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House of Commons

Tuesday 8 June 1993

The House met at half-past Two o'clock


[Madam Speaker-- in the Chair ]

Oral Answers to Questions


Drug and Alcohol Misuse

1. Mr. Connarty : To ask the Secretary of State for Health when she last met representatives of organisations providing residential drug and alcohol projects to discuss the change in community care.

7. Ms Eagle : To ask the Secretary of State for Health if she will review specific funding arrangements for services to drug and alcohol abusers.

The Minister for Health (Dr. Brian Mawhinney) : Representatives of organisations providing residential services for alcohol and drug misusers, and from local authority associations, last met my right hon. Friend the Secretary of State for Health and the then Under-Secretary of State for Health--my hon. Friend the Member for Suffolk, South (Mr. Yeo)--on 15 December 1992. We have undertaken to monitor the implementation of the new arrangements closely.

Mr. Connarty : I am grateful to the Minister and glad to hear that he has been meeting those organisations. Does he share my concern at the report in Care Weekly of 3 June that only £10 million has been identified by local authorities for use in respect of residential alcohol and drug cases? Had the sum been ring-fenced as the Government supplied it directly, it would have been £16.5 million. That means that there is a £6.5 million shortfall in funding for those vital services. Will the Minister do something to rectify the position?

Dr. Mawhinney : I have to tell the hon. Gentleman that the amounts were ring-fenced. He suggests that they should have been ring-fenced within a ring fence, which does not make a lot of sense. We have issued special guidance, which we drew up with the local government associations, telling local authorities that we attach a high priority to those groups. It is for local authorities individually to assess their needs and proceed accordingly.

Ms Eagle : The Minister will not need reminding of the link between drug misuse and the increased threat of HIV and AIDS infection. Does he agree that the shortfall in funding indentified by my hon. Friend the Member for Falkirk, East (Mr. Connarty) has already increased anxiety about that? Would the Minister care to comment on the persistent rumour that the Government intend to announce-- [Hon. Members :-- "Another rumour."]

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Another rumour. I want to give the Minister a chance to deny that rumour, if hon. Members will let me proceed. Would the Minister like to comment on the persistent rumour that the Government intend to end ring fencing for AIDS services in August next year, thus putting health at risk?

Dr. Mawhinney : Like the hon. Lady, we attach importance to the fight against drugs misuse. That is why this year we made more than £24 million available in connection with drugs misuse services--an increase of more than 20 per cent. on last year's figure. It is why we have allocated £19 million this year, which is a 10 per cent. increase for service development. It is why we have increased by 90 per cent. the amount of money that we have made available to fund the expansion of pharmacy- based needle exchange schemes. The hon. Lady will know that, in her own constituency, the Wirral drug prevention team is undertaking many activities, all of which are designed to reduce drugs misuse.

Mr. David Atkinson : Does my hon. Friend agree that the county councillors who were elected as social service representatives on 6 May should now be fully aware of the community care needs of the areas that they represent--including the needs of alcohol and drug addicts--and to whom the excellent voluntary organisations ought now to be making representations?

Dr. Mawhinney : My hon. Friend is, of course, absolutely right. Ultimately, it will not be the decisions of Ministers that are primarily addressed to the individual needs of alcohol and drug misusers but the decisions of those who have the legal

responsibility--the local authorities.

Mr. Hinchliffe : The Minister now has sitting beside him the new Under-Secretary of State, the hon. Member for Battersea (Mr. Bowis), who, in the past, has actively campaigned for the ring fencing of funds for drug and alcohol projects. I remind the Minister of some of the problems that are arising across the country as a direct result of the Government's about -turn on the ring fencing of funds for such projects. Many important projects are now faced with closure. There are people on the streets who have serious problems and cannot get help, there are allegations that at least one person has died as a direct result of the Government's policy. Will the Minister address the problem urgently and reinstate the original ring-fencing arrangements?

Dr. Mawhinney : What I will do is extend the hon. Gentleman's question to a welcome to the new Under-Secretary of State for Health, my hon. Friend the Member for Battersea (Mr. Bowis). The hon. Gentleman is aware that we have made much more money available for the implementation of care in the community than even he, in his wildest moments, fantasised that the Government would make available--£140 million more.

We have made that money available so that local authorities can undertake personal assessments of individual need and so shape services designed to meet those needs--some in residential homes and some in other ways. I hope that the hon. Gentleman will continue to support that broad principle with us.

