PRAYERS [M r. Speaker-- in the Chair ]
[Lords] Order for Second Reading read.
To be read a Second time on Thursday 17 January.
1. Mr. Battle : To ask the Secretary of State for Health if he will publish the views of Coopers and Lybrand Deloitte commissioned by his Department on the self-governing trust implications from St. James's hospital, Leeds and Leeds general infirmary ; and if he will make a statement.
Mr. Battle : That answer is most disappointing because the budget submissions from Leeds general infirmary and St. James's are based on massive underestimates of inflation and on land sales and a large increase in private beds, and it is widely believed that a third of the applicants for self-governing trust status are already massively overspending on their capital budgets. Why cannot the Department make available to the House a full appraisal including all the financial facts, so that the Government can be fully publicly accountable for budget decisions in this crucial area?
Mr. Waldegrave : We are fully accountable and I stand accountable to the House. A range of different advice was offered to us and there would be no more point in publishing the bits that the hon. Gentleman wants than there would any other bits. They were my decisions, taken against the background of the information available to me.
Mr. Batiste : But is not the reality that those two great hospitals, St. James's and Leeds general infirmary, are among the largest in Europe and that the only way in which they can fulfil their potential and deliver the best service to their patients--which after all, is what it is all about--is by stripping away excessive layers of bureaucracy? In today's world, is not self-governing status within the NHS the best way of achieving what really matters, which is patient care?
Column 138Many of the people who object to the return of those hospitals to management from within the hospital probably objected when the bureaucratic system was set up from which they are now escaping.
The Minister for Health (Mrs. Virginia Bottomley) : From next year, it will be for regional health authorities to determine the allocations which are given to family health services authorities and to ensure that they have adequate internal financial arrangements.
Mr. French : I accept in principle the idea of annual budgeting by family health services authorities, but does my hon. Friend accept that the establishment of new doctors' surgeries, particularly in urban areas, requires some co-ordination between the purchase of land and the design and construction of buildings? Does not a rigid annual system with a strict limit on the 12-month budgeting period work to the detriment of the creation of new surgeries?
Mrs. Bottomley : My hon. Friend has a longstanding constituency interest in the arrangements for distributing the substantial resources for the premises improvement scheme. More than £6 million was spent last year on such schemes in his family health services area and he will know that 67 of the 87 practices there have benefited. However, it is important to continue to ensure that the vast resources put into practitioner services are properly and effectively distributed. If there are aspects that we can look at more carefully, we shall certainly do so.
Mr. Kennedy : Given the significant contractual arrangements in the family doctor service, particularly during the past year or 18 months, and the anxiety that was expressed by many hon. Members on both sides of the House about the likely impact of some of those changes on employment prospects for female general practitioners, what evidence does the Minister have of the continuing employment on a part-time or full-time basis of female general practitioners?
Mrs. Bottomley : The hon. Gentleman will not be surprised to know that I share his concern that we should continue to use women doctors in the NHS as well as we can. Half the medical students now are female and they should have an important part to play. The general practitioner's contract has meant that the specialties that many women doctors traditionally took up are particularly popular. We are watching the way in which women doctors are used. For the first time they can be employed as part-time principals, but they have expressed concern about the way in which they are likely to be treated by some male principals-- [Interruption.] I have regular meetings with the organisations representing women doctors to ensure that we do not need to issue further guidance and that their skills are being fully used. [Interruption.]
Dr. Goodson-Wickes : I fully accept my hon. Friend's comments. He may be interested to learn that, owing to the illegibility of my profession's handwriting, what should have appeared as "publicising benefits" has appeared on the Order Paper as "publishing budgets". Despite that, will he confirm that he will encourage national health service trusts to apply some of their budgets to promoting the benefits of NHS trusts to our constituents, notwithstanding the pessimism of my trade union, the British Medical Association?
Mr. Dorrell : My hon. Friend draws attention to one of the benefits of computerising prescriptions--they will in future be more legible. He is also right to stress the importance to patients of the improvements that come from trusts. The Kingston Hospital Trust, which serves my hon. Friend's constituency, was recently approved by my right hon. Friend. It promises to set specific waiting times for patients, to open evening and weekend clinics where there is substantial demand and to set down and follow discharge procedures so that GPs are fully involved in patient discharges. Those are the sort of improvements in the quality of service that can come from an imaginatively run trust.
