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House of Commons

Tuesday 24 May 1994

The House met at half-past Two o'clock


[ Madam Speaker-- -- in the Chair ]


River Calder (Welbeck Site) Bill [

Lords ] Read a Second time, and committed.

Oral Answers to Questions


Care in the Community --

1. Mr. Harry Greenway : To ask the Secretary of State for Health what assessment she has made of the progress of care in the community ; and if she will make a statement.

The Secretary of State for Health (Mrs. Virginia Bottomley) : The community care reforms have got off to a good start, a view confirmed not least by the Association of Directors of Social Services--who are responsible for implementing them--and by the Audit Commission. I am confident that the foundations have been laid for a system providing quality, diversity and choice for users and carers. In implementing care in the community, we must be sure that the most vulnerable patients, especially those who are severely mentally ill, are cared for properly. That is why I am introducing a series of measures, including supervision registers and the proposed new power of supervised discharge, to protect both patients and the public.

Mr. Greenway : Is not it typical of this Government that they should put the vulnerable first ? Will my right hon. Friend assure me that under no circumstances will dangerous people be released from psychiatric care into the community, where they could be a threat to others ? Will she also reassure all elderly people that they will always have the hospital and medical treatment that they need, regardless of their age ?

Mrs. Bottomley : We recently issued guidance on the discharge of patients from psychiatric hospitals. Patients should not be discharged unless or until it is safe to discharge them. We are also introducing supervision registers and hope to introduce the power of supervised discharge. No one wants to turn back the clock to the old days of incarceration in isolated communities, but there are psychiatric patients who need active support in the community ; they need resources targeted on them and we seek to achieve that. My hon. Friend will be well aware that his constituents, like mine, have increased their life expectancy by another two years in the past 10 years. Some

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16 per cent. of the population are over 65, and 40 per cent. of the health budget is spent on them--and quite rightly too.

Mr. Hinchliffe : Is the Secretary of State aware of the very real fears among many people concerned with community care over the Government's proposals to reduce the number of inspections of care and nursing homes, bearing in mind the circumstances of the recent case of a woman in a private nursing home in Dulwich who died with ulcers which had live maggots on them at the time of death ? [Hon. Members :-- "Oh No."] Conservative Members may shout, but in my constituency an elderly lady choked to death in a private care home simply because the staff had no basic first aid training. In view of those cases, is not it nonsensical to move towards reducing inspections ? Should not we be increasing them instead ?

Mrs. Bottomley : Care in the community provides support for some of the most frail and vulnerable. They need access to complaints procedures and confidence in the places where they live. However, there is a difference between inspections satisfying standards of care and petty bureaucracy and interference. Many of my hon. Friends report from their constituencies concerns that left-wing authorities have been hostile to the private and independent sectors. We want to reduce some of the petty regulation. None of that should undermine the safety of the individuals concerned.

Mr. Barry Field : Has my right hon. Friend seen the threatening letter that the Liberal Democrat-controlled Isle of Wight county council sent to pensioners about care in the community, despite the fact that the Government gave the council an additional £1 million ? Does not that have more to do with political ambition than with providing care in the community ?

Mrs. Bottomley : My hon. Friend, who is a great champion of the Isle of Wight, is absolutely right. Care in the community has been formidably generously funded.

Madam Speaker : Question 2. Mr. Dalyell.

Mrs. Bottomley : May I finish my answer, Madam Speaker ?

Madam Speaker : I thought that the right hon. Lady had finished. We seem to have made a very bad start with questions today. I hope that hon. Members will be more brisk from now on. Of course the right hon. Lady must finish what she has to say.

Mrs. Bottomley : I know the Liberals only too well in the Isle of Wight, as does my hon. Friend. I also know the Liberals in Portsmouth, who circulated scare stories about pensioners paying prescription charges. That is par for the course. We get on and deliver the policies and fund them fairly.