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Assessment Procedures

2. Mr. Rowe : To ask the Secretary of State for Health what representations she has received on the workings of the assessment procedures introduced under the National Health Service and Community Care Act 1990 ; and if she will make a statement.

The Parliamentary Under-Secretary of State for Health (Mr. John Bowis) : From the information available, the new arrangements seem generally to have got off to a good start. We have established a monitoring system to ensure that the policy objectives are met. We have received a number of representations on the workings of the assessment procedures and will consider carefully any suggestions to improve still further those processes.

Mr. Rowe : It is a pleasure to see a former director of community affairs at the Dispatch Box for the first time and I warmly welcome my hon. Friend to that position. Does he agree that the new assessment procedures have, as part of their merit, the great advantage that they make it easier for care managers to assess the amount of care and to budget rather more precisely for the delivery of that care? If that is the case, why is the Department so anxious about the possibility of extending direct payment to those clients who are deemed to be best served by it?

Mr. Bowis : From one former community affairs director to another, I thank my hon. Friend for his kind remarks and I express my gratitude to the hon. Member for Wakefield (Mr. Hinchliffe) for having read my collected speeches.

We are all aware of the stout work that my hon. Friend the Member for Mid- Kent (Mr. Rowe) has carried out with Lord McColl in respect of this research and debate. His aims, like ours, are to ensure that patients have a much greater say and are much more involved in planning for their needs. My hon. Friend will accept that at the moment we need to ensure that the new community care reforms have time to settle down, bearing in mind that social security has traditionally been the route for cash and social services the route for services. If my hon. Friend continues to debate, I will continue to listen and perhaps we can look to the future together.

Mr. Redmond : I, too, congratulate the hon. Gentleman on his appointment. Will he instruct all chairmen appointed by the national health service to answer questions from right hon. and hon. Members? Some chairmen refuse to answer questions. Will he request that they answer them?

Mr. Bowis : I am grateful to the hon. Gentleman for his initial comments. Perhaps he can draw to my attention any particular problems that he experiences. I believe that we want openness in the development of our policy. In so far as Ministers are responsible, we will respond and in so far as local health authorities are responsible, they will respond, as will local social services departments. Openness is important and I am glad to know that at least the hon. Gentleman basically supports the aims and objectives of our policy.

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3. Mrs. Angela Knight : To ask the Secretary of State for Health what progress has been made immunising against childhood diseases in the Trent region.

The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville) : The childhood immunisation programme has been an enormous success. At February 1993, Trent region had uptake rates of 94 per cent. for diphtheria, tetanus and polio immunisation, 91 per cent. for whooping cough and 93 per cent. for measles, mumps and rubella.

Mrs. Knight : Will my hon. Friend join me in congratulating all the general practitioners in Trent region on that very successful programme? Has not the GP contract also played a part in that success? However, is my hon. Friend aware of the somewhat erratic supply earlier this year of the mumps, measles and rubella vaccine to the Southern Derbyshire health authority, which covers my constituency of Erewash? Can he assure me that there will be no further interruption in the supply of that very important vaccine?

Mr. Sackville : My hon. Friend will be aware that two vaccines were withdrawn last year, which caused difficulties, particularly in her area. I understand that those difficulties have now been sorted out. I should like to join her in congratulating the local GPs who responded magnificently. Since the Hib vaccine was introduced last year, haemophilus influenza has reduced by 70 per cent. and whooping cough is rarely seen in the surgery. Since 1989, no child has died as a result of acute measles-related diseases.

Mr. Ashton : Is it any wonder that there is a shortage of vaccine when Trent regional health authority can spend £200,000 with a public relations firm to cover its tracks on the Beverley Allitt case? Why has that taxpayers' and health service money been spent when there will be an inquiry in private? Did the Secretary of State for Health agree to spending that £200,000? If so, why has she accepted that there will be a private inquiry?

Mr. Sackville : That is a decision for the region. The important thing is to get the facts with the minimum of disruption to the professionals involved and to the institution, and the qualifications of Sir Cecil Clothier are impeccable for that task.

Psychiatric Beds

4. Mr. Harry Greenway : To ask the Secretary of State for Health how many beds have been closed in psychiatric hospitals over the past 10 years, with the effect of releasing how many patients into the community ; and if she will make a statement.

