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House of Commons

Tuesday 23 February 1993

The House met at half-past Two o'clock


[Madam Speaker-- in the Chair ]

Oral Answers to Questions


The Health of the Nation"

1. Mr. Jenkin : To ask the Secretary of State for Health if she will make a statement on progress in implementing the proposals contained in the White Paper "The Health of the Nation".

7. Mr. Gerrard : To ask the Secretary of State for Health what steps have been taken to implement the proposal in "The Health of the Nation" to consider policies other than those of her Department in respect of their health implications.

The Secretary of State for Health (Mrs. Virginia Bottomley) : We are implementing "The Health of the Nation" in full, and a summary of current action and initiatives is in the Library. The ministerial Cabinet Committee set up to oversee implementation of the health strategy ensures that it is taken forward on a cross-departmental basis. The guidance on how health issues can be taken into account during policy development will be ready later this year.

Mr. Jenkin : Does my right hon. Friend agree that the health of the nation, and of constituencies such as mine in North Colchester, will benefit from the reforms of London's health service that she announced last week because we shall be able to look forward to a fairer share of the region's resources, of which we have been deprived in recent years? May I draw her attention to the press release issued by North East Thames regional health authority, which made no mention of those benefits to my constituents?

Mrs. Bottomley : I thank my hon. Friend and fully agree with his remarks. The firm action that we set out last week for radical change in London will mean a fairer distribution of resources in London, directing them to primary care, and also a more equitable distribution of resources throughout the country. Generally, it is a policy which will improve the allocation of resources throughout the health service. As my hon. Friend comes from a constituency which has long subsidised excessive provision in London, he is one of many Members who stand to benefit.

Mr. Gerrard : The White Paper acknowledges that there are close links between poor housing and unemployment and poor health. Government policies should take that

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into account. Can the Minister tell us precisely what her Department is doing to persuade the Department of the Environment that it ought to spend more to improve housing and not less, and to persuade the Department of Employment that creating real jobs is not merely good economic sense but is good for people's health?

Mrs. Bottomley : The great significance of the health strategy is that a Cabinet Committee oversees progress in meeting the targets. My Department is ensuring full implementation of the general practitioner contract--the Labour party voted against it--which is providing deprivation payments for inner city areas and has resulted in great progress with immunisation and cancer screening targets. There have been improvements in health throughout the country for all social groups, and that is the health strategy which we shall continue to carry forward.

Dr. Liam Fox : Will my right hon. Friend confirm that "The Health of the Nation" is a world model for a complete health policy? In congratulating her, may I ask her to consider the mechanism of health funding so that we can perhaps have a system in which funding allocated for the health service is more closely matched to the targets that we have set for ourselves?

Mrs. Bottomley : I can confirm my hon. Friend's remarks ; the health strategy was commended by Dr. Asvall, the European director of the World Health Organisation, as a model which he would like others to follow. I was talking today about the importance of purchasing and the role of district health authorities. We are proceeding with those changes precisely so that health authorities can achieve the targets set out in "The Health of the Nation". We are confident about the activities of national health service trusts. The task now is to ensure that purchasers commission health care on behalf of local residents which meets the targets set out in the health strategy.

Ms. Eagle : Does the Secretary of State admit that there are connections between poverty rates, the rate of unemployment and ill health? What is her Department doing? What representations is it making to other Departments to cut unemployment and poverty, to increase the nation's health in a meaningful way?

Mrs. Bottomley : As I have made clear, the health strategy is overseen by a Cabinet Committee in which the contribution of different Departments is identified so that, together, we can meet the targets set out in "The Health of the Nation". The White Paper makes it clear that there are associations between, for example, matters of the environment. That is why the inner-city policies are so important and that is why taking forward improvements in housing is so important.

Over and above all that, the Labour party has failed to explain why it opposed the new general practitioner contract which has resulted in improvements for all social groups in all parts of the country. Above all, it has resulted in the introduction of deprivation payments for GPs in inner-city areas.

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Health Care (Rural Areas)

2. Mr. Ancram : To ask the Secretary of State for Health what plans she has to promote improved health care in rural areas.