Mr. Hinchliffe : Although the Minister has made it clear today that he will not publish NHS trust budgets, will he make public the full costs of wining and dining those concerned with the opting-out process? Can he justify the expenditure of £10,000 last Tuesday night on a Banqueting house booze-up for those concerned with opting out at a time when a health authority such as Wakefield has had to close 100 beds because of a lack of Government funding?
Mr. Dorrell : The hon. Gentleman asks a question and then establishes that it would be otiose to answer it because he already knows the answer. What is important is to establish the benefits that come from improving the management of NHS hospitals through their establishment as trusts. The accountability that matters is accountability to patients through the contracting system and the improvement in quality of service that it will provide.
Mr. Andrew Mitchell : Will my hon. Friend underline the point that, whether it is benefits or budgets, the role of the Audit Commission has been significantly enhanced by the National Health Service and Community Care Act? Will he ensure that the Department gives every possible support to the work of the Audit Commission, which does its best to ensure the best value for money for patients from the much-enhanced sums that we are now spending on the health service?
Column 140management, to obtain better value for money for the taxpayer and a better quality of health for the patient. That should be the objective of us all.
Rev. Martin Smyth : Is the Minister aware that there is some anxiety among social workers that there may not be adequate provision in national health service trust hospitals for social workers, bearing in mind the fact that we are trying to move people into the community and that social workers are employed by local authorities? Is he satisfied that the budgets provide adequately for such social services?
Mr. Dorrell : I am satisfied that the contracting system provides the mechanism whereby district health authorities will be able to provide the seamless robe that is essential to proper health and social care, to ensure that an individual benefits first from health care, then from community care and then from social care support when appropriate. The contracting system provides the mechanism for ensuring that all that is in place.
Mr. Waldegrave : It is a fundamental objective of our national health service reforms to give patients, wherever they live in the United Kingdom and regardless of how well off they are, better health care and greater choice.
Mr. Hughes : Does the Minister agree that it is now 10 years since the Black committee report on inequalities in health? Can he explain why, in those 10 years, inequalities in health have got worse instead of better? Is not that a damning indictment of the abject failure of the Government to tackle the problems?
Mr. Waldegrave : The thing to remember is that everyone's health has got better in the past 10 years, as it did in the previous 10 years. Life expectancy has increased by about two years for everyone. I am not going to say that our Government have abolished inequalities in health care any more than the Labour Government did when they were in power. However, we are introducing some powerful new mechanisms that will help. For example, the GP contract, although it has been unpopular with some GPs, is raising the level of immunology--for example, child immunology--in the places where it was worst. When Opposition Members say that they are going to repeal that contract, will they be satisfied with lowering the levels of child immunology again?
Dame Jill Knight : My right hon. Friend may have omitted to mention another important part of the reduction in inequalities with regard to the contract, as elderly people now have regular checks, which was not previously the case. Can he give us any information about that?
Mr. Waldegrave : My hon. Friend is right. That, too, is an important weapon to help us move away from those problems, which occur throughout the world. Another relevant matter is that, under the new financial system, health districts will for the first time have the duty to
Column 141produce a proper health plan for their area, taking into account the problems of social deprivation that they may face. That should also help.
Mr. Graham : Is the Minister aware that under the health plan, school children in Strathclyde are receiving letters telling them that they will no longer get eye tests in school and that they will have to go to hospital? Is that the type of planning that he wishes to see?
Mr. Waldegrave : What I am aware of--although I hope that I do not embarrass my right hon. Friend the Secretary of State for Scotland by saying this--is that the situation in Scotland at least shows that there is no simple connection between resources and health, because Scotland spends rather more than we do in England per head, but has no better health statistics.
Sir Dudley Smith : Is my right hon. Friend aware that, despite the millions and millions that the Government have rightly put into the national health service, regional and local health authorities are at best muscle-bound and at worst insensitive in much of their public relations? Will he bear that in mind and try to do something about it?
