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House of Commons

Tuesday 22 March 1994

The House met at half-past Two o'clock


[ Madam Speaker-- -- in the Chair ]

Oral Answers to Questions


Personal Social Services --

2. Mr. Gunnell : To ask the Secretary of State for Health what research she has undertaken on the relationship between the national health service and personal social services at the local level.

The Parliamentary Under-Secretary of State for Health (Mr. John Bowis) : Considerable and continuing.

Mr. Gunnell : The Minister has not told us very much. Has he studied the Health Service Commissioner's report on the long-term care that Leeds health authority has failed to provide ? Is he aware that a recent meeting of the Leeds community health council reported four similar cases and that other CHCs around the country were getting in touch with Leeds about similar cases ? Does that not demonstrate a failure to provide long-term care ? Is that not why, despite the Government's stated objective of looking after carers, many carers have to finance long-term respite care out of their own pockets

Madam Speaker : Order. The hon. Gentleman might take a leaf out of the Minister's book.

Mr. Bowis : The quick answer is no, but I shall expand a little. I have seen the report. I am pleased to know that Leeds health authority has accepted it and is putting right the individual case. As the hon. Gentleman knows, the case predates community care. It confirms the Department of Health guidelines and underlines why the discharge agreement was one of the conditions for the special transitional grant.

Mr. Rowe : Does my hon. Friend accept that, at least in Kent, the relationship between the national health service and social services has been greatly improved by the introduction of the National Health Service and Community Care Act 1989 ? Does he also accept that further improvements could be made if a small handful of national health service patients who are also clients of the social services were allowed direct control over that part of their budget which allows for domiciliary care ?

Mr. Bowis : My hon. Friend is persistent, persuasive and eloquent in making his cause. As he knows, I have discussed the matter with him. Once the community care system has bedded down for a year, we shall be happy to look further at his ideas.

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Mr. John Evans : Does the Minister agree that one of the most important social services is that provided by school nurses ? Is he aware that St. Helens and Knowsley health authority is proposing to cut by half the number of school nurses in St. Helens and Knowsley ? Will he join me in condemning an action that will be detrimental to the health and welfare of children in St. Helens and Knowsley ?

Mr. Bowis : It is not for me to second-guess the provision of services in the hon. Gentleman's constituency. That is a matter for the local health authority, the local authority and the local education authority. I am sure that he is putting his case to them so that school children can benefit from all the resources available to meet the needs assessed by those areas.

Mr. Nicholas Winterton : Does my hon. Friend accept that there is increasing concern about this subject and increasing evidence that many people requiring long-stay hospital care are not getting it under the national health service but are being directed to the private sector-- either residential homes or private nursing homes--where they or their families are having to pay a heavy price for a service that should be free under the national health service ?

Mr. Bowis : My hon. Friend is knowledgeable about these matters. He is, of course, referring to the Leeds judgment, which underlines the Department of Health guidance that it is for the national health service to provide or to purchase long-term care for those who need it on grounds of ill health. The guidance says that no patient in such circumstances should be required to go into a home where there is a charge. As for people who need social care, rather than health care, for many years the principle has been that the charge should be according to the individual's means.

Mr. Hinchliffe : Will the Minister listen to his hon. Friends--such as the hon. Member for Macclesfield (Mr. Winterton), who is absolutely right in saying that the NHS is not discharging its duties to people requiring long-term care ? Will the Minister tell me why there is no review system allowing consideration of the cases of people who were placed in long-term residential or nursing home care before the community care changes ? Given that people are now paying for care that was formerly freely available under the NHS, has not the ombudsman provided concrete evidence of the way in which the Government are privatising the service ?

Mr. Bowis : Continuing, long-stay care is available for those who need it ; moreover, provision for elderly patients has reached record levels. Under the present Government, the number of elderly people receiving in-patient treatment has risen by 125 per cent. to 526,000, and the number receiving out-patient care has risen by 89 per cent. to 452,000. That is a record of care for the elderly of which we can be proud, and which the hon. Gentleman can only envy.

Maternity Service, Basildon --

3. Mr. Amess : To ask the Secretary of State for Health if she will make a statement on Basildon's maternity service.

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The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville) : Basildon has an excellent new maternity unit, whose staff expect to deliver 4,000 babies each year.

