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House of Commons
Tuesday 5 March 1991
The House met at half-past Two o'clock
PRAYERS
[Mr. Speaker-- in the Chair ]
PRIVATE BUSINESS
Standard Life Assurance Company Bill
[Lords] Read the Third time, and passed, with amendments.
London Underground (No. 2) Bill
Order for Second Reading read.
To be read a Second time on Thursday 7 March.
Oral Answers to Questions
HEALTH
General Practitioners
1. Mr. Andy Stewart : To ask the Secretary of State for Health by how much the number of support staff for general practitioners has changed since 1979.
The Parliamentary Under-Secretary of State for Health (Mr. Stephen Dorrell) : The number of staff in England covered by the practice staff scheme has risen from 20,100 in 1979 to 44,800 at October 1990. That represents an increase of 123 per cent.
Mr. Stewart : I thank my hon. Friend for that valuable information, which belies the suggestion by Opposition Members that we are cutting services in the national health service. How many practice nurses are there in the Nottingham health authority area and how do they help patients?
Mr. Dorrell : My hon. Friend is right that it gives the lie to the suggestion that we are cutting the service. It also emphasises the extent to which we are investing in primary health care. My hon. Friend will be interested to know that we now employ 164 practice nurses in Nottinghamshire and that the family health services authority that covers Ribble Valley employs 84 practice nurses--an increase of 290 per cent. since 1985.
Trade Unions
2. Mr. Campbell-Savours : To ask the Secretary of State for Health whether he has discussed policy matters relating to the NHS with trade unions over the last 12 months.
The Secretary of State for Health (Mr. William Waldegrave) : Yes, Sir. I met the TUC health services committee earlier today.
Mr. Campbell-Savours : Will the Secretary of State confirm that pay rates for ancillary staff in the NHS are as much as £20 a week less than those paid by local
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authorities for very similar work? How can that be justified? Instead of squandering taxpayers' money supporting private health schemes, will the right hon. Gentleman, in the offer that he will be making on 22 March to the trade unions, direct a little of that money towards recompensing health service workers for their low pay?Mr. Waldegrave : I should not wish to draw any conclusions about the employment practices of local authorities or the health service from that comparison, but I have made it clear that, within whatever settlement can be afforded this year, we hope to steer some resources towards the lowest paid.
Mr. Ian Bruce : Does my right hon. Friend agree that the record of the NHS trade unions in not being able to negotiate sensible rates of pay for the lowest earners among their members is a sign that big national pay bargaining systems do not work in the best interests of employees and that the sooner they find more efficient trade unionists to represent them and look to local pay bargaining, the better it will be for everybody?
Mr. Waldegrave : I strongly agree with the latter part of the question. Indeed, the figures show that national pay bargains do not produce the best results for employees and that if we could move towards local deals and more flexibility, everyone would benefit, especially the low paid.
Mr. Robin Cook : May I ask the right hon. Gentleman in a bipartisan spirit whether, during his discussions on policy this morning with the trade unions, there was an opportunity for them to congratulate him on today's reports that he is resisting an extension of private medical insurance? Will he confirm that the current relief scheme for the elderly has produced a tax hand-out for those who are existing clients, but no increase in the number of pensioners who can afford it, even in the Ribble Valley? Will he now admit that the scheme is wholly irrelevant to the health needs of the elderly, so that we may both go into the next election with a commitment to scrap it?
Mr. Waldegrave : That matter did not come up in the interesting talks that I had this morning, but it is true that a large number of trade unions and unionists have sought private health care without needing any incentive to do so.
Cervical Screening
3. Mr. Conway : To ask the Secretary of State for Health what proportion of general practitioners are receiving target payments for cervical screening.
The Minister for Health (Mrs. Virginia Bottomley) : On 1 April 1990, 88 per cent. of general practitioners qualified for a target payment for cervical screening. I congratulate all those involved on this excellent achievement.
Mr. Conway : I am grateful to my hon. Friend for that helpful reply. Obviously, the figures are encouraging. My hon. Friend will be aware that, especially in rural areas, such a degree of screening can be difficult. What are the percentage figures for the Shropshire family health service authority and what can we do to encourage it?
