Health Service is run, without submitting any proposals that he might have for local ballots in the future. If we ever had a Labour Government, it might reduce the dangers of dangerous action, but I do not think that a Labour Government would adopt such a foolish process.
Mr. Rowe : Does my right hon. and learned Friend accept that a growing number of senior doctors, nurses and paramedics in the two district health authorities in my area are growing increasingly excited at the thought that they may have an opportunity to shorten the administrative hierarchy that constantly second-guesses their judgments, frequently to their detriment?
Mr. Clarke : I am interested to hear what my hon. Friend says. I know that quite a lot of those who are interested in NHS trust status are, among other things, looking forward to being free of the day-to-day control of their district, region or other parts of the system. There certainly is widespread enthusiasm. I disapprove of all the ballots, whatever the electorate is. It is a selective way of looking at the interests of everybody who has a common interest in the NHS--it does not belong to the staff. So far, five of the ballots among consultants have been in favour and seven have been against. I hope that everybody will wait until they have a proper application and then go through a sensible process of consultation, making whatever representations they want. That will enable me to make a better-informed judgment in the end, which is in the interests of the Health Service and its patients.
Mr. Rees : Are not dental checks an important part of preventive medicine? Has the Secretary of State noticed that independent research shows that the number of dental checks is falling? Although that may save money, is not it bad for the health of Government policy?
Mr. Clarke : I think that dental checks are important, which is why I think that those who can afford to do so will willingly pay £3.45 for a dental check. The right hon. Gentleman is aware that 40 per cent. of the population is exempt from any charge. I know of no evidence of a sustained decline in the number of dental checks. Indeed, over any lengthy period, there has been a steady increase in the number of dental checks and in the total number of dental treatments in the National Health Service.
Mrs. Peacock : Will my right hon. and learned Friend encourage the dental practice board to make available treatment under the EC 18 certificate? I understand that recently the board was denied all knowledge of it and that therefore some patients have been paying for their treatment.
Mr. Clarke : I am not aware of those problems. I am grateful to my hon. Friend for drawing them to my attention. I shall take up the matter with the dental health board and let my hon. Friend have a written response to her question.
Mr. Kennedy : Further to the answer to the right hon. Member for Morley and Leeds, South (Mr. Rees), the right hon. and learned Gentleman cannot have been talking to dentists, because all the dental surgeons to whom I have spoken over the past few months have said clearly that only people in two income categories can afford a full, prolonged and comprehensive system of dental care--those on full state benefits who do not have to pay and those in an income category such that they can afford to pay--and that the bulk of people, who fall somewhere between the two, are cutting their dental
Column 501treatment because of the cost. How can the Secretary of State deduce from that that there is no downturn in preventive medicine?
Mr. Clarke : Of course, similar representations are made to me by dentists whenever dental charges are raised generally, in line with the longstanding policy of this Government and of previous Labour Governments. However, it is clear that over any sustained period there has been a steady increase in the number of dental treatments given under the National Health Service. Over a lengthy period I expect to see a continued and satisfactory level of dental check-ups. I do not believe that for the 60 per cent. of the population who are asked to pay, £3.45 is a deterrent charge for a perfectly reasonable part of any individual's preventive medicine-- [Interruption.]
Mr. John Greenway : Is not it true that the new dental contract will, for the first time, pay dentists a fee for the regular patients on their list, without requiring any contribution from the patients? Although it is understandable that dentists feel some concern about the details, does my right hon. and learned Friend agree that a positive vote from dentists in the forthcoming ballot on the new contract would be a vote for prevention and would provide a much-needed shift in emphasis towards better dental health?
Mr. Clarke : Yes, I agree. The new contract will enable dentists to offer patients all-round continuing care, including emergency cover, treatment plans, better information and the replacement, free of charge, of certain restorations that fail within 12 months, and so on. I have agreed the new contract with the dentists' representatives and they are commending it to their members. I very much hope that the dentists will vote in favour of the new contract, which represents a substantial improvement in our dental services, for which many dentists have been pressing for many years.
Mr. Tom Clarke : How can the right hon. and learned Gentleman tell the House that there is no evidence of a decline when the Minister for Health told the House in February that there had been a slight dip and when in May his Department reported a reduction of 700,000 cases, thus bucking the upward trend throughout Europe? Does the Secretary of State accept that he has got his figures wrong and will he go back and do his homework-- [Interruption.]
Mr. Kenneth Clarke : There was a dip, but I referred to long-term trends. There is always a dip--I have no doubt that this was the case when the Labour Government were in power--when charges are increased for any part of NHS services. However, over the years, the dips are not sustained. I repeat that I do not believe that £3.45 is a
Column 502deterrent charge for the 60 per cent. of the population who are liable to pay the charge, and nor do I believe that any evidence will be forthcoming to demonstrate that it is.
9. Mr. Wigley : To ask the Secretary of State for Health what policy changes his Department has instituted during the last six months with regard to cottage hospitals ; and if he will make a statement.
"popular cottage hospitals will thrive"?
As there are now six small cottage hospitals under the axe for closure in my county, will the hon. Gentleman confirm whether that is because a different policy is being pursued in Wales or because there has been a change of policy in the Department of Health, which means that such hospitals in England are in as much danger as are those in Wales?