Mr. Amess : Does my hon. Friend approve of the centralisation of services in Basildon, with a specialist neonatal care unit on site ? Will he issue guidelines on the delivery of babies in water ? Finally, does he agree that Basildon's maternity service is now the finest in the world ?

Mr. Sackville : There is a feeling among Conservative Members that to be born anywhere in Basildon gives one an unfair advantage in life ; but to have the benefit of perhaps the most up-to-date, best-managed and best- equipped maternity unit in the country is an additional advantage for this generation.

I am aware that some clinicians believe that water can have advantages in relaxing mothers in labour, but the decision on actual water births must be left to clinicians, midwives and, of course, the mothers themselves.

Mr. Tony Banks : I believe that, at the last count, the hon. Member for Basildon (Mr. Amess) had fathered five children. Has he not already put far too much pressure on Basildon's maternity service ? Would not the decent thing be for the NHS to offer him a large quantity of bromide--or, if it cannot afford that, perhaps a do-it-yourself vasectomy with two bricks ?

Mr. Sackville : I must defend my hon. Friend's right to an equal share of NHS facilities.

Mrs. Ann Winterton : When providing maternity services in Basildon and elsewhere in the United Kingdom, will my hon. Friend ensure that full cognisance is taken of the report of the Select Committee on Health ? The role of the midwife should be brought to the fore in the provision of service for mothers-to-be, and the wishes of pregnant women in regard to how they are confined should be respected.

Mr. Sackville : I can reassure my hon. Friend that my noble Friend Baroness Cumberlege, the Parliamentary Under-Secretary of State in the other place, has done a great deal of work on the whole question of maternity services. Central to her work is the question of the mother's choice.

Incontinence Services --

4. Ms Eagle : To ask the Secretary of State for Health what steps she has taken to monitor the quality and availability of incontinence services at a local level ; and if she will make a statement.

Mr. Bowis : Continence services have been designated a priority for national health service planning for the coming year. The Government have funded a national helpline for incontinence sufferers, and have held a national continence week to publicise its availability.

Ms Eagle : Will the Minister admit that, despite the £100,000 that has been spent on publicising continence week, a recent survey showed that nearly 50 per cent. of health authorities find that they must ration the supply of incontinence services to stay within their budgetary limits ? Will he take this opportunity to condemn that rationing--which forces sufferers to pay for any extra materials that

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they may require--and to assure the House that health authorities will provide sufferers with all the materials that they need to manage their condition ?

Mr. Bowis : No, I do not accept the emotive term "rationing". Of course I accept that GPs and incontinence advisers have to assess the individual's needs--every individual is different in this respect--and decide how to meet them. We have heard a very sad and negative story from the Labour party on this issue ; the Government are trying to overcome the shame, pain, sorrow and embarrassment of sufferers, whereas the Labour party merely picks holes in what is being done. It is a tremendous battle to try to encourage people who could be cured to come forward. One has only to consider the hon. Lady's health authority to see the tremendous provision that is ready and waiting for sufferers if they would only take the first step.

Mr. Ieuan Wyn Jones : Does the Minister accept that hon. Members of all parties are receiving complaints that health authorities are not providing free incontinence pads to residents of residential homes, which is causing great distress ? Can the hon. Gentleman tell us what guidelines the Government are issuing to health authorities so that the problems can be overcome ?

Mr. Bowis : I certainly can. As the hon. Gentleman knows, incontinence pads are available free through the district nursing service. We have issued guidelines under which anyone in a residential care home should be treated in exactly the same way as someone living in his own home and the service should be free.

Personal Social Services --

5. Mr. Robert Ainsworth : To ask the Secretary of State for Health what representations she has received regarding the introduction of charges for personal social services other than residential care.

Mr. Bowis : Local authorities have had a discretionary power to charge since January 1984. In January this year, the Department issued new guidance about the use of these powers, and since then six representations have been received.

Mr. Ainsworth : Will the Minister confirm or deny that his Department is operating unofficial guidance whereby it is expecting local authorities to make at least 7 per cent. of their standard spending assessment in charges for non-residential care ? Does he agree that that is utterly unfair on local authorities in poorer areas and a tax on the elderly and infirm ?