Mr. Bowis : The average number of beds available daily for mentally ill people fell from 85,000 to 50,000 between 1981 and 1993-92. It is not known how many patients have been discharged into the community over that period. Our policy is to enable people with mental health problems to be able to be supported in their own homes for as long as that is desirable and possible, while recognising that there will always be people who require hospital care--some of it long stay.

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Mr. Greenway : Madam Speaker--

Mr. Foulkes : Declare your interest, Harry.

Mr. Greenway : My interest is my constituency of Ealing, North. My concern is that people should not be put back into the community from psychiatric institutions without proper preparation for that and without proper housing. [ Hon. Members :-- "Hear, hear."] Of course, that applies to some Labour Members. Will my hon. Friend give an assurance that no one will be discharged or put back into society without proper preparation? That is damaging to the individual when it happens and most worrying to neighbours and/or members of the community where it happens.

Mr. Bowis : My hon. Friend's notable battles on behalf of Ealing undoubtedly led partly to the opening last year of the new £10 million mental health unit by the Ealing health authority. I assure my hon. Friend that our policy is that no one will be forced to leave a mental health institution unless and until the community is ready to receive him or her. We have the care programme approach in place that ensures that community services, including treatment and housing, are ready to receive an individual and that a key worker is in place to guide that person. I hope that my hon. Friend will be satisfied with that assurance.

Mr. Robert Hughes : Is not the Minister shocked by the appalling ignorance of his Department in not knowing how many people have left mental hospitals and gone into the community? Since the Department does not know how many people have left, how can it know what sort of monitoring and care exists for those who have left? It is a disgraceful answer. I hope that the Minister will look at the matter seriously because it is of grave concern to people all over the country.

Mr. Bowis : I think that the hon. Gentleman misunderstands what a discharge is--a discharge is not necessarily a person leaving a hospital once and for all. The number of discharges does not relate to the number of people because some people go into hospital more than once. The statistics are there for local use and local planning. The important point is that locally the district health authority will ensure that people do not leave hospital unless and until there are facilities in the community to receive them.

GP Fund Holding

5. Mr. Merchant : To ask the Secretary of State for Health what plans she has to extend the GP fund-holding initiative.

The Secretary of State for Health (Mrs. Virginia Bottomley) : GP fund holding has shown itself to be an outstanding success, bringing many benefits to patients. There will be more to come. As the controller of the Audit Commission recently said,

"fund holding is leading the way, with many imaginative innovations which are good for the health of the population."

One in four of the population now benefits from having a fund holder as his or her family doctor. With the numbers preparing to join the scheme from next April, we expect that figure to rise to one in three.

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Mr. Merchant : Does my right hon. Friend agree that, for the reasons that she has given, the fund-holding initiative has proved to be particularly popular with both doctors and patients, as illustrated by the practice of Dr. Kenneth Scott in my constituency? Does she agree that one of the most important priorities now must be to ensure that the smaller practices are able to benefit fully from the fund-holding initiative? Would she care to tell the House what steps she is taking to enable that goal to be achieved?

Mrs. Bottomley : My hon. Friend is right. I am delighted to hear about the progress in his constituency. We should like to see more fund holders across London because they can pioneer new ways of helping patients. The challenge now is to extend the benefits of fund holding to as many general practitioners as possible and to encourage the creation of groups, consortiums and management arrangements. About 70 groups already operate and about 150 are likely to come through for next year.

Mr. Grocott : Is it too much to hope that the Secretary of State will consider the overwhelming evidence that the fund-holding system leads to a two-tier system for patients? Will she look at the evidence that I have sent to her on the issue? Even for this Government, is it not indefensible to treat people not on the basis of their medical need but sometimes on the basis of whether their GP is a fund holder or a non-fund holder? As the Government have made so many U-turns on so many issues, is it too much to hope that they will make one on fund holding?

Mrs. Bottomley : The Labour party likes to centralise control over all decisions. We believe in devolving responsibility. The general practitioner is the advocate for the patient. Fund holding enables GPs to back their decisions with money so that they can pioneer care that is closest to patients' needs. There are clear guidelines on common waiting lists and a requirement that the treatment of patients of fund holders should not disadvantage the patients of other general practitioners.

The real point is that all general practitioners should have the advantage of fund holding. The task now is for all general practitioners to use leverage through fund holding or by working with the district health authority as the purchaser to achieve continual improvements in the quality of treatment for their patients.