Mr. Waldegrave : It is important that health districts and regions should have clearly designated spokesmen to answer questions that it is legitimate for people to ask them. I think that I should be criticised in the House if I encouraged them to launch large public relations campaigns. However, I take my hon. Friend's point. There must always be a clear contact point for inquiries from the public at district and regional level.
Mr. Winnick : I can well imagine it. Is it of no concern to the Government that there is no public support for these substantial changes? For example, in my borough, at the district general hospital, there is overwhelming opposition to what is being proposed. Why are the Government pursuing this path of Thatcherite dogma, instead of dealing with the financial crisis in the health service? It would be far better to deal with the financial crisis, which is due to underfunding, than to gamble with people's health by making unnecessary changes.
Mr. Waldegrave : I spent a large part of yesterday at the Royal Free hospital, where I met many people--doctors, nurses and health service workers--who are strongly in favour of the changes. They may all have been passionate Thatcherites, but I am not sure that they were. Some may even have voted for the Labour party. I think that the hon. Gentleman will find that there is growing support. One should consider the hon. Gentleman's area, where the National Union of Public Employees sent out 2,700 ballot forms. Four hundred came back and 100 were actually in favour of the trust- -I suppose that they went to the wrong people. It is really not very serious.
Column 142that want to opt out and become self- governing trusts within the national health service, does my right hon. Friend give more weight to the views of members of the area health authorities, consultants and other doctors, nurses, paramedics, other staff and patients, or to those of the rather remote chairmen of the regional health authorities?
Mr. Waldegrave : I should probably attach the most weight to the quality of the submission made by the hospital or other unit in question. Those are the people who know most about a hospital and whose future rests with it. If they present good proposals--as they did this year--it is principally to those proposals that we respond, although we also take advice from the districts and regions.
Mr. Ashton : Although the Secretary of State keeps saying that there will be consultation, he never announces what sort of consultation it will be and with whom it will take place. Who will he consult before the trusts are set up--the patients, the staff or the public? If he is not satisfied with the NUPE ballot, why does not he organise a ballot himself? Is he aware that no consultation has taken place with Bassetlaw hospital, except that which I have tried to organise, with no help at all?
Mr. Waldegrave : Ballots are not at all the right way to improve the system of management in a great service such as the national health service. We have been trying to carry out the statutory duties imposed on us by the Act that was passed earlier this year and, above all--as I said to my hon. Friend the Member for Macclesfield (Mr. Winterton)--to study the representations made to us by the hospitals themselves.
Mr. Paice : Following the undoubted success of hospital trusts, will my right hon. Friend find a mechanism whereby hospitals that are not currently part of the NHS--for instance, former military hospitals such as the one in my constituency from which the RAF is to withdraw--can become independent trusts within the NHS and thus build on the success of this initiative?
Mr. Waldegrave : I know the hospital to which my hon. Friend refers very well ; indeed, I talked about it to the regional chairman and officers when I was in Cambridge last Friday. I am not sure that the establishment of a trust is the most likely solution in that instance, but the regional authority is willing to consider any financial proposals that make sense and could save the hospital.
Mr. Robin Cook : Can we tempt the Secretary of State to tell us something about the independent representations that he commissioned from Coopers and Lybrand Deloitte? Can he confirm that that organisation concluded that only 14 of the 56 applications that he approved were financially sound? If that was not its conclusion, why does the right hon. Gentleman keep refusing to publish its report? Should not the public have the right to know the figures and should not Parliament have the right to debate them?
Mr. Waldegrave : The hon. Gentleman has misunderstood the nature of the process. During the summer, Coopers and Lybrand Deloitte and many other advisers produced a variety of advice, much of which was passed back to the trust units and altered in the course of dialogue
Column 143with them. It is as futile to ask for that particular piece of paper as it is to ask for thousands of others that were made available to me.
Mr. Sumberg : Is my hon. Friend aware of the widespread opposition among my constituents to plans to develop a hypermarket on part of the hospital site? Will he join me in urging the chairman of the regional authority to tell his counterpart in Salford to withdraw the plan and thus save my constituents from serious environmental and commercial damage?
