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House of Commons

Tuesday 26 April 1994

The House met at half-past Two o'clock


[ Madam Speaker-- -- in the Chair ]


Crossrail Bill

Motion made, and Question put,

That the Committee on the Crossrail Bill have leave to visit and inspect the site of the proposed works and areas affected by the proposed works, provided that no evidence shall be taken in the course of such visit and that any party who has made an appearance before the Committee be permitted to attend by his Counsel, Agent or other representative.-- [The Chairman of Ways and Means.]

Hon. Members : Object.

Oral Answers to Questions


Industrial Diseases --

1. Mr. Loyden : To ask the Secretary of State for Health what national health service care is available for people with (a) asbestosis and (b) other industrial diseases.

The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville) : The national health service is a universal service. It provides quality health care for people of all ages who need it, regardless of how that need arises.

Mr. Loyden : Does the Minister accept that we are talking about terribly debilitating diseases that men and women have contracted in their places of work ? It appears that the Department of Health has not done enough to improve the detection of asbestosis and related diseases. Is not it time that consultation took place between the Secretary of State for Health and the Secretary of State for Employment to see what improvements can be made in the early detection and treatment of such diseases ?

Mr. Sackville : Mesothelioma and asbestosis of all kinds are a tragedy that will unfortunately affect many people who have come into contact with asbestos. The diseases are difficult to detect in advance, but we try to monitor the incidence closely to ensure that everything is done to avoid further contact and further contracting of the disease.

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Accident and Emergency Sites, London --

2. Mr. Austin-Walker : To ask the Secretary of State for Health if she will list all accident and emergency sites that have been closed in London since 1988-89 ; and which sites she plans to close as she implements her policy of "Making London Better".

The Secretary of State for Health (Mrs. Virginia Bottomley) : London is served by a dense network of accident and emergency departments. There are currently 40 A and E departments in the capital. No department will close until alternative cover is available and this will be the case before any changes arising out of "Making London Better" go ahead. I will write to the hon. Gentleman with the available information since 1988-89.

Mr. Austin-Walker : When will the Secretary of State stop deluding herself and attempting to deceive the public ? Having confirmed in a recent answer that the number of accident and emergency sites has gone down by 17 per cent. since 1989, will she also admit that 9,000 beds have been lost in London in the past five years, that London now has fewer GPs and health visitors than it had three years ago, and that the number of people waiting for treatment in London has risen by 10 per cent. in the past year ? Will she admit that, far from "making London better", her so-called reforms are making the health of London much worse ?

Mrs. Bottomley : I would ask the hon. Gentleman to reflect a little on the need to rationalise health care in London. Before they became too populist, the Opposition supported investment in primary care. There can be no doubt that the £85 million going into primary care this year is essential. We need to strengthen our centres of excellence and our A and E departments. The hon. Gentleman seems to have overlooked in his catalogue of misery the £8.2 million that King's is spending on A and E, the £4.3 million that Lewisham is spending on A and E, the £3.2 million that St. Thomas's is spending on A and E, the £2 million that the Whittington is spending on A and E and the £1.1 million that the Homerton is spending on A and E. Those are all in areas represented by Labour Members who never praise the successes of the NHS or our investment in it.

Mr. Evennett : Does my right hon. Friend agree that better GP services will reduce the pressure on the accident and emergency departments ? How much cash will her Department put into primary and community care in the coming year to improve the delivery of health care services to patients ?

Mrs. Bottomley : My hon. Friend is aware that as many as 40 per cent. of the people who use accident and emergency departments in London could be helped either by minor injuries clinics or by better primary health care. That is why it is essential that we invest £85 million more in primary health care in London. It also matters to Londoners that there is a substantial investment in the London ambulance service, amounting to £14.8 million this year.

Mr. Blunkett : In justifying the fact that one in five A and E units have been closed, will the Secretary of State tell us how she justifies spending £150,000 of public money in the run-up to the local and Euro- elections on a

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propaganda leaflet, "NHS Changes in London", which has been put into every household in London and is a straight piece of Tory party propaganda ?

Mrs. Bottomley : That is an outrageous comment. Members of the hon. Gentleman's party will confirm that I was pressed by the Select Committee on why we had not taken more steps to explain to Londoners the need for change.

When we started on the process, the Labour party pretended to be a responsible party of opposition and supported the need for change. It is only as the elections have come closer that Labour Members have become so populist that now even their health spokesman is not prepared to speak in the debate on London's health services this week.

