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Resolved,That this House welcomes the speed and effectiveness with which Her Majesty's Government has responded to the threat of famine in Sub-Saharan Africa through the provision of food and emergency aid ; and endorses its diplomatic action to bring an end to the armed conflicts which have contributed to food shortages.
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Social Services (Northern Ireland)
Mr. Speaker : We now come to the Northern Ireland orders. 10.14 pm
The Parliamentary Under-Secretary of State for Northern Ireland (Mr. Jeremy Hanley) : I beg to move
Mr. William Ross (Londonderry, East) : On a point of order, Mr. Speaker. I seek your guidance. There are two orders on the Order Paper this evening which relate to Northern Ireland, one of which is small and merely makes consequential changes and the other relates to a major issue for Northern Ireland health and social services. We wish to take them together over a three-hour period. I must protest in the strongest terms, if the Government decide to carry on the business giving us only an hour and a half on a subject which should properly be contained in a Bill, so that Northern Ireland Members can have a chance to table amendments and discuss the matter properly. Is there any way in which you can extend the business of this House for three hours, Mr. Speaker so that the two orders can be taken together rather than each taken separately for one and a half hours?
Mr. Speaker : I am afraid that I have no authority to do that. I understand that the Minister was intending to propose that the orders be taken together. If the House does not wish that to happen, they must be taken separately. I remind the House that an hour and a half would be given to each order. If such matters could be sorted out through the usual channels before we got to the debate, it would be much easier.
Mr. Kevin McNamara (Kingston upon Hull, North) : Further to that point of order, Mr. Speaker. I do not want to delay proceedings, but as the second order, granted, is rather narrow, but is consequential upon the major order, would it not be possible to refer to some of the contents of the major order because of the consequential amendments thereto?
Mr. Speaker : The second order is confined to a narrow matter. It is up to the House to decide. Perhaps the Minister should propose that the orders be taken together, and then I shall consider the feeling of the House.
Mr. Hanley rose --
Mr. William Ross : Further to that point of order, Mr. Speaker. Since the debate will last for one hour and a half only, and since the Minister knows all about the order and it is evident to the rest of the House exactly what has been done, can we have an assurance from the Minister that he will restrict his comments to five minutes so that those hon. Members representing Northern Ireland have more time to state their case?
Mr. Speaker : That is not within my power either. We are now taking time from the one and a half hours available. The more points of order we have, the less time there will be for the debate. The clocks have started.
Rev. Martin Smyth (Belfast, South) : Further to that point of order, Mr. Speaker. I appreciate what you have said, but you will remember that on Thursday I asked the Leader of the House to make arrangements so that the debate was not curtailed to an hour and a half. We are
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about to debate a major piece of legislation and it is scandalous that the Government, knowing that the second order is consequential and has little in it, did not consent to my request. The reason given for that was that the Government believed the debate would not last for three hours. They should put that to the test as they will discover that there is enough in the first order for the debate to last right through a parliamentary Session and beyond.That the draft Health and Personal Social Services (Northern Ireland) Order 1991, which was laid before this House on 22nd January, be approved.
It might be for the convenience of the House if the Northern Ireland consequential amendments order, a draft of which was laid before the House on 22 January and which has been considered by the Joint Committee on Statutory Instruments, is dealt with at the same time.
Mr. Speaker : Is that for the convenience of the House?
Mr. McNamara : On a point of order, Mr. Speaker. Does this mean that the House will not divide in an hour and a half?
Mr. Speaker : If the House wants to divide, it will divide. I sense the mood of the House that it is not for its convenience that the orders be taken together. [ Hon. Members :-- "Aye."] Order. The Chair will need the unanimous consent of the House for the orders to be taken together, and I sense that that is not forthcoming.
Mr. Hanley : It seems that it is not for the convenience of the House for the orders to be taken together and, therefore, I shall speak about the order that comes first, the Health and Personal Social Services (Northern Ireland) Order. I assure right hon. and hon. Members that I shall deal with the matter as briefly as the important issue allows.
This is an important issue and I recognise the concern that has been expressed. However, I am sure that hon. Members will recognise that this important issue has been dealt with after considerable consultation. We have had consultations with at least two hon. Members and some 17 district councils. The matter has been carefully considered and, following consultation with certain hon. Members, changes were made to the order. I therefore believe that democracy has been served.