Mr. Allason : Does my right hon. Friend see a parallel between the opposition expressed by some general practitioners some time ago to generic medicines and the opposition that was experienced recently to fund holding? Is she aware that in the Torbay constituency the GP who was virulent in his opposition to fund holding is now a fund holder? Does she agree that the opposition that we saw to generic medicines and fund holding has vanished? Is not that an endorsement of the policy?

Mrs. Bottomley : My hon. Friend exactly characterises the position. Time and again, I meet fund holders who were initially cautious about the scheme but now say that it has profoundly redressed the previous balance of power in the health service. We believe in a health service in which patients, not institutions, come first. The general practitioner is the advocate on behalf of the patient. Once again, we see the Labour party promoting a sneering campaign of denigration which shows its hallowed principle of equal misery for all. It does not like excellence.

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Mr. Burden : Would the Secretary of State care to consider the case of Dr. Zuckermann in my constituency, who referred a patient to a local orthopaedic hospital and received a reply that the patient could not be seen until January next year? He then received a telephone call saying, "Sorry, we did not realise that you were a fund-holding general practice. We can see the patient in four to six weeks." The hospital got it wrong because Dr. Zuckermann is not a fund-holding GP. Does not that prove that fund-holding GP systems are about queue-jumping and creating a two-tier health service?

Mrs. Bottomley : There are clear agreements with the profession about the way in which fund holding operates. The answer for the general practitioner involved is either to become a fund holder-- [ Interruption.] I am pleased that in Birmingham, where there are many singlehanded practices or two-handed practices, there are several schemes to encourage them to form fund-holding practices. Alternatively, the answer for the general practitioner is to work with the district health authority to get the purchasing improvement that the fund holders are establishing.

Once again, the hon. Gentleman fails to recognise the dramatic achievements in reducing waiting times for everyone. We have now established a maximum waiting time for all hip, knee and cataract operations, so the length of time anyone waits for treatment is substantially less than it was in the long distant past when the Labour party was, regrettably, in power.

Patients Charter

6. Mr. Mark Robinson : To ask the Secretary of State for Health if she will make a statement on the implementation of the patients charter waiting time guarantee in the South Western region.

Mrs. Virginia Bottomley : Latest provisional waiting time figures show that the South Western regional health authority has been extremely successful in meeting the waiting time commitments in the patients charter. In line with the patients charter, no one in the region has had to wait for more than two years for any in-patient or day case treatment, or 18 months for hip or knee replacement or cataract operations.

Mr. Robinson : I am sure that my right hon. Friend knows that, five years ago, 13,500 people in the south-west were waiting for more than one year. I hear a rumour that that figure is down to 300. Can my right hon. Friend confirm that figure? Does she agree that it shows the effectiveness of hospital trusts, such as the East Somerset hospital trust? Does not it give the lie to some of the myths being peddled by the Liberal Democrats and others in the south-west?

Mrs. Bottomley : I can confirm the rumour. Of course, the south-west has an excellent record of delivering on patients charter commitments, but across the country there have been dramatic falls in waiting times. Last year, for example, there was a fall of 24,000 in the number of people waiting for more than a year--almost a third--so the figures are the lowest ever. I am pleased that my hon. Friend paid tribute to the East Somerset trust, because there has been a great deal of investment in it. Like others, it is solving its problems and pioneering ever-higher standards of patient care.

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Ms Primarolo : The patients charter is wholly irrelevant to the real needs of patients, whether in the south-west or the rest of the country. While the Secretary of State has been concentrating on the time people wait in out-patient departments to see a doctor for non-urgent operations, one in 10 cardiac patients is dying while waiting for treatment. Children needing emergency beds in intensive care are being turned away from hospitals. Today's report in the Daily Mirror of the death of a young girl

Madam Speaker : Order. This is Question Time and I require a direct question to the Secretary of State.

Ms Primarolo : The question is that the report in the Daily Mirror today of the death of a young girl follows on from a report that the Secretary of State has on paediatric care

Madam Speaker : Order. If the hon. Lady would put

Ms Primarolo : I am going to.

Madam Speaker : No, not going to. The hon. Lady will put what she has to say in the form of a question.

Ms Primarolo : The Secretary of State has a report. Will she confirm that a quarter of paediatric intensive care beds are closed because of underfunding? Will she now make an emergency statement to the House that children who need emergency treatment will not be turned away from the national health service?