Domiciliary Care --

3. Lady Olga Maitland : To ask the Secretary of State for Health what is her estimate of current total expenditure by local authorities on domiciliary care ; what was the figure in 1979 ; and if she will make a statement.

The Parliamentary Under-Secretary of State for Health (Mr. John Bowis) : Gross expenditure by local authorities on domiciliary care in 1991-92 was £3,111 million. This is the latest figure available. In 1978-79, the figure was £611 million.

Lady Olga Maitland : I warmly congratulate my hon. Friend on those excellent figures. Does he agree that the elderly deserve the highest standards of care in their homes, and that they deserve flexibility, choice and respect for their dignity ? Will he confirm that he will continue his drive to develop the community care policy programme, also paying attention to the residential care afforded by local authorities ? In particular, will he condemn Labour-controlled Lambeth and Islington councils, which have an appalling record of abuse of the elderly and vulnerable in their care ?

Mr. Bowis : My hon. Friend is quite right. The fact that we are spending 38 per cent. more in real terms on services for the elderly this year than we were four years ago shows that we are putting into practice our commitment to looking after the elderly in the community. My hon. Friend is also right to criticise some of those Labour London boroughs which seem incapable of doing the same. If Charles Dickens were around today, he would recognise the conditions in some parts of Labour London. He would not understand the nuclear-free zones, but he would understand the neglect, incompetence and misery that sum up Labour London.

Mr. Hinchliffe : But has not any expansion of domiciliary care been achieved largely thanks to the efforts of Labour-controlled councils which, unlike the Government, have a clear political commitment to developing alternatives to institutional care ? If the Government believe in domiciliary care, why do not they drop the dogmatic requirement that councils spend the bulk of the care grant in the so-called independent sector ? Directors of social services are telling me that that requirement is forcing people unnecessarily into expensive residential care placements. Why do not the Government put the needs of users and carers before Tory party dogma ?

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Mr. Bowis : I should have thought, after all this time, that the hon. Gentleman would at least understand that the transfer element in the special transitional grant relates to residential care which, before, was all spent in the independent sector. He should also recognise the considerable growth, shown by the figures that I gave my hon. Friend the Member for Sutton and Cheam (Lady Olga Maitland), in the domiciliary care provided by local authorities around the country. He should stand up and pay tribute to the councils and directors of social services who have made that possible--thanks to the resources given by this Government. Resourcing for social services, including community care, has increased from £3.6 billion to £6.4 billion in four years. That is what has made the growth possible, and the trend will continue under this Government.

Mr. Sims : But does not what my hon. Friend has just said completely contradict the Opposition's forecast that community care would not work because the resources would not be made available ? Does my hon. Friend know of any local authority that has been unable to carry out the community care policy because of insufficient funds ? Is not the truth of the matter that the policy is successful ?

Mr. Bowis : All the surveys of community care undertaken since it came into being one year ago this month show that there has been steady progress throughout the country. None of the surveys has shown any problem over resourcing. The problems that have arisen have been due to dogma on the left of the political spectrum, which has stopped local authorities benefiting from the input of the independent sector into the care of people in need.

NHS Trusts --

4. Ms Quin : To ask the Secretary of State for Health what new proposals she has regarding the public accountability of NHS trusts.

Mrs. Virginia Bottomley : National health service trusts are fully accountable to me, through the NHS executive, for the delivery of health care and for the effective use of resources available to them. The new codes of conduct and accountability that I shall publish on 28 April will further strengthen trusts' accountability both to me and to the public. The codes will keep public service values at the heart of the operation and management of the NHS.

Ms Quin : Will the new rules allow community health councils to be represented on trust boards ? Can the Secretary of State explain why my local community health council in Gateshead has for two years been denied access to the NHS trust and has even been denied observer status ? Does she agree that that contradicts any idea of proper public accountability ?

Mrs. Bottomley : I regret that the hon. Lady's community health council is perpetuating a party political vendetta against the establishment of the trust in the hon. Lady's constituency, which is performing outstandingly, with some of the best out-patient waiting times and patients charter achievements. The hon. Lady's community health council has been offered a great number of arrangements short of actually becoming a member of the trust board : it has been offered a meeting in the autumn to discuss the year ahead ; it is invited to a further meeting in

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the spring to finalise plans in detail, to a meeting in the summer to review progress and to bi-monthly meetings with the chairman and the chief executive, quite apart from other visiting rights. It is time for it to forget the past and work for the future.