The order implements the policies that were described in the White Paper "Working for Patients" and in the Northern Ireland policy paper on community care "People First." In broad terms, the order does for Northern Ireland what the National Health Service and Community Care Act 1990 has achieved for the rest of the United Kingdom. As such, it is the most significant piece of legislation involving health and personal social services in the Province since 1972. Therefore, I readily accept the importance of the order.
Although the order makes a number of important changes, its main purpose is to build upon the strengths of the existing system and to give the highly trained and dedicated people working in the services greater freedom to use their skills to the benefit of patients and clients. It
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will do this by introducing a new flexibility into the system and by delegating responsibility as much as possible to those directly involved in providing care.At the heart of the order are the provisions which will allow the Department to redefine the responsibility of health and social services boards. This power will be used to direct that the primary functions of boards should include providing directly, or through contracts, services for their resident populations. This change is central to the Government's reforms and will allow the development of a system of contracting through which boards as commissioners of services will secure them from a range of providers. In future, the primary responsibility of boards will be to identify and to make arrangements through contracts to secure access to a comprehensive range of good quality, value for money services which will best meet the needs of their resident populations.
To facilitate all this, the order makes provision for health and social services contracts. HSS contracts will be analogous to NHS contracts in Great Britain. They will enable boards and other health and social services bodies to make arrangements with each other for the provision of services to agreed standards in return for funding. They will allow much greater flexibility in the provision of services and they will remove one of the major problems in the present system.
At present, a hospital that improves efficiency and effectiveness and attracts more patients can find itself in financial difficulty because budgets have been set on an historic basis ; in other words, they become almost too popular. In future, money will follow patients and successful hospitals will be resourced according to the work that they actually do-- that seems very much more fair to me.
It must be stressed that the new HSS contracts will not be enforceable by the courts and they will not be the subject of litigation. That may puzzle some hon. Members, but it is because they are internal arrangements. Nevertheless, the contracts will be binding on the parties, which will have recourse to my Department for arbitration.
The order also provides for the reconstruction of the health and social services boards themselves. It will allow the Department to appoint smaller, management-oriented boards comprising an equal number of executive and non-executive members and a non-executive chairman. At present, the boards, as most people would agree, are unwieldy bodies comprising up to and more than 30 members. In future, therefore, there will be no more than 12 members plus the non-executive chairman. Boards' membership will reflect the skill and experience required for the efficient and effective planning and delivery of health and personal social services.
In the case of the Eastern board, the largest, one of the non-executive members will be drawn from the Queen's university medical school. There will no longer be places on the boards specifically for district council nominees or for representatives of professions and trades unions. It is felt that because members will no longer be tempted to represent narrow sectional interests, boards might be better placed to provide the strong, strategic leadership needed to plan for and obtain the optimum range of services for their local population.
I am conscious that the new, smaller health and social services boards will require strong advice from the public and from users of the services. To this end, the order
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requires the Department to set up four mirroring health and social services councils, one relating to each board. These will replace the existing structure of 16 district committees.During consultation on the proposed order, our plans for health and social services councils, I admit, attracted the most attention--and some criticism. After careful consideration of the comments that we received both on the proposed order and during earlier consultation on the same issue, I remain convinced that each board in its role as a commissioner of services will be best served by having a single, coherent source of strong public and consumer advice.
I do not accept that links with local communities will be lost. On the contrary, it will be the duty of individual councils to ensure that they retain strong ties with users and the public. They will be able to do this through publicising their activities and providing the necessary means of communication. They will also be able to set up committees and sub- committees, which can have either a geographical or a subject base and they will be able to co-opt people. I pay tribute to the hon. Member for Belfast, South (Rev. Martin Smyth), who considerately came to see me last week to discuss these issues with me. I am grateful to him for that.
I am still not convinced of the need for an advisory tier at regional level. The new health and social services councils will be able to co- operate with one another--should they wish, and I hope that they will--and they will be free to form associations if they wish. Because I want our position on this important issue to be beyond doubt, it has even been included in the order, with a specific provision enabling councils to collaborate freely with each other. The initiative for such collaboration must come from the councils themselves. I am committed to ensuring that they have the necessary resources to develop that association--again, if they wish. I have made another minor amendment to the order. During consultation, we were reminded of the importance of ensuring that the new councils get into their stride as quickly as possible. Therefore, I have decided that, initially at least, the Department should appoint the chairman of each council. However, it is our firm intention that in future, chairmen shall be elected by the members, and this will not be prejudiced by any of the regulations.