Mrs. Bottomley : In the Shropshire family health service authority 99 per cent. of GPs qualified for a target
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payment. That was a substantial achievement. Shropshire is one of 24 family health service authorities that managed to achieve that level.Rev. Martin Smyth : Although I welcome the reasonably high overall percentage, is it true that in inner cities there is still a low take-up? What is being done to encourage a higher take-up?
Mrs. Bottomley : Some notable inner cities have made remarkable strides. For example, all Barnsley's GPs are claiming target payments for cervical cytology and child immunisation. In recognition of the needs of inner cities, for the first time the Government have made deprivation payments to inner-city GPs. We have made it clear that we want health opportunities for those in the less-advantaged areas to be as good as those in the more-advantaged areas.
Mr. Sims : Does my hon. Friend recall the fuss made by some general practitioners and their professional bodies when the contract was proposed? Does she agree that the figures that she has given to the House suggest that their fears and objections were illfounded? Can she tell us the extent to which target figures have been met in respect of child immunisation and vaccination?
Mrs. Bottomley : I endorse my hon. Friend's point. I refer him to remarks by the hon. Member for Livingston (Mr. Cook), who said that the figures were quite heroic. Many GPs thought that they would not be able to achieve them. We have seen remarkable progress in increased immunisation, vaccination and cervical cytology. At last the NHS is a health service rather than a disease service and is preventing illness.
Ms. Harman : Does the Minister agree that as well as getting more women to come forward for screening, it is important for the results to be conveyed to them promptly? One in three health authorities reports that it is unable to meet the target of getting the results back to the GP within a month. How does the Minister propose to ensure that health authorities can meet that target? Does she agree that it is unfair that women who are screened privately can get their results within a week, whereas women who are screened in the national health service sometimes have to wait for three months?
Mrs. Bottomley : The hon. Lady is right that any backlog in waiting for the result of the test is unsatisfactory. We make it clear that we want the result within a month and two out of three authorities are achieving that target. The average for authorities that are not making the results known within a month is seven weeks and we want them to do better. The hon. Lady is always the first to condemn her own health authority. She will be pleased to know that the waiting time there is three weeks.
Regional Pay Bargaining
4. Mr. David Evans : To ask the Secretary of State for Health what plans he has to introduce regional pay bargaining to the NHS.
Mr. Dorrell : The Government's objective over recent years has been progressively to introduce greater flexibility in order to allow local managers to relate pay rates to local conditions and to reward individual performance. That process is continuing.
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Mr. Evans : I thank my hon. Friend for that reply. Does he agree that local pay bargaining is all about incentives and about giving managers the total resources to look after their workers? Local managers know exactly what local people want. Our policy is in stark contrast to that of the Labour party, which talks about care, talks about the national health service, talks about patients, talks about doctors and talks about nurses, but at the end of the day its policy is about union power and a return to beer and sandwiches at No. 10.
Mr. Dorrell : My hon. Friend is right to point to the importance of pay as a key question facing national health service managers. Pay represents over 70 per cent. of NHS expenditure. It is absurd to ask a manager to use the resources within his control as effectively as possible while at the same time saying that he has no discretion over the way in which 70 per cent. of those resources are used.
Mr. Michael J. Martin : The Minister has given a commitment that in areas like the highlands, which are rural and spread out, the health service will be as good as in any urban area. How does he square that with saying that we will have local pay bargaining in communities where jobs are hard to find? Does not it mean that if wages in the health service are lower in those areas, it will not attract nurses and other ancillary workers?
Mr. Dorrell : What it means is that we are committed to delivering a high-quality health care service throughout the country, investing in managers the powers necessary to allow them to deliver that in the locality for which they are responsible.
Mr. Jacques Arnold : I thank my hon. Friend for the steps that he has taken to break up national pay bargaining, which is so beloved of the trade unions which Opposition Members serve. I suggest to him that the current system of national pay bargaining, with its attempted alleviation through London allowance and the like, is very unfair to boroughs on the fringes of such allowance areas such as Gravesham. With that increased flexibility, will my hon. Friend ensure that the funding goes with it to particular areas to reflect local employment costs?
Mr. Dorrell : As my hon. Friend knows, funding will reflect the weighted capitation formula through the regional health authorities. We are talking about discretion in the hands of managers over the way in which those resources are used. We envisage an evolutionary process which involves not the overnight demolition of traditional structures but the progressive introduction of greater flexibility, to ensure that the service meets the aspirations that we all have for it.