Madam Speaker : Mr. Nicholas Winterton.

Hon. Members : Wake up.

Mr. Nicholas Winterton : I am sorry, Madam Speaker, but there is another Winterton in the House and I misheard.

I accept what my right hon. Friend the Secretary of State has said--that the public accountability of NHS trusts is adequate and satisfactory--but does not she accept that the real problem lies with district health authorities, which are not in any way accountable to the public ? They force policies upon the trusts which, in many cases, are unwilling to accept them because the DHAs are not accountable to the public in the same way as the trusts.

Mrs. Bottomley : The task for district health authorities is to ensure that they communicate effectively with local people. They have to assess need and set priorities, and it is important that they work closely with local authorities and Members of Parliament and with all those in the community who feel strongly about the delivery of health care. The distinction between the purchaser and the provider is now well established and, thankfully, is the subject of agreement on both sides of the House.

Mr. Blunkett : How are we to hold the Secretary of State to account when she has every intention of bailing out of her present job ? Which of the shambolic changes with which she has been associated over the past four and a half years has contributed most to her decision to go ?

Mrs. Bottomley : I have a great sense of achievement. Beyond our expectations, we now have 419 NHS trusts and 1 million more patients are now treated than were treated before the NHS reforms. Child immunisation is up to 90 per cent. and 80 per cent. of out-patients and people at A and E departments are being seen within half an hour. Those were all targets that we set the health service ; we are delivering them effectively and I want us to do even better. I ask the Labour party why the hon. Gentleman feels unable to speak on London health services in the debate that is to be held this week. That is the question that we want answered.

Mr. Rowe : Does my right hon. Friend agree that what the public really want to know about national health service trusts is how well they are doing, and will she make absolutely certain that she encourages them to publish the good news, such as the £45 million investment in the Medway trust and the state-of-the-art oncology unit in the Maidstone trust ?

Mrs. Bottomley : There has been a transformation in the amount of information available about how hospitals work--an annual report, an annual meeting, accounts that have to be audited and the business plan--quite apart from the codes of conduct and accountability that I am announcing today. My hon. Friend rightly refers to his own trust, but almost every trust in the country has seen great progress. Trusts are better for staff and patients.

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Tobacco Advertising --

5. Mr. Martyn Jones : To ask the Secretary of State for Health what discussions she has had on banning all tobacco advertising from hoardings within one or three miles of schools.

The Minister for Health (Dr. Brian Mawhinney) : We are currently negotiating with the tobacco industry to strengthen the voluntary agreement on tobacco advertising and promotion. The negotiations are confidential and we shall publish their outcome in due course.

Mr. Jones : Is not there very clear evidence from abroad to suggest that advertising increases smoking in under-age smokers ? The Exchequer gets an estimated £96 million-worth of funds from under-age smokers through taxation, yet the Department spends only £5 million on health education. Is not it time to do something for the health of under-age smokers in Britain and ban tobacco advertising ?

Dr. Mawhinney : First, though he may not want to do so, I suggest that the hon. Gentleman reads the evidence that I presented to the House in my Second Reading speech on the Tobacco Advertising Bill, which clearly illustrates that no concurrent evidence links cause and effect in the way that he suggests. We agree with the hon. Gentleman that advertising has a part to play and that is why we have had a voluntary agreement for 18 years. It is why we have sought over the years to tighten that agreement when it was appropriate to do so. That is what the current negotiations are about and I look forward to their success.

Dame Jill Knight : Will my right hon. Friend encourage the present trend in tobacco advertising, which seems to produce advertisements so obtuse that they fail entirely to give any message about smoking itself and merely have clearly written on the bottom the warning that smoking can severely damage health ?

Dr. Mawhinney : My hon. Friend makes a good point, although I am told that some in the community understand that they are tobacco advertisements. I take her point about the size of the warning, and I will bear that strongly in mind in the coming days.

Mr. McCartney : The Minister must know that in the 18 years since the agreement came in, 1,100,000 citizens have died directly because of the tobacco industry. Will the Minister give a commitment on the 13th of this month to support the all-party initiative in the Tobacco Advertising Bill-- or is the simple fact that, because of the £100,000 donation to his party by Rothmans in the month before the general election, he finds it difficult to change Government policy to protect children ? If he is serious about children and tobacco, perhaps he will give a commitment to give Rothmans back the £100,000 and do something to stop kids smoking.