Mr. Ken Maginnis (Fermanagh and South Tyrone) : It is all very fine to say, "Live, horse and you'll get grass," or in other words, that one day we can appoint the chairmen of our health and social services councils. Those who have served on the existing boards fear that the standards will have been set at the behest, and under the guidance, of chairmen appointed by the Minister and that the wrong standards will be set by the time we get our hands on the health and social services councils. By then, their whole method of operation will have been guided and they will have been spoilt by ministerial and departmental interference.
Mr. Hanley : I cannot believe that the hon. Gentleman could think such a thing of me or the Department. I am sure that he recognises that we take great care in appointing chairmen of many boards throughout the Province. In this case, the chairmen will be acting within fairly rigid guidelines. I am sure that the hon. Gentleman will remember that 40 per cent. of the members of the
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council will be the result of district councils nominations, 30 per cent. will come from voluntary bodies and a further 30 per cent. will be appointed by the Department from those who are representative of the community. A great deal of guidance is given to the chairmen to ensure that the councils are fully representative. If they are not, the Department will be the first to complain.The creation of health and social services trusts was another cause for concern. These bodies are a practical expression of the Government's determination to delegate responsibility to those directly involved in the care of patients and clients. I regret that a great deal of nonsense, some of it deliberate, has been talked and written about self-governing hospitals. I hasten to add that it has not come from right hon. and hon. Members. I should like to clarify what these new bodies imply.
First, I must stress that hospitals or facilities that opt for self- governing status will remain firmly within the health and personal social services structure of Northern Ireland. There is no opting out of the NHS. To say so is wrong and wicked.
The freedom that trusts will be given is the freedom to manage and for this reason, they will be outside the direct managment control of health and social services boards. Their freedoms will include an ability to create their own management structure, to determine the terms and conditions of staff, to borrow money within certain limits and to acquire, own and dispose of assets in a way that ensures that the most effective use is made of them.
But despite their managerial freedom, trusts will not be able to act in ways which might be detrimental to the health service. For example, they will be required to participate fully in medical and other education and research ; there will be powers to ensure that they continue to provide services which must be available locally and the Department will be able to step in if there is evidence that the freedoms are being abused. However, in practical terms the main control will be not departmental diktat but the fact that the success of self-governing hospitals will depend on their ability to meet the needs of health boards, which will be the main purchasers of the services that they provide. There will be no virtue in trusts concentrating exclusively on high-cost, high-turnover services, as some have suggested. Instead, they will have every incentive to provide the wide range of services that boards require.
Trust status is voluntary, but hospitals and services which aspire to it will need to meet strict criteria. They will need to demonstrate that they have the management ability, professional involvement and financial capacity to do the job. Most importantly, they will need to demonstrate to my satisfaction that genuine benefits and improved quality of service to patients and clients will flow from the trust status.
The order will also enable certain larger general medical practitioners to opt to have their own practice fund. That will allow them to buy services on behalf of their patients, including a defined range of services direct from hospitals. The scheme will be entirely voluntary, and practices that have joined will be free to leave at any time.
The funds will be set at a level that will ensure that patients get the services they require. As an additional safeguard,there will be an upper limit of £5,000 on the cost to a practice fund of hospital treatment for an individual patient in any one year. Any reasonable excess will be met by the health board. Fund-holding general practitioners
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should have no good reason, as some have suggested, for keeping certain patients off their lists. If the patients are expensive, the funds will be there.Complementary to that provision, the order will also enable health and social services boards to give all general medical practices that are not fund-holding practices an indicative prescribing amount. The aim is to make GPs more aware of their prescribing practices and to eliminate wasteful prescribing. The scheme will be administered in such a way as to ensure that patients will always get the drugs they need. Furthermore, indicative amounts themselves will be adjusted where necessary to take account of patients with special needs for medication. Many GPs will welcome the guidance that the indicative scheme will give them.
During consultation on the draft order, considerable media attention was given to the proposed power to restrict the overall number of general medical practitioners in Northern Ireland. That will only bring Northern Ireland into line with the rest of the United Kingdom. There is certainly no intention to use the power to ration GPs as some have suggested.