Mrs. Bottomley : So far as I know, the question is about the South Western region. It is typical of the Labour party, with its shroud-waving approach to health care, that it should seek to use a question on the South Western region to refer to that other case. It is certainly a tragic case and all of us would greatly sympathise with the family involved. An investigation is under way by the British Paediatric Association into intensive paediatric care. Once its report is published we will certainly make it available and see what necessary action should follow.

Perhaps the Labour party might grudgingly be prepared to recognise that today is also one on which a dramatic fall in cot deaths has been reported. The gentleman who pioneered the work on cot deaths comes from Bristol and the hon. Lady might have wished to pay him credit, given that he comes from the south-west. We are also seeing improvements in child health as a result of the immunisation programme.

Dame Elaine Kellett-Bowman : Since the hon. Member for Bristol, South (Ms Primarolo) introduced, quite improperly, another hospital authority in her question, may I set the record straight? There have been no cuts in intensive care paediatric beds in Manchester or Liverpool. The young girl who died so tragically--

Madam Speaker : Order. Much as I am interested in what the hon. Lady has to say, she must put a question. If not, we shall move on.

Dame Kellett-Bowman : Madam Speaker, I was doing as you did-- reprimanding the hon. Member for Bristol, South for mentioning a different region--

Madam Speaker : I am the umpire here.

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8. Mr. Hardy : To ask the Secretary of State for Health what is her estimate of the numbers of pharmacies which are at risk of closure during the next three years.

Dr. Mawhinney : Community pharmacies are independent commercial businesses. We have made no estimate of the number that might close, or open, in the next three years, as such events could be affected by a variety of factors.

Mr. Hardy : Is the Minister aware that the present policy will mean that a large number of pharmacies will be severely penalised and that many hundreds are now imperilled? Is he also aware that, as a result of that policy, enormous additional burdens will be placed on family doctors in less well-populated areas? Since the Government purport to care for rural England, will the Minister ensure that that policy is reconsidered in the interests of rural communities?

Dr. Mawhinney : The hon. Gentleman is wrong. That is not the consequence of the policies that are currently being pursued. I believe that the hon. Gentleman is referring to the negotiations that are now being undertaken between officials in the Department and representatives of the pharmacists. Those negotiations are proceeding constructively. We are seeking to replace indiscriminate subsidies to pharmacies with payments related more closely to professional services. The hon. Gentleman will find that the Public Accounts Committee has strongly endorsed that strategy. May I also assure him that we are committed to protecting the essential small pharmacies to which he referred.

Mr. Sims : Does my hon. Friend accept that it is just as important that pharmacies should be easily accessible in suburban areas as in rural ones? Does he also agree that patients could make fuller use of their local pharmacy for health care? There is a great potential for pharmacists to play an increasing role as part of the local primary health care team.

Dr. Mawhinney : As is so often the case, my hon. Friend is absolutely right. We attach importance to maintaining essential small pharmacies not only in rural areas, but in suburban ones, particularly isolated pharmacies, perhaps on housing estates where people live at some distance from the main shopping centres. I assure my hon. Friend that it was precisely because of the current negotiations with the pharmacists that we have recognised that they have a value-added health role to play in offering professional advice and that we are, as part of those negotiations, looking to introduce a professional allowance for them.

Mrs. Mahon : The Government's policy affects the business of pharmacies. Does the Minister agree that any savings generated from a cheaper contraceptive pill could lead to more unwanted pregnancies and terminations as well as affecting the business of those pharmacies? The cost of one termination is £270 to the NHS, the cost of 10 years' supply of the contraceptive pill, so surely that is the economics of the madhouse.

Dr. Mawhinney : The hon. Lady's second question falls outside the scope of the main question. On her first question, I agree that hon. Members attach importance to maintaining an effective provision of pharmacies and the

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health advice that pharmacists can give. Over the past 10 years, the number of pharmacists has increased by 9 per cent. and the total number of pharmacists has increased by 13 per cent. Our desire to emerge with a stronger range of pharmaceutical advice for the constituents of all hon. Members forms part of our negotiations with the Pharmaceutical Services Negotiating Committee.

Mr. Cormack : Will my hon. Friend do everything that he can to publicise the figures that he has just given to the House? Is he aware of rumours sweeping Staffordshire and other parts that the Government have evil designs on pharmacists? Will he unequivocally state that that is not the case?