The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville) : Health authorities have a responsibility for securing services to meet the needs of local people regardless of whether they live in rural or urban areas. We have encouraged health authorities to develop local purchasing to ensure greater sensitivity to the needs of individual communities.

Mr. Ancram : I thank my hon. Friend for that answer. Is he aware that community health care, such as the provision of local hospitals, is especially important in widespread rural areas such as my constituency? Will he encourage the purchasing authorities to recognise that fact in their purchasing policies, perhaps by himself recognising the additional cost of providing health care in rural areas such as mine?

Mr. Sackville : The Government are well aware of the need to preserve the fabric of the countryside, which involves not only transport and jobs, but local health services and taking those services as close to people as possible. My hon. Friend will know that over the past few years £4.5 million has been spent on improving and updating the community hospitals in Malmesbury, Corsham, Warminster and Westbury. Furthermore, £8 million is to be spent over the next few years on redeveloping the St. Andrew's site at Chippenham.

Mr. Denham : Does the Minister accept that there would be a great deal more money for the improvement of health services in rural areas and in many other areas if national health service funds were not wasted? Why has the Department done so little to sort out the scandal in Wessex regional health authority? Tory Ministers have appointed Tory friends to be chairmen of health authorities, and they have been lobbied by Tory Members to give contracts to companies run by friends of the Tory party. Some £40 million is being wasted. Why has the Minister done nothing about that scandal and why have his predecessors done nothing?

Mr. Sackville : I can assure the House that very tight controls are now in place to monitor the procurement of information technology and other equipment. The hon. Gentleman talks about waste. I remind him that, despite limitations on finance, we have put a great deal of money into the health service in recent years. The activity figures continue to go up, more patients are treated and there are more nurses and doctors. Waste is something which we do not recognise.

GP Fund Holders

3. Sir Roger Moate : To ask the Secretary of State for Health if she will make a statement on progress in the number of GP fund holders.

6. Mr. Jack Thompson : To ask the Secretary of State for Health if she will make a statement on the savings achieved by general practitioners who are fund holders.

Mrs. Virginia Bottomley : Increasing numbers wish to join the scheme. More than 3,000 GPs in 585 practices are

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now fund holders. A further 600 practices join the third wave this April, when one in four of the population should be covered by fund holding. Overall, fund holders made efficiency savings of between 3 and 4 per cent. on their budgets in 1991-92, which will be ploughed back into patient care.

Sir Roger Moate : Has my right hon. Friend seen the survey reported in Doctor magazine which shows that 70 per cent. of GP fund holders have already managed to cut waiting times for their patients? Is it not extraordinary that the Labour party should seek to abolish fund holding altogether, when more and more GPs are seeking to become fund holders, when there is ample evidence of growing patient satisfaction with GP fund holding and when we need to extend fund holding even more widely?

Mrs. Bottomley : My hon. Friend is exactly right : it is positively bizarre that the Labour party should choose to shun a scheme which is leading to such clear advantages for patients, showing the way in which innovative and pioneering patient care can be organised. I noticed the survey in the Doctor magazine. The same survey shows that more than 60 per cent. of fund holders reported improved follow-up arrangements for appointments, more than 50 per cent. were providing extra services in their surgeries and almost 40 per cent. had introduced consultant visits. All those are real improvements for patients of fund holders which the Labour party--as ever, with its politics of spite and envy--wants to abolish.

Mr. Jack Thompson : Is the Secretary of State aware that 30 GP fund holders have made a profit of about £100,000 by establishing limited companies? Is she also aware that 11.2 per cent. of GP fund holders made a profit of £12.8 million in 1991-92? What evidence can she produce to the House that the money is being returned to the district health authorities for patient care?

Mrs. Bottomley : What I have seen is the most deplorable document produced by the Labour party with the most inaccurate data one could believe possible. The hon. Member for Sheffield, Brightside (Mr. Blunkett) suggested that he wanted the spirit of intellectual renewal in the Labour party. The document on which the information is based has double and treble -counted a great number of the elements. The local element of management allowance is counted three times. Everything else that is covered by the management allowance is counted twice and the Audit Commission component is counted twice. It is the most deplorable document. What I can make clear to the House is that the savings from the GP fund-holding scheme have been ploughed back into better patient care.