Drugs
6. Mr. Illsley : To ask the Secretary of State for Health whether he has received any representations regarding the prescribing of high-cost drugs ; and whether he will make a statement.
Mr. Waldegrave : Yes, Sir. We have received some representations. All doctors are free to prescribe high-cost drugs. The extent to which hospital doctors do so is
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governed by how they choose to spend their share of the increasing resources being made available to the NHS, in the light of local health care priorities.Mr. Illsley : I am grateful to the Secretary of State for that reply. Is he aware that even now there are problems with the prescribing of certain drugs to children, especially child growth hormones? Is he further aware that a conference was held on Monday to try to determine the future prospects for prescribing such drugs? Children in my area are still being denied drugs which are necessary to them because of cuts in funding in the run-up to 1 April. Will he urgently consider organising a new basis for the prescription of such drugs?
Mr. Waldegrave : I am aware of the continuing pressures and I believe that there will always be such pressure in the national health service, whatever the level of funding. If by special measures the hon. Member means that all decisions should be centralised, as some of my hon. Friends have urged on me, I think that that would be wrong. It would mean that a group of doctors in the Department of Health would take away local clinical decisions and that would be wrong. This has to be a matter in which those in hospitals use their clinical judgment to make the best decision for the patient against the other competing claims which will always be made of them.
Dame Jill Knight : Is my right hon. Friend aware that pharmacists believe that there is still much over-prescribing of drugs by GPs and that positively millions of pounds worth of unused drugs lie on the shelves of British bathroom cupboards? Will he continue to fight waste in all departments of the NHS, especially this one?
Mr. Waldegrave : My hon. Friend is entirely right. Against the predictions made, the indicative drug prescribing scheme is already saving unnecessary prescribing. The newspapers this week carried a story which I must draw to the attention of hon. Members, as it is not always the latest and most expensive drugs which turn out to be the best for patients. The story concerned a rival series of heart drugs, but, as the companies involved are suing each other, I had better be careful about what I say. I agree with my hon. Friend that we must be careful to root out waste. My bathroom cupboard certainly has too many unused drugs in it.
Dr. Kim Howells : Does the Secretary of State agree that some of the most expensive drugs are those of the steroid family, which are used as preventive medicine in the treatment of asthma? He will know that 2,000 young people die of asthma each year and it has been estimated that 80 per cent. of those deaths could have been avoided, had the illness been properly diagnosed and the disease treated with the right steroid drugs. Will he ensure that proper diagnosis is made and that treatment is given not on the basis of cost but on the basis of the need to save lives, especially young lives?
Mr. Waldegrave : Of course, that is the criterion on which decisions are made. I agree that it is disturbing that asthma is one of the diseases that are currently on the increase, for reasons that are not fully understood. I also agree that early diagnosis is important : if that will help--along with the primary health care measures that we are introducing-- steps can be taken that are much cheaper and much more effective than later treatment.
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Mr. Michael Morris : Is my right hon. Friend aware that the success of PACT--prescription analysis and costs--has provided the major savings in GP prescribing, rather than the indicative drug budget scheme? In view of those savings, is not it time to consider prescribing specialist hospital products to meet the commitment made by my right hon. Friend's predecessor that patients will have every drug that they need and that it will not be left to consultants to make clinical judgments based on the resources available to their regional or district health authorities?
Mr. Waldegrave : I agree with my hon. Friend that PACT has played a large part in the current developments, although in due course he will find the indicative drug budget scheme helpful, too. I caution him that there will always be difficult clinical decisions for doctors and clinicians to make. Drugs are not of themselves in a different category from other expensive forms of treatment--for example, those that involve high capital- cost equipment.
Mr. Wareing : Have any of the representations made to the Secretary of State concerned benzodiazepines? They still seem to present a considerable problem, despite the number of circulars that have been sent out. Is not it high time that legislation was introduced to control the prescribing and re-prescribing of dangerous drugs which are addictive and are causing more havoc than cure in the health service?
Mr. Waldegrave : As the hon. Gentleman knows, we strongly sympathise with his anxiety. I am not sure that legislation is the best way forward ; it would be difficult to frame. This is the sort of problem which the indicative drug prescribing scheme is aimed to deal with and we continue to press for it to be properly addressed.