Mr. Bowis : The answer is no. I do not know where the hon. Gentleman gets the 7 per cent. figure from. The charges are long-standing and discretionary and it is entirely up to local authorities whether and to what extent charges are made. The guidelines to which he referred state that charges should be reasonable and should take account of the ability to pay. If he is concerned about the way in which the system is operating in Coventry, I am sure that, as he is a former chairman of finance, he can have a quiet word with his friends who are running the council to ensure that they play the game fairly.

Dame Jill Knight : May I encourage my hon. Friend not to be nervous about making a small charge for these

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extremely valuable services provided that people can afford to pay ? Is not it the case that at present only £1 in £10 spent on the services is recovered ? Bearing in mind the fact that every penny of the recoverable sum will be spent on patients elsewhere, is not such a charge a good idea ?

Mr. Bowis : My hon. Friend is entirely right. As I said, the charge is discretionary and each council must decide the sort of scheme that it introduces--whether there are flat charges or a scale of charges and whether there are exemptions or discounts. My hon. Friend makes a valid point, however ; in fact, 9 per cent. of costs--less than £1 in £10--are recovered through charges, which means that about £69 million is recovered out of a total spend of £815 million. It is perfectly reasonable to expect that modest charges, tailored to the ability to pay, should be made. My hon. Friend is not making me nervous ; she encourages me to encourage local authorities to do just that.

Mr. Blunkett : But where does the discretion lie when the Government control the council tax, the distribution of grant and the standard spending assessment and therefore make an assumption of a 7 per cent. charge which, if not levied, would mean that local authorities would have to cut services instead ? Is not this very much like the proposed 25 per cent. increase in dental charges--having stung the nation for tax, the Government are now also stinging the nation in charges ?

Mr. Bowis : The hon. Gentleman might just look at the figures. He might just remember that, in the current year, the Government are spending £6.4 billion on personal social services. That is a measure of support through the social services to the people of the country. It is entirely at the discretion of local authorities whether and how they introduce charges. If the hon. Gentleman is looking for real discretion that his party could use in local government, may I suggest that he considers the cost of services ? Clearly, charges must be related to cost. If efficiency savings are made in the provision of services, the costs are lower. That is why in Conservative-controlled authorities there are lower costs through efficiency savings and why there will probably be lower charges, too.

Mr. Garnier : Will my hon. Friend assure me that those patients who are currently in the Carlton Hayes and the Towers hospitals in Leicestershire, which serve my constituency, will not be moved into the care of the social services department of the county without a proper clinical appraisal of the need for their care ?

Mr. Bowis : I can certainly give my hon. Friend that assurance. It is the task of our mental health task force to ensure that such moves are made into adequate residential accommodation, if that is what is needed. I am assured by Leicestershire health authority that the hospitals concerned will not close unless and until that provision is available.

GP Fundholders --

6. Mr. Kevin Hughes : To ask the Secretary of State for Health what were the average savings made by GP fundholding practices in 1992-93 ; and if she will make a statement.

The Secretary of State for Health (Mrs. Virginia Bottomley) : Provisional figures suggest that in 1992-93 fundholders achieved efficiency savings of between 3 and

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4 per cent. That means that an extra £30 million is to be re-invested in patient care. It shows what can be achieved when GPs take control of managing resources for their patients.

Mr. Hughes : By being able to cream off national health service funding in that way, are not some GP fundholders giving yet more credence to the fast-track, two-tier health service, while other people are having to wait in long queues for out-patient appointments and are facing hospital closures ? Does not the Secretary of State agree that it is time that we got back to a needs-led health service, in which patients come first all the time ?

Mrs. Bottomley : I do not accept the hon. Gentleman's comments at all. I am perplexed to hear his remarks because in Doncaster, there is a high standard of care for all patients, whether or not they are with GP fundholders. Almost all out-patients are to be seen in three months by July and no patient will be waiting longer than a year by July, whatever category that patient is in. That is an achievement about which I should have thought the hon. Gentleman would take the opportunity to tell the House. He has fundholders in his constituency, as elsewhere. They are at the leading edge of the reforms and all general practitioners are benefiting from the changes pioneered by the fundholders.