Dame Elaine Kellett-Bowman : Does my right hon. Friend recall the quite outstandingly excellent practice in the southern end of my constituency which has done absolutely everything the Minister could possibly want? That practice has every person in the area--there is absolutely no one else that the practice can get--but it has only 6, 500 patients. Will my right hon. Friend stretch the limit and allow the GPs in that practice to become fund holders, which they feel is the only way forward for them in already excellent conditions?

Mrs. Bottomley : My hon. Friend, as ever, speaks for a great number of general practitioners and their practices in the United Kingdom. The success of the fund-holding

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scheme is being admired and emulated by many others. We have been able to find new ways of developing the scheme. Recently, I announced that the scheme would be extended to diagnostic and further surgical techniques. This year, we shall introduce the use of community nurses and it may well be that at a later date we shall be able to reduce the numbers required to join the scheme. I know that that will receive a warm welcome from many hon. Members in the House.

Mr. McCartney : We have just heard a rant from the Del Girl of health economics. The Labour party report on GP fund holders was based on information provided by family health services authorities--information which the Government want to keep secret. The truth is that nearly £100 million in the first wave has been spent trying to bring GPs into line in terms of the fund-holding policy. That money was top-sliced from patient care. Thirty companies have been set up and have raided patient care funds to the tune of over £100,000. At the same time, for example, in Manchester 32 seriously ill children have been turned away from Booth Hall children's hospital since October because it has run out of money. When will the Secretary of State stop top-slicing hospital authorities to give resources to GP fund holders and implement the Labour party policy of joint commissioning, which is much more successful in both funding and care for patients?

Mrs. Bottomley : The overall cost of the fund-holding scheme is about £40,000 per year, which is about 2 per cent. of the budget set. There can be no doubt at all that that has resulted in much better patient care and a great spirit of innovation across general practice overall.

The report to which the hon. Member for Makerfield (Mr. McCartney) referred is positively bizarre. It mentions people such as Dr. Paul Lambden. I quote from him elsewhere :

"I remain as convinced as ever that GPs should have financial as well as clinical responsibility for their patients fundholders are pragmatic and dynamic. As time goes by Trusts will come to understand the value of fundholding The scheme is undeniably excellent." There is no doubt at all that fund holders have developed excellent services.

The hon. Member for Makerfield referred to the difficulties that some hospitals have had in managing their budgets through the year. Those hospitals need to learn from the way in which fund holders have diligently and shrewdly managed their budgets. Instead of begrudging fund holders, hospitals should admire them. We believe in levelling up, not--like the Labour party--in levelling down.

Mr. Hayes : Does my right hon. Friend agree that it is either incompetent or downright fraudulent for the Opposition suddenly to claim that GP fund holders are getting an extra £44,000 a year--which, of course, is being spent on patient care--when only a few months ago they were saying that there would not be enough money to treat patients?

Mrs. Bottomley : My hon. Friend, as ever, is right. He and I will recall that in Committee the Opposition were always saying that fund holders would be too mean to provide care for their patients. Now they spend all their time saying that the care that fund holders provide for their patients is too good. The Opposition always want to

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have it both ways. The fact is that the fund -holding scheme--a voluntary scheme--has been a great success. We want all GPs to have the same benefits as the fund holders.

Prescription Charges

4. Mr. Miller : To ask the Secretary of State for Health what plans she has to exempt youth training scheme trainees from prescription charges.

The Minister for Health (Dr. Brian Mawhinney) : Help with national health charges, including those for prescriptions, is already available under the NHS low income scheme and is directed towards people, including youth training scheme trainees, who may have the greatest difficulty in paying. The scheme ensures that no one need be deterred from obtaining necessary medication on financial grounds.