The power that we intend to take is a reserve power. If at some future date there were to be a disproportionate growth in the number of doctors entering general practice, the Department would be able to make regulations limiting the number of GPs entering the list. In the meantime, boards already exercise control over the distribution of GPs, and that should be sufficient for the foreseeable future. I see no danger in that provision.
Rev. Martin Smyth : Does the Minister acknowledge that young men and women seeking training positions in Northen Ireland are already restricted in a way which is not the case in England and, as a result, they come to England for training? We also have the problem of graduates from universities in the Republic of Ireland coming in that roundabout way. Therefore, how can the Minister say that the measure is bringing us into line with England?
Mr. Hanley : The hon. Gentleman is right to say that Northern Ireland has an enviable record in the training of doctors. It has a superb record, of which we can all be proud. But I was referring to the fact that the proposed power to restrict the overall number is exactly the same as that which applies here. There is nothing new about the power. It is merely a reserve power that could be used in future if limits are necessary. At the moment I do not anticipate that the power will be used within the next few years or even longer. The measure merely brings Northern Ireland into line with the rest of the United Kingdom.
Right hon. and hon. Members will agree that community care provisions are among the most important, but the measure contains only a small number to achieve the Government's national policy objectives for developing and improving care services. Since local government reorganisation in 1973, there has been in Northern Ireland a fully integrated structure for the delivery of health and personal social services by the four boards--so there is no need to make new and complicated special arrangements for co- operation, communication and joint planning between the health service and the social services. There is no need either to make a separate
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provision to require boards to undertake duties such as assessing care needs or establishing complaints procedures. Unlike local authorities in Great Britain, the four Northern Ireland boards are agents of the Department, which already has wide powers of delegation and direction.When implemented, the new provisions will significantly enhance the boards' role in developing and funding community care services. Their role will change from being primarily the direct providers of some community care services to that of being the orchestrators of all such services, and they will become the holders of community care budgets. A framework will be created, within which boards will assume direct responsibility for assessing individuals' total health and social care needs, and for strengthening co-operation between themselves and other relevant public, voluntary, and private organisations.
I am conscious of the need to be brief. I will listen carefully to the speeches that follow, and I will limit my winding up speech to as little time as may be necessary to answer the points that are made. As in the rest of the United Kingdom, the founding principles of the NHS are the firm base for our proposals for the future provision of a comprehensive service, funded primarily from general taxation. The draft order ensures that those guiding principles will remain the bedrock for health and personal social services well into the next century. I commend the order to the House.
10.30 pm
Mr. Jim Marshall (Leicester, South) : I congratulate the Minister on his first proper speech at the Dispatch Box. He commended himself to the House during Question Time some weeks ago, and I feel sure that the House has again been impressed with the manner of his delivery--if not by the content of his speech.
I thought it strange that the Minister spent so long dwelling on the bureaucratic changes that the order will make to health services in the Province, rather than on the realities and on the problems facing the people who want to use those services. There is no doubt that the new structures will remain fundamentally non-democratic. They neither respond to, nor show any responsibility towards, those who work in the health service or who make use of it. I wish that the Minister had spent more time discussing the realities of health provision, instead of reciting Government dogma.
Despite increased expenditure in past years, there is still massive underfunding of the Province's health service, which in recent times has led to large-scale bed and ward closures and to an increasing number of seven-day wards being downgraded to five-day wards. For example, the number of acute beds in Northern Ireland has been reduced to the third worst in the whole of the United Kingdom. In the Eastern health board there is a £8 million maintenance backlog, equivalent to a full year's funding, and the board recently announced further cuts of £2 million as it attempts, on Government orders, to balance its books for this year.
Mr. Roy Beggs (Antrim, East) : Does the hon. Gentleman acknowledge that the hospital beds which are now being closed by the Government were created under the former Ulster Unionist Government?
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Mr. Jim Marshall : I have no reason to doubt that what the hon. Gentleman says is true, and I therefore verify his assertion. The Eastern board has recently announced further cuts of £2 million in its attempts to balance its books for this financial year. Finally, there has been no remedial work, including painting, on residential homes in the Province for the past five years. That is the reality of the health service in the Province. What is the Government's response? From what the Minister said one would have expected him to announce that increased financial resources would be made available. However, that was not his response--it was that the health service will be handed over to the marketplace, and thereafter everything will be for the better.Mr. Hanley : I do not want to take up too much time, or other hon. Members may not be able to take part in the debate. However, yet again, the hon. Gentleman seems to be looking after beds rather than patients. He mentioned the Eastern health board. The latest booklet describing the statistical data for that board shows that in the past nine years admissions have increased from 129,000 to 140,000 ; the number of out- patients has increased from 701,000 to 748,000 ; the number of major operations has gone up from 21,000 to 23,000 ; the total of operations has increased from 116,000 to 138,000 ; and accident and emergency attendances have risen from 331,000 to 358, 000. It seems that patients are more important to the Eastern health board than mere beds.