Mr. Congdon : Is my right hon. Friend aware of the significant savings that GP fundholders have made in their drug budgets ? Will she consider how such good practice may be extended to all GPs ?

Mrs. Bottomley : My hon. Friend is exactly right. GP fundholders are showing a 4 per cent. advantage over the non-fundholders in curbing the increase in their drug budgets. It is an example of the way in which, when GPs are the gatekeepers of the NHS and have direct control over resources, they steward those resources more carefully and can invest in better patient care for others. We want to extend that system to all GPs at the earliest opportunity.

Ms Primarolo : Is the Secretary of State aware of the survey and report in Doctor magazine showing that, in the current year, GP fundholders will accrue £50 million in profit ? Is not it obscene that £50 million should be accruing to fundholders when hospitals are turning patients away and cannot treat them because they are running out of money ? Does not that finally prove that fundholding is inefficient, expensive, unfair and wasteful ? When will the right hon. Lady act for the patients ?

Mrs. Bottomley : I am sure that the hon. Lady appreciates by now that the savings achieved through greater efficiency by GP fundholders are ploughed back into patient care. Fundholders show how we can get better value for the inevitably finite resources invested in the national health service. I commend to the hon. Lady not only Doctor magazine, admirable though it is, but a study of the recent King's Fund report on evaluating the NHS reforms, which states that abolishing fundholding

"would probably lead to a substantial exodus from the NHS of fundholders setting up private insurance based HMOs. The Labour party would have finally broken up the NHS, which would be par for the course in stupidity!"

I commend those remarks to the hon. Lady.

Mr. Thomason : Will my right hon. Friend confirm that she is aware of, and welcomes, the Bromsgrove project in

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my constituency, which has been possible because all four fundholding practices in Bromsgrove are fully behind what her Department is doing ? Will she commend the scheme and back its aims, and recommend that if it proves successful it should be extended to other parts of the country ?

Mrs. Bottomley : The first of April will be a watershed in the establishment of GP fundholding, with about 36 per cent. of the population being covered. The task now, as my hon. Friend has described, is to find out how we can take fundholding forward, extending its benefits to non- fundholding GPs and ensuring that fundholders are able further to influence the way in which resources are allocated. GPs are the advocates on behalf of their patients, and GP fundholding has been one of the most important initiatives of the past five years.

GP Fundholders --

7. Mr. Barnes : To ask the Secretary of State for Health what research she has undertaken into the effect of GP fundholding on equal access to health care ; and if she will make a statement.

11. Mr. Ian Taylor : To ask the Secretary of State for Health what recent discussions she has had with GPs on the impact of fundholding.

The Minister for Health (Dr. Brian Mawhinney) : Ministers and officials regularly meet the British Medical Association and other organisations to discuss the successes of the national health service reforms, including GP fundholding.

Mr. Barnes : Is the Minister aware that a BMA survey shows that 42 per cent. of acute units have special arrangements for GP fundholders ? How does that relate to the question that was asked about equality between GP fundholders and GPs without that facility ? Is not there a terrible injustice in the difference between the two categories ?

Dr. Mawhinney : I am aware that, despite repeated requests for evidence of a two-tier system, no evidence has been forthcoming from the BMA, the Joint Consultants Committee or the Labour party. I am also aware that the BMA is in favour of continuing to work with the Government on GP fundholding. That will come as a great shock to the Labour party, which is committed to abolishing fundholding.

Mr. Ian Taylor : Will my right hon. Friend acknowledge the fact that all GPs are effectively in the private sector, as self-employed people contracting with the national health service ? It is not surprising, therefore, that they want to use the best techniques that they can to achieve efficiency savings on behalf of their patients. Will my right hon. Friend welcome the two new fundholding practices in my constituency, in Esher and Claygate, which are joining the existing fundholding practice in Horsley ?

Dr. Mawhinney : My hon. Friend is absolutely right. I congratulate and welcome the two fundholding practices in his constituency. He will be interested to know that from 1 April the 20.3 per cent. of the population of the Kingston and Richmond family health services authority--of which his constituency is a part--that is covered by GP fundholders, will increase to 74.5 per cent. The House may

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also be interested to know that from 1 April there will be an extra 562 fundholding practices, 850 GP practices within those fundholders, and 2,740 GPs becoming fundholders. More than one third of the population of the country will then be covered by fundholding practices. That fact speaks louder than the weasel words of the Labour party.