Mr. Miller : Does the Minister agree that it is outrageous that my constituent, Catherine Ormerod, who suffers from a life-threatening illness, should have to choose which medicines she takes? Does he further agree that, but for the good will of pensioners, shop stewards and friends, she would still not be able to afford the season ticket? Is it not about time we saw the same good will from the Department of Health as we see from the people of Ellesmere Port and Neston who have helped my constituent?

Dr. Mawhinney : The hon. Gentleman had a full explanation of these matters in a letter from me dated 15 December--

Mr. Miller : Four lines.

Dr. Mawhinney : It was not four lines, as the hon. Gentleman well knows.

He also had a letter from the Under-Secretary of State, my hon. Friend the Member for Bolton, West (Mr. Sackville). In both those letters it was explained to him--but I shall explain it again--that YTS trainees have an income, which may well be supplemented by employers, in which case, like everyone else of relatively low income, they are considered under the NHS low income scheme. I have to tell the hon. Gentleman, although he clearly does not want to accept it, that in this case age is not a relevant factor.

Dame Jill Knight : Will my hon. Friend confirm that even those patients who have no exemption at all from the prescription charge, which I understand is in excess of £4, are paying considerably less than the true cost of the prescription, which I understand is about £9?

Dr. Mawhinney : My hon. Friend is right to point out that the prescription charge is much less than the average cost of the prescription to the NHS.

Mr. Chisholm : Will the Minister take this opportunity to deny the recent report that pregnant women and women with children under one year old will no longer receive free prescriptions? Is it not enough for the Government to have raised prescription charges by 2,000 per cent. without imposing that burden on 1 million extra women?

Dr. Mawhinney : The hon. Gentleman and his question would be taken slightly more seriously by the House if his question had some vague rigour. He knows perfectly well that there was no recommendation or report in the terms

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that he has described. He is referring to the Bloomfield report, which looked at the system of remuneration for dentists. That report is out for consultation and we shall bring forward proposals in due course.

Community Care

5. Mr. Jacques Arnold : To ask the Secretary of State for Health what plans she has to ensure that the clients of community care services have a wide degree of choice over services which they are to receive.

The Parliamentary Under-Secretary of State for Health (Mr. Tim Yeo) : New assessment arrangements will ensure that individual users and carers are fully involved in deciding how their needs can best be met. Public funding will be available for a wider range of services from an increasing range of suppliers. Those requiring residential or nursing home care at public expense will have the right to choose their own home, subject to certain practical limitations on cost and suitability.

Mr. Arnold : Are not competition and choice the best way to achieve standards and services both in the national health service and in community care? Is it a coincidence that Conservative authorities such as Kent county council are already well under way with that, to the benefit of the clients that they will be serving?

Mr. Yeo : My hon. Friend is right. The Government are promoting competition and choice both through the requirement that local authorities spend 85 per cent. of the money transferred from the Department of Social Security purchasing services in the independent sector and through the binding direction requiring local authorities to honour individual preferences in the choice of residential home. The real way to promote competition, choice and higher standards will be to vote Conservative in the county council elections on 6 May so that there will be more excellent county councils such as Tory-controlled Kent county council.

Mr. Alfred Morris : Does the Minister accept that severely disabled people should have choice and freedom to make their own arrangements for personal care? For that to happen, local authorities must be empowered and adequately resourced to make direct payments which relate to individual need.

Mr. Yeo : The right hon. Gentleman makes a point which has been canvassed before in the House. The cornerstone of our community care changes in April is placing the wishes and needs of individual users of services at the heart of the decision-making progress when the assessment is made. That will ensure that far greater attention than can be paid under the present system will be devoted to the personal needs of each individual who approaches his or her social services department. Further, it is our intention that individual needs should include much better consideration of alternatives to residential care. In future, it is far more likely that people approaching social services departments will be given a package of domiciliary, day or respite care services to keep them in their own homes for longer than was previously possible.

Mr. Sims : Does my hon. Friend agree that in the provision of sheltered housing, special needs housing such

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as that for the disabled, and what is often referred to as part 2 accommodation, housing associations have an important role to play in community care policies? Will my hon. Friend ensure that housing associations are fully involved in the preparation and implementation of community care plans?