Dr. Mawhinney : I am happy to say that there are some cracks from the Opposition Front Bench that are not worthy of a serious response. The hon. Gentleman and I together deplore the number of unnecessary deaths caused in this country by smoking. We deplore together the millions of working days lost as a result of smoking. We recognise together the importance of parental influence, parental behaviour and price--and also, I suspect, that the evidence surrounding those three issues, which is

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compelling, is far more likely to be effective in reducing the death rate, which he and I deplore, than a ban on tobacco advertising.

Mr. Jessel : Is my right hon. Friend aware that in a typical constituency there are 1,300 15-year-olds, of whom about 24 per cent. smoke, and that, according to the Royal College of Physicians about one third of those--or 100 of the 1,300--will die of smoking if we continue at the present rate ? Is not it totally unacceptable to advertise within easy reach of those who are young and gullible, perhaps leading them into a habit that is likely to be lethal for them ?

Dr. Mawhinney : My hon. Friend makes an important point. We have already made it clear in the House that there is particular concern about children and their exposure to advertising. My views on that are on the record. They are part of our current negotiations with the industry, the outcome of which we shall report to the House in due course.

Ministerial Visits --

7. Sir Michael Neubert : To ask the Secretary of State for Health what plans she has to make an official visit to Oldchurch hospital, Romford, to assess the effectiveness of the accident and emergency service.

Dr. Mawhinney : As my hon. Friend knows, I had the pleasure of visiting Havering hospitals national health service trust on 14 February this year. It is the responsibility of the local health authority to ensure that the most effective possible accident and emergency service is available for the people of Barking and Havering.

Sir Michael Neubert : Is not any proposal to reduce accident and emergency services, such as that in the Barking and Havering health district, a matter of understandable concern ? Should not ease of access by road and proximity to the main centres of population be the overriding factors in determining the location of casualty departments ? Does not that consideration point to the continuing need for Oldchurch hospital in that all important life-and-death role ?

Dr. Mawhinney : My hon. Friend is right in identifying a number of those features : they are exactly the sort of features, together with the public response, that the health authority must take into account. My hon. Friend will know that, following the public consultation, the health authority has already said that it wishes to have more information before coming to a judgment. I encourage my hon. Friend to keep reflecting to the health authority the views that he has so eloquently expressed on his constituents' behalf, today and to me in private.

Ms Primarolo : The Minister will be aware of the problems already being experienced by Redbridge healthcare trust and that the closure of the Oldchurch hospital will put extra pressure on the accident and emergency units. Will he explain to the House why the Government are not only closing accident and emergency units in London but, with the closure of the Queen Elizabeth hospital in Hackney, plan to reduce the number of paediatric beds in London by more than half by 2003 ? How will children in London be treated under his Government ?

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Dr. Mawhinney : I am happy to be able to tell the hon. Lady that children in London are getting better treatment than they ever have before and that that will continue to be the case. I am aware of the concerns about Redbridge healthcare NHS trust. I am also aware, as the hon. Lady may not be, that the response of the Redbridge healthcare NHS trust to the public consultation was welcoming. It made it clear publicly that it would have preferred the centralisation to be at the Harold Wood hospital. As I have told the House before, if there are to be changes in accident and emergency provision in London, they will take place only when we are entirely satisfied that adequate and appropriate alternative arrangements are in place.

Mr. Wolfson : May I ask a broader question on the issue of accident and emergency units ?

Madam Speaker : Order. The question is much narrower than that. Does the hon. Member's question refer to Romford and Oldchurch hospital ?

Mr. Wolfson : In comparison with the Romford situation, Madam Speaker, what criteria are used, in deciding whether such a unit should remain open, to measure the time that it takes to get emergency cases to accident and emergency units in times of heavy traffic ?

Dr. Mawhinney : As in Romford, Oldchurch, Havering and other parts of the country, it is for the local health authority to consult, taking into account local circumstances and expert advice, before making judgments about what is appropriate.

Civil Servants (Health Scheme) --

8. Mr. Miller : To ask the Secretary of State for Health how many civil servants in her Department have taken up the offer from the Friendly Society to join the health scheme.

Mr. Sackville : This is a matter for the individuals concerned.