Ms Lynne : The Minister has mentioned the BMA report about so-called fast-tracking for GP fundholders' patients. Does not he agree that the report's conclusion is that a two-tier health service has been created ? However much he denies it, he cannot get away from that fact. Will he tell us what he intends to do about that problem ?

Dr. Mawhinney : I have an advantage over the hon. Lady in that it was to Ministers that the JCC produced its 35 examples of two-tierism last September. We examined every one of those examples and not one was found to be true. What is interesting about the latest BMA survey is that it is framed in such general terms that the BMA itself cannot substantiate the charge of two-tierism.

Mr. Sims : May I encourage my hon. Friend to continue vigorously to rebut allegations of two-tier care ? Does he agree that both health authorities and fundholding GPs must work within budgets and although it is perfectly possible that the health authority may have completely allocated its budget while GP fundholders still have funds in hand, the reverse situation could equally arise ?

Dr. Mawhinney : As is so often the case, my hon. Friend is precisely right. What is interesting about Labour Members is that they have got themselves caught up in structures when what the national health service is about is patients. The proof of the pudding is the fact that we are treating more patients in this country than ever before. The increase in the number of patients that we are treating is higher than before, the quality of the treatment is higher than before, the convenience of the treatment is better than before and GP fundholders are in the lead in virtually all those areas.

Mr. Bayley : The Minister has been able to provide me with information about the amount of money per patient that is allocated to fundholding doctors, but he says that he does not have information about the amount of money per patient that is allocated for the same services for patients of non-fundholding doctors. As he does not have the figures, how can he say that there is equal access when he cannot say that there is equal money for the two types of patients ?

Dr. Mawhinney : The allocation of resources is done on a basis that is not only fair but seen and recognised as fair by everyone except Labour Members.

Derriford Hospital, Plymouth --

8. Mr. Streeter : To ask the Secretary of State for Health what plans she has to visit Derriford hospital, Plymouth to discuss cardiac surgery.

Mr. Sackville : My right hon. Friend the Secretary of State has no current plans to visit Derriford hospital, but she maintains a close interest in the issue of a possible second cardiac unit for the south-west.

Mr. Streeter : Is my hon. Friend aware that there is a growing sense of anticipation in the south-west as we look

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forward to Derriford hospital becoming an NHS trust in April, thus going from one degree of excellence to another ? Is he aware that he could make our joy complete by confirming at an early stage that Derriford hospital will have its own cardiac surgery unit to service people in Devon and Cornwall ? When will that announcement be made ?

Mr. Sackville : I congratulate my hon. Friend on his persistent advocacy of a second cardiac unit. It is common ground between us that it is unsatisfactory for people to travel long distances for heart surgery from the south-west to Oxford, London or, indeed, Bristol. However, he must recognise that a case must be made. It is generally thought that no cardiac surgery unit would be viable without perhaps 750 surgical cases per year split between three consultants. A business case has been made. We hope that it will come to the Department in the next few days, and I hope that there will be an early decision.

Mr. Jamieson : Is the Minister aware that Plymouth and the Torbay area have one of the highest rates of cardiac disease in the whole country, yet it is the only area without a dedicated coronary unit ? Is he also aware that many hundreds of patients travel each year from Plymouth to London to get their treatment and that that is putting patients' lives at risk ?

Mr. Sackville : Yes, I certainly agree that it is unsatisfactory for people to travel that distance. I have said to the hon. Gentleman that as soon as we receive a business case we will deal with it promptly, and I hope that there will be a favourable outcome.

Project 2000 --

9. Mr. Heald : To ask the Secretary of State for Health what assessment has been made of the progress in implementing the Project 2000 initiative.

Dr. Mawhinney : The Comptroller and Auditor General reported on the implementation of Project 2000 in December 1992.

The final report from the National Foundation for Educational Research, which was commissioned by the Department to undertake an independent evaluation of the implementation of Project 2000, was published on 15 February.