Mr. Marshall : The hon. Gentleman knows that I said, at the outset, that there had been increases in funding in the health service in the Province. I have not sought to deny that. The only point that I am seeking to make--the Minister may think that I am taking too long about it--is that, despite those increased resources, the level of health care and social deprivation in the Province dictate higher levels of funding than the Government are prepared to provide. The specific examples that I have cited represent the reality in the Province. Two of the examples that I quoted refer specifically to problems faced by the Eastern board.
The Government's response to the problem is to introduce the concept of the marketplace, not merely throughout Great Britain, but into the Province. Throughout the various stages of discussions on other Bills, we have made no secret of the fact that we believe that it is nonsense in Great Britain, and will prove to be nonsense in the Province.
While experiments do not always prove beyond peradventure what is likely to happen, I am sure that even the Minister will be aware that the experiment recently carried out by the East Anglian regional health authority showed that disaster, rather than paradise, lies ahead for the health service under this new concept. That will prove to be even more the case in Northern Ireland.
How can one have an internal market in such a small area, and in an area where one group of hospitals--the Royal--has such a dominant role in the provision of health service facilities?
Health care is unlikely to improve as a consequence of the proposed changes, but one small, select group has already benefited : that group of the elect who have responded to recent advertisements for middle and senior management jobs in the new boards. I hesitate to use the
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word "inflated", but the salaries are certainly commensurate with the duties that they will perform--duties which have not yet been detailed in job specifications.Despite the differences that may exist between Government and Opposition over funding, I think that both agree on the need for increased resources in the Province because of the scale of social deprivation there--despite the lack of evidence provided by the 1981 census. While I recognise the inadequacies of that census, given the relatively poor returns in the Province, I think that we all agree that there is more social deprivation there than elsewhere in the United Kingdom. Will the Government consider reducing the Jarman index threshold from 30 to 16 to take account of that factor? That would provide only a rough-and-ready yardstick, but it would constitute a recognition of the special problems in the Province. I mentioned the regionally funded medical services to the Minister before the debate began. The Government have accepted that some specialty services will still need central funding. Let me ask the Minister three specific questions. How many applications for treatment have been received so far? Which specialties are involved? How many applications have, to the Minister's knowledge, been successful?
It will come as no surprise to the House that my party is still opposed to the principle of opting out ; but we believe that, if it is to remain, it should be tested by ballot. Two groups should be balloted : the staff of the hospital concerned and the local community. That would, at least, gauge the opinions of both providers and recipients of the service. I am sorry to learn that the Royal group of hospitals has decided not to hold those two ballots. The group has indicated a desire to opt out, but I gather that that feeling is limited to members of the board and, perhaps, the Department headed by the Minister ; it is widely known that the majority of the staff, including consultants, are opposed to the principle.
As I said earlier, the position of the Royal group in the Province highlights the problems associated with the internal market system in Northern Ireland. Nearly all the specialties are based there ; far from creating the competitive atmosphere described by the Minister, and far from enhancing the availability of choice, the group will probably become a monopoly in many respects, and that is not likely to increase the provision of health care according to the free-market principles enunciated by the Minister.
Evidence from the Province shows that competitive tendering has led to a decline in hospital standards. Contractors estimate that it is possible to clean toilets and wash basins in 0.39 seconds. It is not surprising that standards have declined under that regime. Figures show that any savings that may have accrued from competitive tendering have been outweighed by the increased costs arising form cross-infection. That is typical of the Government's
Alice-in-Wonderland attitude to the application of market principles in the health service, but perhaps I am being a little unkind to Alice.
All sections of the community have welcomed the community care provisions not only of the order but of the National Health Service and Community Care Act 1990. It has been said time and again not only by politicians but by interested organisations that unless these changes are accompanied by substantial increases in finance, their aims will be laudable but unattainable. The Government seem reluctant to commit themselves to enhanced funding.