Natural Medicines
7. Mr. Colvin : To ask the Secretary of State for Health when his medicines review committee will report on the natural medicines licence fee system ; and what increase in fees he proposes in the meantime.
Mr. Dorrell : The Medicines Control Agency is undertaking a full review of the licensing fee structure and will be issuing a consultation document shortly. We are not proposing an interim increase in fees.
Mr. Colvin : Will my hon. Friend acknowledge that the manufacturers of natural medicines tend to be small businesses with a large number of medicines to license? High fees, and the high costs involved in obtaining licences, could drive the smaller manufacturers out of business, cutting consumer choice and possibly pushing up the cost of natural medicines. I am sure that that is not my hon. Friend's intention, but can he give the House a guarantee that the new system will not have that undesirable result?
Mr. Dorrell : My hon. Friend is right that it is no part of our intention to drive the small companies providing such remedies out of business. As he will know, the points that he made have been put during the review to which I referred and they will, of course, be taken into account when the report is published.
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Mr. Corbett : Will the Minister reconsider the answer that he has just given and acknowledge that an increasing number of people choose to use natural alternative medicines? It would do the health service and all who make that choice no service at all to ladle unwarranted extra costs on to those who provide the alternative medicines.Mr. Dorrell : It is precisely because I accept the force of the consumer choice argument that the hon. Gentleman advances--slightly improbably--that I told my hon. Friend the Member for Romsey and Waterside (Mr. Colvin) that we were receptive to what he was saying.
Mr. Anthony Coombs : Is my hon. Friend aware that some manufacturers of herbal and homeopathic products, such as Weleda, make no fewer than 2,000 such products, and that to impose on them a flat-rate licence system, rather than one based on turnover, would place burdens on them that could drive some products from the market?
Mr. Dorrell : We recognise the force of that argument and it is being taken into account in the review, which will shortly lead to a report.
Health Authorities
8. Mr. Cunliffe : To ask the Secretary of State for Health what is his latest estimate of the number of health authorities currently in deficit.
Mr. Waldegrave : The latest figures that I have show 59 district health authorities spending at a higher rate than their regular income. Almost all districts will have corrected this by the end of the year.
Mr. Cunliffe : Is the Secretary of State aware that there are conflicting reports about the figures that he cited? In a recent survey of community health councils, 92 per cent. agreed that nine out of every 10 district health authorities were seriously underfunded and had been forced to make cuts in essential services. They agreed that that mammoth task was being imposed on them as a result of unrealistic budgets.
Is the Secretary of State aware of the position in the north-west of England--in particular, in the Greater Manchester area, where, at the Royal Manchester children's hospital, implant ear operations for tinnitus sufferers have had to be suspended? Budgetary controls have forced that hospital not to perform the £46,000 ear operation : the district health authority has had to cut its income.
Will the Secretary of State take note of that and stop asking our health authorities to run hospital services like a chain of supermarkets--
Mr. Speaker : Order. That is enough.
Mr. Cunliffe rose --
Mr. Speaker : Order. The hon. Gentleman knows that this is not an Adjournment debate.
Mr. Waldegrave : I missed the latter part of the hon. Gentleman's speech, but his general drift does not entirely coincide with the figures from the Wigan district health authority area which show that waiting lists are falling and that the number of long waits has fallen markedly. The hon. Gentleman was referring to the telephone poll of some community health councils arranged by the hon. Member for Livingston (Mr. Cook). I do not deny that
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some district health authorities are under pressure to balance their budgets, but if Opposition Members think that bad management and inefficient financial management are in the interests of patients, they are wrong.Mr. Nicholas Winterton : I appreciate my right hon. Friend's rational reply, but does he accept that there is a problem and that many more health authorities would be in deficit had they not closed beds and wards at a time when there are people who need to go into hospital for treatment and when hospital theatres and many excellent consultants are available for much-needed operations?
Mr. Waldegrave : Where a budget is overrun, action has to be taken to correct the deficit and sometimes the action is not the most efficient in terms of using that hospital's resources. It would be wholly unfair to the great majority of districts throughout the country which are balancing their books properly if those which overran were allowed to pre-empt resources from them.