Mr. Yeo : My hon. Friend raises an important point. We certainly want to see all local authority social services departments in close consultation with housing associations and with many other bodies. One of the biggest difficulties that we have encountered in making the necessary preparations for the changes is that too many Labour-controlled authorities refuse to engage even in a proper dialogue with independent sector providers of all kinds of care and services. That is why we had to issue a further direction, requiring consultation to take place and authorities to state in their community care plans in future how they will consult independent sector bodies.

Mr. Hinchliffe : How does the concept of choice square with denying the right to advocacy by not fully implementing the Disabled Persons (Services, Consultation and Representation) Act 1986? How does it square with denying the right to choose good quality public services, and with telling local authorities not to record unmet need during the assessment process? The Minister talks about giving people the right to choose which home they will enter--what about giving them the right to choose not to enter a home in the first place? Is that not the real issue which the Government ought to be addressing?

Mr. Yeo : It is indeed the real issue, and the Government are addressing it. For that reason, every local authority will be required in future to make an assessment of the individual's needs before he or she enters residential care. The exact weakness of the present system is that it is possible to obtain an automatic social security payment to finance a person's entry into residential care. In future, there will be much more detailed consideration of individual needs, so that there will be a good chance that a person who might otherwise have entered a residential nursing home will receive a package of individually tailored domiciliary, day and respite care services. I only hope that Labour-controlled authorities will address that issue rather more successfully than Sheffield city council, which is currently diverting resources from social services into payment for the provision of offices for Labour Members of Parliament.

Limited List Prescribing

8. Mr. Viggers : To ask the Secretary of State for Health what estimate she has of the impact of her proposal to introduce a further limited list of pharmaceuticals available for prescription under the national health service on investment in research and development by the pharmaceutical industry.

Mrs. Virginia Bottomley : The British pharmaceutical industry is a major international success story, accounting for nearly 10 per cent. of global pharmaceutical research and development, and contributing a positive trade balance of over £1 billion. I welcome the fact that the industry recognises the need to reduce the NHS drugs bill,

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which is expected to rise by over 14 per cent. this year. I also welcome its co-operation in the work that we are taking forward. Decisions on research and development investment depend on many factors. It is not possible to identify specifically the impact of the proposed extension of the selected list.

Mr. Viggers : Does my right hon. Friend agree that our pharmaceutical industry can be rightly proud of its record in research and development? Has the Department carried out a survey of comparative costs, and the cost saving in the NHS that has resulted from its treating patients with drugs rather than taking up hospital beds? Is my right hon. Friend prepared to meet representatives of Cyanamid, which is the largest civilian employer in my constituency? Its current development plans are being held up because it is concerned about future profitability.

Mrs. Bottomley : I certainly commend the United Kingdom pharmaceutical industry. It is, as I have said, an important industry : two of the world's largest pharmaceutical companies are United Kingdom-based.

My hon. Friend has made an important point. We want to encourage the pharmaceutical industry to assess the cost effectiveness of new products and the contribution that they make to improving health care generally. We are making good progress on health technology assessment and we hope soon to commission a code of practice for economic assessment in clinical trials.

Ms. Primarolo : Is the Secretary of State aware that the contraceptive pill is included in the 10 categories being considered for inclusion in the extended limited list? Is she aware that 3 million women take the oral contraceptive pill, which is 95 per cent. effective? The reduction in availability of the pill will force women to change to other forms of contraception and will lead to an increase in the number of unwanted pregnancies and abortions. Will the right hon. Lady make a statement to the House, agreeing to withdraw contraceptive pills from the 10 categories?

Mrs. Bottomley : Contraceptive pills are free for all women, regardless of means. We are seeking to ensure that all therapeutic categories are safeguarded, but the health service should not fund products that are too costly and have no unique therapeutic value. The hon. Lady's question is typical of the Labour party's attitude. Labour always shuns or ducks difficult issues. In 1985, when we last introduced a selective list, Labour adopted the same scaremongering approach. It has cried wolf too often. We shall ensure that therapeutic categories are covered, but, in a year when pay increases are being held at 1.5 per cent., we are determined to consider all the options in seeking cost-effective health care.