Mr. Heald : Can my hon. Friend confirm that this important training scheme is being fully and properly funded ? Does he agree that the early success of the scheme, coupled with the 50 per cent. increase in real terms in nurses' pay since 1979, shows the commitment of the Government to nursing, not only in North Hertfordshire but in the country at large ?

Dr. Mawhinney : My hon. Friend is absolutely right to draw attention to the Government's commitment to that important project. We share that commitment with the nursing profession and, I believe, with others from all parties. Since 1989, the Government have invested £321 million to introduce the reforms.

Mr. George Howarth : Does the Minister accept that the nursing profession will greet the proposals with a great deal of cynicism if the proposals to halve the numbers of highly trained, skilled school nurses in St Helens and Knowsley go ahead ? Does that not mean that possible

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cures through the school nursing service for the terrible health problems that people in St Helens and Knowsley often experience will simply be cut off ?

Dr. Mawhinney : The people of St Helens and Knowsley will want nurses who are trained to the highest possible degree, and that is what they will get with Project 2000.

Cancer Screening --

10. Mr. Bates : To ask the Secretary of State for Health what proportion of general practitioners are achieving either the higher or lower targets for cancer screening in the northern region ; and if she will make a statement.

Mr. Sackville : Ninety-nine per cent. of general practitioners in the northern region have achieved one of the targets for cervical screening. That is an excellent record.

Mr. Bates : Is not that answer somewhat at odds with the statement made by the hon. Member for Livingston (Mr. Cook) when the targets were set that the immunisation and screening targets were so heroic that many doctors would give up even trying ? Does not the excellent news about northern region GPs demonstrate that the hon. Gentleman was not criticising the policy, but was severely underestimating the professionalism and abilities of northern region GPs ?

Mr. Sackville : I agree with my hon. Friend. Given what has happened since, it is particularly shocking that the Labour spokesman should in effect have exhorted GPs to give up, to screen fewer women and to save fewer lives. That typifies the thoroughly negative attitude that the Labour party maintains towards the NHS.

Mr. McCartney : A rising issue is that of prostate cancer and the Government's failure to provide for screening. Some 41,000 men have died in the past five years from that silent killer ; yet the Government refuse to recognise that level of death by introducing a national screening system. If there is a national screening system for cervical cancer--which the Opposition support--for 2,500 deaths per year for women, there should be a national screening system for prostate cancer, from which 10,000 men a year die. When will the Secretary of State act and introduce such a national screening system ?

Mr. Sackville : As the hon. Gentleman knows, before we introduced a national scheme for cervical and breast cancer, we had to make sure that we had an efficient and effective method of screening which would not lead to a lot of false diagnoses or to false and unnecessary surgery.

In the case of colorectal, ovarian and prostatic cancer, it may be that in time we shall find a consensus and the possibility of bringing in effective national screening systems. When that happens, we shall undoubtedly save more lives, but it cannot be brought in overnight.

Codes of Conduct and Accountability --

12. Mr. French : To ask the Secretary of State for Health how many responses have been received to consultation on the NHS draft codes of corporate conduct and accountability.

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Mrs. Virginia Bottomley : There has been a universal welcome for the draft national health service codes of conduct and accountability which I issued for consultation on 13 January. Almost 400 NHS trusts, authorities and non-NHS bodies and individuals have commented.

Mr. French : Does my right hon. Friend agree that good practice, as set out in her codes of conduct, is in most cases already the normal practice ? Will she join me in condemning the Labour party for picking on a few isolated examples to cast a slur on the NHS generally when most of the NHS staff are dedicated, highly motivated and ethical public servants ?

Mrs. Bottomley : Public sector values are very much at the heart of the management and operation of the NHS-- [Interruption.]-- and that will continue to be the case. Like my hon. Friend, I condemn and deplore the way in which the Opposition take every opportunity to denigrate the commitment of those who have achieved a great improvement in patient care in this country. [Interruption.]

Madam Speaker : Order. I should be obliged if the House would come to order and if conversations were less noisy during Question Time.

Dr. Wright : May I ask the Minister for her reaction to the fact that when I attended a recent meeting of my own NHS trust, at which the trust was adopting the new code of conduct to which she referred, I asked to speak and was told that I could not ? Indeed, I was told that I was lucky to be there at all. Does that not show precisely what is wrong with the national health service ?

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