Dr. Mawhinney : My hon. Friend is right--there have been suggestions in places further afield than Staffordshire that the Government have some sort of hidden agenda to close pharmacies. That is not true and I give that categorical assurance. I would deplore any attempt by anyone to try to gain advantage during the negotiations by scaring members of the public unnecessarily.

Elderly Patients

9. Mr. Kevin Hughes : To ask the Secretary of State for Health what increase there has been in the emergency admissions for elderly patients over the last two years ; and if she will make a statement.

Mr9 T Mr. Hughes : Is the Minister aware that the reason for that increase in admissions is the fact that more and more admissions are turned down by hospitals that are trying to operate in the market forces world of medicine which the Government have introduced? The only way in which some general practitioners can gain admission for elderly people is to dial 999 after the patients have already been turned down by hospitals.

Mr. Sackville : I am well aware that there have been complaints from general practitioners in the hon. Gentleman's district about Tickhill Road hospital. I am also aware that Doncaster Royal and Montagu are taking steps to ensure that all elderly patients are admitted locally. If the hon. Gentleman thinks, as do many other Labour Members, that provision can be measured by the number of beds, and if he ignores advances in day surgery and medicine and other improvements which mean that more people can be better treated in fewer beds, he knows nothing about what is happening in the health service.

Ms Lynne : Does the Minister accept that a crisis is looming for elderly patients due to the closure of many geriatric beds and hospitals and the underfunding of community care? Does he accept that we could see a number of elderly patients on the streets in the same way as we have seen mental health patients on the streets?

Mr. Sackville : May I correct the hon. Lady--community care is extremely generously funded. If there are insufficient places for elderly people, the hon. Lady should address her remarks to the provider, the local social services.

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Market Power

10. Mr. Cousins : To ask the Secretary of State for Health what plans she has to control abuses of market power in the NHS.

Dr. Mawhinney : There is no evidence of abuse of market powers.

Mr. Cousins : Does the Minister recall that last year in my constituency an experimental and brilliant way of delivering long-term rehabilitation had to be stopped because the bigger providers would not allow it? Does he know about Hertfordshire, where purchasers are strangling the hospitals? Does he know that nurses are on the streets of Newcastle today defending their hospital against the bigger providers who are trying to strip the services? If the Minister is not willing to act, why will not he let the Monopolies and Mergers Commission into the national health service to sort out the abuses and ensure that there is fair play?

Dr. Mawhinney : I will tell the hon. Gentleman what I know about Newcastle. The average general practitioner list size has decreased by more than 6 per cent. I know that the number of child health surveillance patients treated has increased by more than 10 per cent. I know that the number of minor surgical procedures has increased by 164 per cent. What I understand, but the hon. Gentleman does not, is that the health service is not confined to hospitals. It also extends into the community and primary care. The record in his part of the world is as good as it is in the rest of the country. People understand that they do not have to spend time in hospital when treatment and care are frequently available to them in their homes. I should have thought that the hon. Gentleman would welcome the fact that more day surgery is available to his constituents so that they spend less time in hospital. I have news for the hon. Gentleman--that is what his constituents would prefer to do.

Mrs. Roe : Does my hon. Friend agree that the implementation of the national health service reforms has been a great success, resulting in the treatment of more patients, shorter waiting times and better patient care? I congratulate him on taking the reforms forward, particularly in the development of purchasing. Will he give an assurance that that vital work will continue and that we shall not be deflected by Labour party scaremongering?

Dr. Mawhinney : My hon. Friend is absolutely right. Last year, we treated, in terms of general and acute patients, 13.5 per cent. more than we treated in the year before the reforms were introduced. My hon. Friend will be pleased to know that activity in trusts last year was 7.6 per cent. higher as against 4.5 per cent. in directly managed units.

I can certainly offer my hon. Friend the assurance she seeks. We are moving to the next phase of the reforms, which is to increase and improve purchasing arrangements in this country. Purchasers are the advocates and agents of patients and it is their responsibility to see that an increasing amount of service, and increased quality of service, is made available to patients.

Rev. Martin Smyth : The Minister will agree that while improvements have been made in the national health service, we have not reached heaven yet. So let us return to the question and deal with the abuses. Is not it an abuse for

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a major pharmaceutical company to use its front-line position to bring pressure on small wholesale chemists to turn them into agents of the company? Is not it an abuse for a health authority to refuse to purchase good-quality services at reasonble cost, thereby trying to shut out a provider?

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