Mr. Miller : It is extraordinary that the Minister seems unwilling to comment on advertising that clearly seeks to encourage people to queue- jump in the health service. Will he unequivocally condemn the advertising material that is currently circulating, which encourages queue-jumping among civil servants in his own Department ?

Mr. Sackville : The Post Office and Civil Service Sanatorium Society, now known as The Society, offers certain services that cost its members 45p a week to supplement, rather than substitute for, the NHS. Its 1 million or so public sector or ex-public sector members will take due note of the hon. Gentleman's attitude. Perhaps he will find something more substantive to ask me on another occasion.

Mr. Dickens : Is not it always the Conservative party that has stood for freedom of choice ? Do not we believe that people should be allowed to spend their own money on whatever they choose ? Of course, that is a fact, and long may it continue.

Mr. Sackville : My hon. Friend is absolutely right. The hon. Gentleman's question gives us some foretaste of the horrors to come in the unlikely event of a Labour Government.

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Personal Social Services --

9. Mr. Mandelson : 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 ; and if she will make a statement.

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 seven representations have been received.

Mr. Mandelson : Is the Minister aware that, as a result of the Government's insistence on users paying for services such as home care, day centres and meals on wheels, some of the most frail and vulnerable members of the community must either do without those services or make invidious spending choices between heating or eating and cleaning or laundry ? Does he accept that that undermines any true concept of care in the community ? Does he further accept that the Government have a responsibility at least to monitor and to assess the impact of those charges in every part of the country ?

Mr. Bowis : The answer is no. I do not accept the premise on which the hon. Gentleman makes his assertion. The average charge in Cleveland, the hon. Gentleman's own authority, is 4 per cent. I do not believe that that will cause hardship to anyone who can afford it. I remind the hon. Gentleman that it is entirely up to his authority, which has discretion in the matter, whether to set charges and the level at which to set them. All that we require is that charges are reasonable and reflect the individual's ability to pay. There is no reason on earth why Cleveland council should not exempt people in need or give discounts to those on lower incomes.

Mr. Ian Bruce : Is not the truth that people who might otherwise be forced to enter a residential home and perhaps pay £1,000 a month would like to contribute to the cost of local authority services that enable them to remain in their own homes ? That is good value for money and councils should be encouraged to charge where that is sensible and people can afford to pay.

Mr. Bowis : I entirely agree. My hon. Friend is right to say that people who can afford to pay would think it entirely reasonable to be asked to make a contribution to the cost of the services provided to them. If a reasonable charge taking into account ability to pay is levied, that income can bring more benefits to more people in need and raise the quality of the care provided. That must be in everyone's interests.

Ms Lynne : Is not it a fact that a number of authorities throughout the country are introducing charges for community care and that that is the ultimate responsibility of this Government, because of the underfunding of community care ? Instead of blaming the local authorities, the Minister himself should take responsibility.

Mr. Bowis : That is quite absurd. The average across the country is under 9 per cent. I remind the hon. Lady about the amount that the Government are putting into community care : in the first year, it was £565 million ; this year, it is up to £1.2 billion ; next year, it will be £1.8 billion ; and the year after, it will be £2.2 billion. If she looks at the top-up that we have been able to incorporate

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in that for respite and day care, she will see that the Government are backing councils around the country in enabling them to look after people in their own homes, when that is appropriate and when that is what they want.

Mr. John Marshall : Does my hon. Friend agree that the revenue from the charges allows local authorities to expand the services on offer ? Those who oppose the charges should tell us which services they would cut or which taxes they would increase.

Mr. Bowis : My hon. Friend is exactly right. It does indeed give councils that possibility. The level of charge depends on the level of cost. Cost depends on efficient delivery of service, and in the partnership between the usually good Conservative councils and the independent sector, which provides better services at lower costs, charges will be lower than those in the high-spending, high-cost Labour authorities.

Breast Cancer --

10. Mr. Connarty : To ask the Secretary of State for Health what funds have been allowed by her Department in each of the last three years to support research into breast cancer.

Mrs. Virginia Bottomley : The Government spent £3.8 million on breast cancer research in 1992-93, of which £3.1 million was through the Medical Research Council. My Department provided £381,000 in 1990- 91 for research specifically into breast cancer ; £526,000 in 1991-92 ; and £607,000 in 1992-93--an increase of 59 per cent. over the three years.