Mr. Dorrell : As my hon. Friend knows, this is a planning matter that falls within the responsibility of my right hon. Friend the Secretary of State for the Environment. Nevertheless, I cannot be blind to the fact that the £12.5 million that is in prospect if the planning proposal goes ahead would allow for a £6.5 million investment in new regional mental illness facilities on the Prestwich site and a further £6 million to improve provision for the mentally ill in the community. At a time when we are constantly--and rightly--pressed to provide investment to improve facilities for the mentally ill, that is a major advantage to which, as I have said, I cannot be blind.
Mr. Campbell-Savours : Is the Minister aware that that hospital in Prestwich and other hospitals throughout the north-west region and Cumbria send patients to St. Paul's eye hospital in Liverpool for jag laser treatment? Is he further aware that that hospital is also under threat and that it is causing deep concern throughout the north-west? Will he take some action to ensure that people in Liverpool, my constituents and people throughout the region are satisfied about the future of those services?
Mr. Dorrell : The hon. Gentleman has got it completely wrong. The "threat" in Prestwich is that there should be a £12.5 million investment programme to improve hospital facilities and facilities for care in the community to provide for the mentally ill. That is the sort of threat that we want to see to develop an improving health service for all patients in the health service and especially, in this context, for the mentally ill.
Mrs. Virginia Bottomley : We are committed to improving out-patient departments. We have recently issued advice on the physical environment, questions of skill mix and on appointment systems to reduce waiting times at out-patient departments. In addition, we are
Column 144funding 10 demonstration projects as part of our quality initiative, addressed particularly to out-patient departments.
Mr. Stevens : I am grateful to my hon. Friend for that answer and for the initiatives that have been taken to improve out-patient facilities. The improvements that have been made over the years in North Warwickshire district health authority are very much appreciated. How many new out- patient attendances were there in 1979 and how does that figure compare with those today?
Mrs. Bottomley : There has been a considerable increase in the number of people coming to out-patient departments. There were 36 million out-patient attendances last year, which is 7 per cent. higher than in 1979. In my hon. Friend's health authority, the figures have increased by 20 per cent. over the past four years.
Mr. Cousins : What out-patient facilities does the Minister plan for the over-85s? Six old people's homes have closed in Newcastle as a result of poll tax capping and two long-stay geriatric hospitals are closing as a result of hospital cuts, with the inmates and patients being put up for auction. Clearly, we shall need a lot more facilities at out-patient departments in hospitals to deal with the consequences of that, so what plans does the Minister have?
Mrs. Bottomley : The hon. Gentleman will know that he has a first- rate health authority in Newcastle which is addressing precisely those problems. Its work on implementing community care is going very well. The point that my right hon. Friend the Secretary of State made a moment ago about the need for general practitioners to offer their patients who are over 75 an annual visit to check on their welfare and well-being will also help to improve the quality of care. We are seeing improved services for the elderly. Our community care proposals will challenge health and local authorities to work together successfully to ensure that there is comprehensive and integrated cover.
Mr. Tredinnick : Has not the treatment of out-patients improved immeasurably over the past 10 years? Does my hon. Friend agree that the number of out-patients being treated at the moment in Leicester is at a record level?
Mrs. Bottomley : I think that I can, almost without doubt, confirm the Leicestershire figure, but my hon. Friend will understand that I shall write to him if I am wrong. Out-patient departments are the interface between community services, general practitioners and hospitals. We are concerned that a recent survey found that 15 per cent. of people with out- patient appointments failed to show up in one area. We must be sure that our appointment systems are effective and that people are well treated when they reach the out-patient departments. We must also ensure that we are making proper use of skill mix and that the quality of the environment and experience is as good as it can be. We shall issue further advice to health authorities in the new year on the basis of the lessons that we have learnt from the first six demonstration projects.
9. Mr. Tom Clarke : To ask the Secretary of State for Health when he expects to announce Her Majesty's Government's policies for introducing assessment for patients leaving long-stay psychiatric hospitals and going into the community.