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The Minister will agree, despite the point that he made about the close relationship between health and social services, that social services in the Province have always been underfunded. Compared with other regions of the United Kingdom, the Province's social services have been underfunded. Across-the-board cuts in expenditure by health boards have hit social services budgets particularly hard. The Minister will know that that has forced several boards to put the cleaning of health and day centres out to private contract--that could not happen in the remainder of the United Kingdom--with an inevitable decline in standards.The Minister will be aware that the arm's-length registration and inspection units are supposed to provide a complete registration and inspection service for public, private and voluntary sector homes. Will the Government insist that the criteria that they adopt when they carry out their inspections are published? In England and Wales, the criteria must be published, whereas there is no such need in Northern Ireland and the boards have shown themselves to be extremely reluctant to publish them.
The Minister must realise that the additional powers being conferred on those units will lead to increased expenditure. The local authority in Leicestershire is facing increased expenditure of £150,000 per annum, but no increased finance is being made available there or in the Province to meet that expenditure. Will the Minister undertake to consider the problem and, if possible, ensure that those units are not financed from within the existing budget? If they are, the level of service will be reduced. Will the Minister consider that and give at least some commitment that any additional expenditure involved in carrying out the work of the units will be financed by increased resources rather than from the existing budgets? It will come as no surprise to right hon. and hon. Members representing constituencies in the Province that the home help service has been a continuing major source of discontent there. Despite Government claims to the contrary, the home help service has been dramatically and drastically reduced in recent years. As far as I can see, the future is even bleaker. The boards' business plans reveal the intentions for the home help service. Following the implementation of this legislation, the directly managed home help service will be available only to the most acute cases.
Mr. Hanley : For clarification, in Northern Ireland at the moment there are 15.8 home helps per thousand of the population, compared with 7.8 in England. That is a remarkable record.
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Mr. Marshall : I am grateful for that further information. It just so happens that the Minister's figures do not invalidate my criticism that the home help service has been dramatically and drastically reduced over the past few years. [Interruption.] As a former Whip, I realise that there are time when one needs to discuss things with one's silent colleagues, but, as I listened to the Minister in silence, perhaps he will listen to me for a few seconds in silence. In response to the Minister's statistics, I will quote the example of an elderly person who was assessed five years ago as needing six hours a week home help provision. That person may now be receiving only one hour a week in spite of their obvious increasing frailty. The Minister's figures are meaningless in terms of the service that is actually provided. I am sure that hon. Members from the Province can verify that the service provided to individuals has declined seriously, particularly over the past five years.
As I said, following the implementation of this legislation, the directly managed home help service will be available only to the most acute cases. The health boards do not specify in their plans what "acute cases" are likely to be. We have no idea how many people are likely to be relieved of the service, nor are we aware of other consequences. If the Minister can give us some idea of what is meant by "most acute cases", that will be helpful.
The remainder of the home help service would be provided by the voluntary sector and, despite the valiant work that it is carrying out in the Province, it cannot pick up the slack released by the public sector.
Mr. William Ross : Surely the Minister's figures are meaningless, because it is not the number of home helps per thousand of the population that matters, but the number of hours that each home help spends with each individual case. The hon. Member for Leicester, South (Mr. Marshall) was right to state that that time has been greatly reduced.
Mr. Marshall : The hon. Gentleman has reinforced my point. I referred to a specific example in which the number of hours of home help provision per week have been reduced from six to one. Nothing could be clearer. The level of service has decreased quite dramatically over the past five years.
Despite the Minister's remarks, the order is typical of the Government. It fails to address the real health needs of the people of Northern Ireland. It also fails to guarantee that the necessary financial resources will be provided. We oppose the order.
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10.59 pmRev. Martin Smyth (Belfast, South) : The order gives effect to proposals in the White Paper entitled "Working for Patients" and the Northern Ireland Office's policy paper entitled "People First". It is broadly analogous to the National Health Service and Community Care Act 1990 of Great Britain. Whereas that Bill received proper legislative scrutiny, the order will have less than one and a half hours' scrutiny, without any line-by-line Committee consideration. It is impossible to do justice to health services in Northern Ireland, not to mention the order itself. Not only does the legislative process suffer, but patients will likewise suffer. People are not being put first. As I told the Minister recently, the consultative process resembles the worst experiences of patients in some surgeries--the doctor is already writing out the prescription before he has consulted or examined the patient. The procedure is an insult to parliamentary democracy. The Minister said that he did not have time to explain the order, but the Government are unwilling to debate it for a longer period.