Mr. Robin Cook : Does not the Secretary of State realise that it is not deficits that damage patient care, but the cuts that are made to avoid deficits? If he is in any doubt about that, will he accept my invitation to visit the accident department at King's College hospital where, last night, 11 patients spent the whole night on trolleys and where, this afternoon, there are 18 emergency cases on trolleys because more than 100 beds were shut at that hospital to avoid deficit? Is balancing the books really worth that indignity and that delay in patient care?
Mr. Waldegrave : Encouraging bad management is strongly against the interests of patients. There is a well-understood problem at the accident and emergency department at King's, but the latest figures show that about half the surgery being done at that hospital is non-emergency surgery-- elective surgery. That shows that the hospital is not under as much pressure as the hon. Gentleman suggested.
Prescription Charges
9. Mr. Sumberg : To ask the Secretary of State for Health what representations he has received to extend the exemption from NHS prescription charges on medical grounds ; and if he will make a statement.
Mr. Dorrell : The Department has received regular correspondence on exemption from prescription charges since 1968 when prescription charges were reintroduced by the Wilson Government.
Mr. Sumberg : Is not it about time that we considered the very strict criteria that apply to those exemptions? In particular, will my hon. Friend consider exempting treatment for Parkinson's disease? Parkinson's disease is a chronic condition, the patients always deteriorate and a very high drug bill is required to treat it. It is about time that we reconsidered exemptions for Parkinson's disease and for one or two other diseases.
Mr. Dorrell : My hon. Friend has been assiduous in pressing the case for Parkinson's disease victims. However, the case that he must answer is that to take the course that he espouses would mean channelling resources to people who are, by definition, not those on the lowest incomes. At the moment, any Parkinson's disease sufferer on a low income receives free prescriptions. When discussing
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prescription charges, we should remember that individual prescription charges are now paid on only one item in every five that are dispensed.Mr. Eastham : Is it not a fact that low-income families are suffering real financial hardship because when they take their prescriptions to the chemists those prescriptions cost more than £3 each while at one time under a Labour Government the cost was 20p?
Mr. Dorrell : Low-income families are entitled to exemption. In 1979 under Labour, two items out of every five rather than one in five carried a prescription charge. In 1968 the figure was three in five. The number of prescriptions carrying charges has been falling sharply since Labour left office.
Mr. Paice : Does my hon. Friend agree that one of the most important facilities for people with constant demands on drugs is the ability to buy an annual prescription under which the maximum charge for anyone in any one year, however serious the problem, is about £40?
Mr. Dorrell : My hon. Friend is exactly right. The season ticket system is designed to address the problem of those people who have a regular need for drugs and for whom an individual prescription charge would represent a significant burden. No one need pay more than the total cost of the season ticket for an individual drug need.
Care in the Community
10. Mr. Michael : To ask the Secretary of State for Health what fresh initiatives he plans to take to ensure that elderly and disabled people receive a high standard of care in the community.
Mrs. Virginia Bottomley : Local authorities will be introducing the new inspection and complaints arrangements as the first part of the Government's community care policies in April.
Mr. Michael : Is that really the best that the Minister can do? Does she not realise that having promised care in the community, the Government have failed to ring-fence it, delayed its implementation for three years and now appear to be about to abandon it altogether? Does she not also realise that we want care in the community now for those people--the number of whom is increasing--who are already in the community? It is about time that the Minister made way and allowed the Secretary of State to promise us real care in the community for the people who need it now.
Mrs. Bottomley : Frankly, the soap box will get nowhere in terms of producing effective community care. The policy is on course with implementation. In April we are moving ahead with complaints, with inspection, with special help for drug and alcohol abusers, with extra care for the mentally ill and a very substantial increase in money for training. Local authorities and health authorities are working with voluntary organisations and the private sector to make a real success of this popular and important policy which now needs to be implemented with care and detail with the extra resources that we have made available.
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Mrs. Currie : Does my hon. Friend realise that there are real fears in Derbyshire about the funding for care in the community being switched from the central Government to Derbyshire county council, which has already declared its opposition to placing any money with the private sector, particularly in relation to private residential homes? Does she also accept that it might not be a good idea to make that switch when we are seriously considering abolishing the county councils altogether? Would it not be better, if the money is to be shifted from central Government, to give it to the health authorities which we know and trust to do a good job?