Mr. Connarty : I am very disappointed with the answer that I have just received from the Minister. It reeks of complacency in the light of the 26,000 cases that are diagnosed every year and the 16,000 deaths among women in the UK every year. I wonder whether the Secretary of State shares the concern of Professor Baum, who spoke to the all-party group on breast cancer, and said that the incidence of breast cancer in Britain is increasing faster than diagnosis through screening. Does she support his contention that research in molecular biology is the way forward ? Is she aware of the £15 million that the Royal Marsden is trying to raise for research into breast cancer ? Will she show some seriousness in the matter and put some serious money into the research to help the women who are frightened by the growing incidence of breast cancer in this country ?

Mrs. Bottomley : We give extremely high priority to breast cancer, it being the most common form of cancer suffered by women. One in 12 women is likely to develop some form of breast cancer at some stage. The hon. Gentleman mentioned Professor Baum. I received a letter from him only yesterday commending the excellent mammography screening service that takes place in this country and referring to the great improvement in life expectancy, which he--as the hon. Gentleman will understand--was also associating with the need to take forward some of the treatments that he advocates.

Mrs. Ann Winterton : Is not my right hon. Friend concerned about the high incidence of breast cancer ? As one who has recently been screened, I commend her on the screening process and suggest that it be widened, but is she

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aware that we need to put more resources towards research, because, at the end of the day, that will save the NHS money on treatment costs ?

Mrs. Bottomley : I accept my hon. Friend's comments. She may wish to know that 7 per cent. of all expenditure on the health service goes on the treatment of cancer. The screening programme has been a success. Some 70 per cent. of people keep their appointments. I am concerned, as my hon. Friend will be, about the 30 per cent. who are not keeping their appointments. We know that we could do better in picking up cases earlier if only people would keep their appointments. As for research funding, we have to weigh this matter alongside other important priorities.

Dr. Wright : Did the Minister see the recent "Panorama" programme in which many women who were dying of breast cancer described how their impending death would be the result of inadequate clinical treatment in the areas where they lived ? Is not it a disgrace that high-quality, specialist treatment is not available to every woman who needs it ? Why will not the Government divert their attention from the organisational mayhem that they are causing inside the health service and devote their resources to driving up clinical standards ?

Mrs. Bottomley : Frankly, I deplore programmes that seek to generate great alarm unreasonably among members of the public. I know that that is the Labour party's stock in trade, but I nevertheless deplore it.

The standard of treatment for cancers is improving all the time and life expectancy is increasing as a result. However, as we learn from the most beneficial forms of intervention, we need to carry forward good practice. An expert advisory committee reports to the Chief Medical Officer on cancer generally and I hope that we will be able to produce better guidance on cancers that need to be treated at specialist centres and those that can be properly treated at local centres.

District Health Authorities --

11. Mr. Paice : To ask the Secretary of State for Health what steps are being taken to ensure that district health authorities involve the public fully in their purchasing decisions.

Dr. Mawhinney : I wrote in January this year to all district health authorities to ensure that arrangements were in place to seek, and act upon, the views of local people. The responses to my letter indicated that many, but not all, authorities had done much good work to involve local people.

I have asked the chief executive of the national health service executive to write to regional directors to ensure that appropriate action is taken locally to address identified shortcomings and to report back to me later in the year.

Mr. Paice : I thank my right hon. Friend for that reply. Does he accept that the convenience of facilities is vital, especially to people living in rural areas ? In that context, is he aware that my constituents in Ely are anxious for the Princess of Wales former RAF hospital to have a wide range of services, including the treatment of minor injuries and, they hope, day surgery in the near future ? Will he speak to the local health authority to ensure that it notes the views of local people, not just those of the professionals involved ?

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Dr. Mawhinney : My hon. Friend is right to draw particular attention to the issue of convenience as it relates to people who live in rural areas. That is one of the issues that I have drawn to the attention of the service generally. As for the latter part of my hon. Friend's question, I know that he and other Conservative Members are acting assiduously on behalf of their constituents--not least because they have already raised the matter with me.

Mrs. Anne Campbell : Is the Minister aware that if the public in my constituency had been consulted about purchasing decisions, they would have asked for resources to cut the present four-year waiting list to see an orthopaedic consultant at Addenbrookes hospital ?

Dr. Mawhinney : I am encouraged by the fact that, for the first time that I can remember, the hon. Lady is starting to take a constructive attitude to the delivery of health care in her constituency.

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