Mr. Clarke : In view of the great distress that has been caused to many patients who are leaving long-stay psychiatric hospitals supposedly to go into community care, which simply does not exist, when precisely will the Government implement section 7 of the Disabled Persons (Services, Consultation and Representation) Act 1986? Does the Minister recall that the former Secretary of State for Health announced, after over three years of negotiations with local councils, that the Government's National Health Service and Community Care Act 1990 and their provisions for community care transcended section 7, and that once that had been monitored, the Government would decide what they were going to do? Now that the Government have abandoned their proposals for community care until 1993, what will happen to the patients? Is that community care in the 1990s, or is it saying to those patients, "Look forward to cardboard homes and cardboard hopes"?
Mr. Dorrell : The hon. Gentleman is completely wrong. We have not abandoned community care ; we are committed to implementing it. Furthermore, we are committed to implementing community care for mentally ill people on an accelerated timetable. The mental illness specific grant will make available £30 million of expenditure from next April. Capital approvals to local authorities will make available a further £10 million from next April. The capital loans fund has provided £10 million this year to invest in reprovision for mentally ill and mentally handicapped people. The initiative that I announced in July for homeless mentally ill people provides £5 million for that client group. Approximately £55 million has been made available by the Government in the current year to invest in improving the facilities available to treat mentally ill people in the community.
Mr. Anthony Coombs : I warmly welcome the Government's proposals for improved assessment of people leaving long-term psychiatric hospitals and, more important, the provision of a key worker for each patient to co- ordinate the services available to him, but will the Government support and promote the additional voluntary service of Citizens Advocacy, a branch of which is in my constituency, which provides a friend--not a professional-- to help formerly mentally ill or mentally handicapped people reintegrate into the community?
Mr. Dorrell : My hon. Friend rightly draws attention to an interesting and useful contribution to care for mentally ill people. I welcome the initiative that he referred to and the opportunities that it represents. The care programme approach that I announced on 10 September provides, for the first time, an ordered framework to assess the needs of
Column 146each mentally ill individual and to ensure that they are met in the community. My hon. Friend referred to advocacy schemes, which have a part to play in that process.
Mr. Rooker : Does not the Minister appreciate that it is the belief of millions of carers and the cared-for that the Government have abandoned their community care programme? Sticking to the narrow confines of the question, does the Minister accept that the guidance for the assessment must be much wider than that which is published? How does it meet, for example, the criticism of the MIND survey, which mentioned the lack of choice and dignity, the lack of keys and the lack of the chance to keep pets? The survey in the west midlands found that virtually no social activity is offered in the private residential sector. How can it meet the problems that are caused by the lack of co-ordination between health authorities, social service departments and the planning authorities? In our large cities, hostels for mentally ill and mentally handicapped people are located next to another hostel, across the road from another hostel or round the corner from another hostel. Care in a community of hostels is not what patients or their families want.
Mr. Dorrell : It may be true that there is a belief in the field that community care has been abandoned, but it is quite simply wrong. When it has repeatedly been stated to be wrong, it does no one any good for the hon. Gentleman to repeat it from the Dispatch Box. As regards the suggestion that the care programme approach is too narrow, that was out to consultation throughout most of the summer, which offered an opportunity for those in the field to argue for the widening that the hon. Gentleman advocated. He did not do so and most of the people in the field did not do so at that time. The guidance that we published on 10 September represents the first structured attempt to ensure that the needs of an individual mentally ill person are assessed and that effective machinery is put in place to support that individual in the community.
Mr. Hind : Will my hon. Friend carefully consider respite care for the relatives or friends of psychiatric patients who return home? As well as the carers of psychiatric patients, many other carers need a break and we must cater for their needs in future programmes.
Mr. Dorrell : My hon. Friend is absolutely right. We recognise that respite care is an important part of a proper programme for community care for psychiatric patients and we shall ensure that provision is made.
Mr. Bennett : Will the Minister join me in congratulating Mr. Graham Pink on having the courage to describe so movingly in The Guardian and on television the major problems faced in Stepping Hill on the night shift on geriatric wards? Will the hon. Gentleman condemn the
Column 147district health authority for suspending Mr. Pink for his whistle-blowing activities rather than solving the problems at that hospital? Does he agree that that is deplorable?