Sir John Hannam : Is my right hon. Friend aware of the drug wastage that results from the present system of repeat prescription, whereby a three-month supply of drugs is dispensed in one go? Will she consider the triple-prescription scheme proposed by the pharmacists, under which drugs would be dispensed only on a month-by-month basis?

Mrs. Bottomley : I am determined to examine any way in which we can eliminate waste. We spend £100 million a day on the NHS and eliminating waste is the secret of

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providing ever higher standards of cost- effective care. I appreciate the pharmacists' suggestion : they are an enormously important member of the health-care team and I greatly respect their particular knowledge and skill. I shall explore the suggestion later.

Ambulance Service

9. Mr. Tony Lloyd : To ask the Secretary of State for Health what information she routinely obtains about the ambulance service.

Mr. Sackville : Health authorities and national health service trusts provide annual returns on ambulance staff numbers, the number and nature of patient journeys and emergency response times, as well as a range of financial information.

Mr. Lloyd : Is it not a disgrace that we had to learn from a leaked document that ambulance stations--for instance, the Sharston ambulance station, which is the closest to Manchester airport--have been closed because of shortage of staff? I understand that the Minister had a recent meeting with the ambulance service in Greater Manchester. Did he receive from the people there a guarantee that all ambulance stations near the airport will be kept open to ensure that, in the event of a disaster, front -line services will be available?

Mr. Sackville : I can assure the hon. Gentleman that adequate arrangements will be made for Manchester airport. He should know that the real test of Greater Manchester's ambulance service is that it achieved a response rate of 97 per cent. of calls met within 14 minutes, making it one of the best ambulance services in the country.

Mr. Tracey : Will my hon. Friend confirm that the London ambulance service is getting £70 million in the current year and that one could conclude that the public are not getting a very good return for that investment? When will my hon. Friend do something positive to improve the disgraceful London ambulance service?

Mr. Sackville : My hon. Friend will know that the publication of a report of the London ambulance service is imminent. We believe that lessons will have been learnt from the events of late last year. We are confident that performance can be improved. As my hon. Friend has indicated, a large amount of money is spent on the LAS and there is no reason why it should not match performance in the rest of the country.

Ms. Lynne : Will the Minister now recognise that the ambulance service should be treated in the same way as the fire and police services by being given emergency-service status?

Mr. Sackville : The hon. Lady will be aware that there has been a transformation in the performance of ambulance services in this country. We are very lucky to have probably the most dedicated and professional ambulance personnel anywhere in the world and it is improving all the time. Soon a paramedic will be on every front-line ambulance. That is something of which we should all be proud.

Mr. Nigel Evans : Following the remarks that my hon. Friend has just made, may I ask whether the service is still

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on target in its intention to have one paramedic on every ambulance by 1995? We have talked about the importance of health services to rural areas. I represent a rural constituency. It is extremely important that the people there can be assured that all ambulances will have a paramedic on board by 1995--earlier, if possible.

Mr. Sackville : I can provide the confirmation that my hon. Friend seeks. Recently I announced that the target date for a paramedic being on every front-line ambulance was being brought forward by one year--from 1996 to 1995--and that adequate funds would be made available for that purpose. Paramedic training has been one of the great success stories of the modern NHS.

NHS Trusts

10. Mr. Foulkes : To ask the Secretary of State for Health what is the total remuneration to chairpersons and members of NHS trusts estimated for 1992-93 in England and Wales.

Dr. Mawhinney : The estimated figure for 1992-93 in England is about £8 million. Questions relating to Wales are a matter for my right hon. Friend the Secretary of State for Wales.

Mr. Foulkes : The estimate is £8 million. How many doctors would that employ? How many nurses? How many physiotherapists? How many chiropodists? Is not it the case that this money is being taken away from patient care and stuffed into the pockets of Conservative cronies? Is not that tantamount to corruption?