Mrs. Bottomley : Derbyshire county council could well take to heart the remarks of my right hon. Friend the Prime Minister speaking at the local government conference on Saturday. He said that in local government we need
"less paper and more action. Less empire-building and more innovation ; less government and more service."
A local authority like Derbyshire, which believes that there is great virtue in providing a home help for one in three people aged over 75 and not charging any of them for that, must think again. We are committed to the implementation of care in the community. It is important to achieve value for money and to consult users and carers. It is good policy which makes sense and it will bring an end to the warehousing of those with disadvantages and it will treat them with dignity and privacy in their own homes. We shall certainly ensure that all local authorities understand the realities of the policy and exercise the disciplines that are necessary in taking that care forward.
Mr. Wigley : Does the Minister recall that when the Government decided not to implement in full the Disabled Persons (Services, Consultation and Representation) Act 1986, the reason given was that they were pressing ahead with care in the community legislation? Now that that has been delayed for up to another two years before any benefit comes through, surely the Government should implement now--and in full--the 1986 Act?
Mrs. Bottomley : It would be a travesty for the hon. Gentleman to think that no action has been taken on care in the community for two years. A great deal of work has been carried out by local authorities and health authorities to improve their assessment procedures, to ensure that they bring forward their community care plans--and, especially, in keeping with the spirit of the Act to which the hon. Gentleman referred--to ensure that the users and carers are given the consideration that they require. Part VII of the Act deals with the policy being introduced by my hon. Friend the Parliamentary Under-Secretary in the mental illness care programme for proper procedures for those discharged from hospital.
Mr. Thurnham : Does my hon. Friend agree that the most disadvantaged in society--the elderly, the disabled and the sick--suffer most from waste and inefficiency? Does she also agree that high standards in community care require good management, not the practices of loony left Labour councils?
Mrs. Bottomley : My hon. Friend is right. I am sure that he is well aware that in his speech on Saturday, the Prime Minister said that the Opposition often think that the answer to every problem is to appoint an officer, whereas we believe that often the answer is to dis-appoint an officer.
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We want to achieve value for money, to introduce good community care policies of the type toward which many health and local authorities are already making excellent progress. I pay a warm tribute to all of them and to the way in which they have collaborated with our draft guidance and have taken part in consultations to ensure that they have the practical tools to undertake their new responsibilities.Mr. Rooker : Does the Minister accept that if the policy was as good as she claims it is, it would have received overwhelming support from both sides of the House if it had not been abandoned but had been implemented? Does not she also accept that there is now abundant independent evidence that the cost of delaying the implementation of care in the community far outweighs the benefits in both financial and human terms and puts a continuing strain on the carers and the cared for? The Secretary of State himself expressed that view to the Select Committee on Health only a few days ago. All parties have wanted to end the uncertainty surrounding the policy since the Audit Commission's report of December 1986. We shall expect full support from both sides of the House when we announce implementation in April 1992 after the summer election.
Mrs. Bottomley : I very much hope that no local authority or health authority is under the misapprehension peddled by the hon. Gentleman. A great deal of work is already under way. Implementation begins on 1 April this year. With that in mind, we have increased the training available to local authorities by 20 per cent. this year to enable them to spend £35 million on training. We have increased the standard spending assessment for local authorities by 23.5 per cent., which is the largest increase in social service spending for 15 years.
Mr. Rowe : Does my hon. Friend accept that one of the great inhibitions to giving good community care to the elderly and the disabled is the accommodation in which they frequently have to live? Will she speak to her hon. Friend the Minister for Housing and Planning to add her weight and that of her Department to the efforts of those who are trying to get builders to build new houses with level access and many other features which are beneficial to the elderly and the disabled?
Mrs. Bottomley : I appreciate, as ever, my hon. Friend's constructive remarks. We are now at the stage in the development of care in the community at which practical and innovative schemes must be arranged, often between departments of local government and between local government and health authorities, with the voluntary and private sectors. My hon. Friend will be aware that in Committee, our hon. Friend the Member for Ealing, Acton (Sir G. Young), the Minister for Housing and Planning, constantly referred to the need to collaborate with housing authorities. He joined me only the other day for a discussion about the way to carry forward collaboration between social services departments, health authorities and housing departments. We have met a number of local authorities to talk precisely through the practical ways in which they can ensure that schemes such as that to which my hon. Friend refers can make progress.
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