Mr. Dorrell : No, Sir. I shall not join the hon. Gentleman in congratulating Mr. Pink. The trouble with Mr. Pink's allegations is that he does not have the support of his colleagues, the clinicians in the hospital or the health authority's chief nursing officer ; nor can it be established on any of the published criteria that his allegations are justified.
Mr. Favell : The best way to improve hospital services in Stockport is to amalgamate Stockport infirmary with Stepping Hill hospital, which are both in my constituency. Is my hon. Friend aware that the consultant in charge of the accident and emergency department at the infirmary has been pushing for that amalgamation for years, yet it is opposed by the Labour party because of cynical, short-term opportunism? The Labour party is prepared to put lives at risk to buy short-term popularity. At Stockport infirmary there is no blood bank or intensive care unit and there are facilities to deal only with broken bones and ear, nose and throat problems. Unless a person suffers from such problems, he has to be taken by ambulance to Stepping Hill hospital, down one of the busiest roads in the north of England. That is the Labour party's wish.
Mr. Dorrell : My hon. Friend makes his point powerfully, but he is not quite right in every detail. Although the Labour party here opposes amalgamation, the National Union of Public Employees supports it, so my hon. Friend has support from a wider section of the community than he might have expected. He is right to draw attention to the improvement that can come from the investment programme to which he referred. I hope that it will be possible to provide for that within a reasonable time scale.
Mr. Hayes : Is my right hon. Friend greatly encouraged by the warm welcome with which his speech last week was received by the National Association of Health Authorities and the other caring professions? Coupled with the clear commitment of my hon. Friend the Minister for Health to cut junior doctors' working hours, does my right hon. Friend believe that that shows without doubt that the Government believe in a health service for everyone, financed primarily out of taxation and free at the point of delivery?
Mr. Waldegrave : I am grateful to my hon. Friend. I should like to take the opportunity provided by his question to pay tribute to my hon. Friend the Minister for Health and to her colleagues, including Dr. Diana
Column 148Walford and Dr. Stephen Hunter, who have achieved what will turn out to be an historic breakthrough on the long- standing matter of junior doctors' hours.
Mr. Madden : Will the Secretary of State launch an urgent investigation into the funding crisis gripping the national health service in Bradford? Does he understand that, because of that cash crisis, there is widespread dismay at the fact that the Bradford NHS trust has gone ahead and still greater dismay at the fact that the chairman is a millionaire business man from Wakefield who knows nothing about the NHS in Bradford and still less about the health care needs of the people of Bradford?
Mr. Waldegrave : It is astonishing that the Labour party should regret the fact that some of the best business men want to give their skills to the health service. That action will benefit the people of Bradford and that principle will benefit us all more widely.
Mr. Walden : Does my right hon. Friend agree that, although many Conservative Members are entirely behind the reforms that were introduced by his predecessor and which he carried through, in several areas--not least the Aylesbury Vale health authority and Stoke Mandeville hospital--a serious situation is developing as the hospital seeks to make ends meet before the new regime comes in next spring? As a result, there have been serious cuts in the number of operations performed. Will my right hon. Friend look at the overall costs of writing off the debts of those areas that are in serious financial difficulty, before the new regime comes in next spring, so that they can start with a clean slate?
Mr. Waldegrave : It is understood that some of the London districts will not have to remove their deficits before the beginning of the new system. However, it would be a bad managerial signal to allow those that have overspent their budgets again to pre-empt resources that should be available to the whole of the health service, including those that have achieved their budgets.
Mr. Robin Cook : Hon. Members of all parties have pointed out to the Secretary of State the immense pressure on health authorities from the obligation to remove their deficits. May I remind him that three years ago this week, one of his predecessors found an extra £100 million for a similar crisis in the hospital service? As beds are now closing faster than they did three years ago and as waiting lists are now longer than they were three years ago, why cannot the Secretary of State do the same? Why cannot the Government, who have written off the debts of every privatised industry, now write off the deficits of our hospitals?
Mr. Waldegrave : The hon. Gentleman knows very well that it has been a long-standing objective to bring districts back into balance. That is the right thing to do and we shall continue to do it, although, as I said, there will be some flexibility in London. That remains the position.