I welcome the Minister to the Dispatch Box on this major occasion. He is the third Minister with responsibility for health care provision in Northern Ireland since consultations began on the draft order. Obviously, we have moved beyond a second opinion--we now have a third opinion. In this pseudoscientific and superstitious age, some people hope that the third time might be lucky.
In the 1990 MacDonald Critchley lecture, our former colleague, Enoch Powell, showed how the original National Health Service Act 1946 transferred responsibility for providing health care from a variety of different quarters largely to the hands of Government. There are, of course, two major derogations. The first limited the amount spent on the national health service to that which Parliament financed. The second derogation allowed the nature of the care provided to be vested in the discretion of individual members of the healing profession. That was wise. Few of us would cherish the Minister--delightful though he might be-- diagnosing or prescribing, let alone operating on us. Nevertheless, without the Minister providing the hospital, the clinic and the theatre and hiring the staff, there would be little or no opportunity for the medical professions to practise in our system.
There has been and there is a cleavage. The physicians blame the politicians for not providing the tools that are necessary for patients to be given their statutory right to health care. The politicians, of course, to whom the nation has entrusted financial control, would quietly urge physicians to stand for election and put their theories to the test of the ballot. However, we must face an aspect that we suffer in Northern Ireland. Not only in this order but through the absence of a Select Committee, sufficient opportunity is not given to scrutinise the work of the Northern Ireland Office, its various departments and the boards under its control.
Central Government and the Northern Ireland Office cleverly contrived a device to escape from the conflict between politicians and physicians. The Government would transfer responsibility to local concerns and the professions to manage. In effect, there is a reversal of the national health service procedures. This is manifestly heightened by the accelerated development of the
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technology and the transfer from centrally- financed institutional care to locally-financed care in the community.There is also the problem of getting value for money. There has not yet been developed a method whereby efficiency or value for money can truly be fully measured and compared. Within current practice, and under this order, the search will continue. Ministers to whom the responsibility has been given now seek to delegate to others. Most of us--not only those in the health field--have already suffered a ministerial answer that, in effect, says, "That is not my responsibility, but I shall direct your query to ". But responsibility for expenditure and for the implementation of policy should rest in this House.
That is why I question some of the fundamental points in this order. They merely continue, in a refined way, mistakes of the past. The stated aims of the order will probably be accepted by most people in Northern Ireland. The reality is otherwise. "People First", for example, called for the development of domiciliary services, such as home help, day care and respite care services, to enable people to maintain their independence--to live at home wherever possible--and to support those caring for them.
What is the practice? The Minister drew comparisons with the provision that is made in England. Even the Public Accounts Committee said that Northern Ireland indicators, rather than what is done in England, should be the test. But that is a point to which I shall return.
Mr. Maginnis : I think that my hon. Friend will agree that it would be better if the Minister were to compare like with like. In the case of home helps, the need on the mainland is not so great, in that a larger proportion of people who require that type of care live in urban areas where there are drop-in centres and other facilities. By contrast, Northern Ireland is still, by and large, a rural community, where the elderly are isolated.
Rev. Martin Smyth : I agree with my hon. Friend.
The home help service is being cut back throughout Northern Ireland. There is hopelessly inadequate provision for domiciliary physiotherapy, and occupational therapists--scarce enough in hospitals--are as rare in the community as gold dust.
There are few who dispute the desirability of improved management. However, there are many who fear two of its consequences. First, the emphasis will not be on improved health care, except as a token theory, and value for money will predominate, with the emphasis on cost rather than on care. Secondly, local management, including doctors who welcome the challenge, fear that the dead hand of bureaucratic civil servants will impede good management and progressive health provision, while local politicians and trade union representatives are explicitly excluded from the boards.
Contrary to the impression given in the explanatory memorandum, which refers to representatives of the professions, there is a mandated place for someone who holds a post in a university medical or dental school. Was I correct in understanding the Minister as saying that the Eastern board would have one person from Queen's university in that category? Will not similar provision be made for the other boards? Why, in this context, is the Eastern board mentioned specifically? Obviously, and understandably, there is a clear medical, dental, ophthalmic and pharmaceutical input through local
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