Dr. Mawhinney : I hope that the hon. Gentleman feels better for getting that off his chest. If we may take his questions literally, it is clear that he would leave the NHS without any oversight, without any public accountability and without any advice about the issues which, throughout Question Time, he and his right hon. and hon. Friends tell us are important.

Mr. Rowe : I am married to a trust member who has been employed by the national health service, in a fully professional capacity, for many years and my experience is that the amount of work expected from members of trusts exceeds by far what was indicated in the prospectus that was dangled in front of them. The work is done conscientiously and late into the night. Will my hon. Friend pay tribute to all those NHS trust members who give far more to the national health service than the hon. Member for Carrick, Cumnock and Doon Valley (Mr. Foulkes) could possibly imagine?

Dr. Mawhinney : I am happy to pay such tribute, particularly to my hon. Friend's Gentleman's wife who, as he has rightly and objectively said, makes a significant contribution. As to all trust members, they represent the public. They represent the need to put our reforms on a firm footing and they are largely responsible, with doctors, nurses and the rest, for seeing the increase in the number of patients treated, which is the hallmark of the national health service reforms.

Mr. Blunkett : In the light of the Secretary of State's speech earlier today on the continued future for regions and the role of the management executive and outposts, does the Minister agree that this is an admission that the market has failed and that trusts cannot be left to

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self-governing status? Will he tell the House why we should be expected to pay £8 million a year to place people who are not accountable in any way to their local communities and who are not democratically elected and where central control is now to be exercised? Why the continued dithering and confusion with further reviews? Why are the outposts and regions to continue? Why more money announced today--on top of the £8 million to keep the trust in place, a £4 million announcement to make the system work better? Who is actually running the Department--the Home Secretary, the Chief Secretary to the Treasury or the right hon. Lady?

Dr. Mawhinney : The hon. Gentleman has just confirmed what we all suspected : he neither understands nor appreciates what the national health service reforms are about. The reforms are now widely seen to be successful, and successful against the target that the hon. Gentleman refuses to recognise : that they are good for patients, although not necessarily good for the National Union of Public Employees. More patients are being treated. What my right hon. Friend said this morning, which is absolutely central to the development of the reforms and even better patient care, is that we shall now focus as much attention on developing the purchasing side of the national health service as we have to developing the trust side. As that purchaser-provider split develops, so even more patients will be helped, treated and cared for, and the hon. Gentleman will no doubt continue to be unhappy about that fact.

Dr. Spink : Does my hon. Friend agree that the very essence of the health service debate is the number of patients that we treat each year? Will he tell us the growth in number of patients treated in trust hospitals in 1991-92 and compare that with the growth in number of patients treated in other hospitals? We need to know these facts.

Dr. Mawhinney : My hon. Friend understands these matters much better than Opposition Members. Last year we saw about a 7 per cent. increase in the number of patients treated within the national health service, and in trust hospitals the increase was over 8 per cent. In other words, trust hospitals delivered better patient care, more patient care and a higher quality of patient care than directly managed units. That is why, as my hon. Friend will understand, more hospitals will become trusts in April and even more will become trusts in April 1994, by which time 95 per cent. of all hospital and community units will be trusts. That is the good news that patients want to hear.

Young People (Secure Accommodation)

12. Mr. Michael : To ask the Secretary of State for Health if she will outline her Department's strategy for providing secure accommodation for young people who currently have to be held in prison accommodation.

Mr. Yeo : A number of local authorities have already registered an intention to provide some of the 60 to 65 additional secure places that we have assessed as being required nationally. We are continuing to discuss with other authorities how the balance might best be provided.

Mr. Michael : Does the Minister realise that the problem exists now and has existed for many years? It was two years ago that the Government accepted, under pressure from Labour Members and others, the need for

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secure places to end the scandal of young people being kept in prison accommodation because there was nowhere else for them to be kept, and there remains nowhere else for them to be kept. Two years later his Department has not provided one additional place anywhere in England and Wales. Is it not time that the Government stopped talking about doing something about this problem and started to provide the places?

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