Human Foetus Research --

2. Mr. Dalyell : To ask the Secretary of State for Health what representations she has had from the Research Defence Society about her policy in relation to research on the human foetus.

The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville) : I have received no such representations

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Mr. Dalyell : How come that in January, Ministers welcomed the public consultation that was initiated by the Human Fertilisation and Embryology Authority on donated ovarian tissue, yet come April, they agreed to an amendment tabled by the hon. Member for Birmingham, Edgbaston (Dame J. Knight), apparently drafted in their Department, to the Criminal Justice and Public Order Bill, which completely pre-empted what they had said back in January ? What happened to change their minds between January and April ?

Mr. Sackville : May I make it absolutely clear to the House that the drafting help that was afforded to my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) was simply to put her amendment in order? It was the subject of a free vote in the House of Commons and, in the event, it went through on the nod. Every single hon. Member was able to vote entirely according to his or her conscience.

Dame Jill Knight : Is my hon. Friend aware that I was in touch this morning with the Research Defence Society, with which I have some connections ? The society assured me that it has absolutely nothing to say about the matter, and that the hon. Member for Linlithgow (Mr. Dalyell) had been misinformed. The society exists to protect research against animal liberation groups and is absolutely nothing to do with the preservation of human fertilisation from the eggs of aborted foetuses.

Mr. Sackville : While I am aware of the continuing and consistent interest in research of the hon. Member for Linlithgow (Mr. Dalyell), I am also aware of the accuracy of what my hon. Friend has said.

Health Service Staff --

3. Mr. Win Griffiths : To ask the Secretary of State for Health what estimate she has made of the effect of this year's pay award on the number of health service staff employed by trusts and health authorities.

Mrs. Virginia Bottomley : None. The pay award is covered by efficiency savings. The estimate that we have made is that by using efficiently the extra £1.6 billion provided for the National Health Service this year, a further 4 per cent. of patients will be treated.

Mr. Griffiths : I thank the Secretary of State for that answer ; I hope that it turns out to be true. If it is, I ask her to speak to the Secretary of State for Wales, because the chairman of the trust in my constituency, which is in Wales, has written on behalf of all the other trusts to tell him that the provision made for funding in Wales will result in cuts in staff and services to patients. Will she please give him advice on how to achieve the targets about which she has just told me ?

Mrs. Bottomley : I have frequent discussions with my right hon. Friend the Secretary of State for Wales. Both of us are determined to put patients first and to use the resources that the taxpayer gives to the health service to provide an ever higher quality and quantity of care. That is taking place in Wales, and in England, too.

Mr. Rowe : Is my right hon. Friend aware that one of the inhibitions to the continuing astonishing success of the trusts is the continuation of the Whitley national scales ?

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Will she give the House some assurance that that shadow, which hangs over all the negotiations conducted by trusts, will soon be looked at again ?

Mrs. Bottomley : One of the most important freedoms that NHS trusts have is the ability to devolve pay and negotiations. Pay is the central cost in the NHS, and inflexible, rigid patterns, much loved by the Labour party--the poodle of the public sector unions--is an inhibition to our using our staff as flexibly and effectively as we can for patients.

Community Care --

4. Mr. Ronnie Campbell : To ask the Secretary of State for Health when she last met representatives of the local authority associations to discuss community care changes.

11. Mr. Heppell : To ask the Secretary of State for Health when she last met the Carers National Association to discuss the community care changes.

The Parliamentary Under-Secretary of State for Health (Mr. John Bowis) : I frequently meet the local authority associations and the Carers National Association to discuss a range of issues including community care.

Mr. Campbell : When the Minister next meets the association, will he take up the case of community care for drug abusers ? Is he aware that five teenagers in my constituency have died over the past two years, four of them in the past six months ? People are beginning to feel that care in the community is not quite working. Although some money has been put into it, we feel that those teenagers died without even getting to the first stage of care in the community. Will the hon. Gentleman call for an inquiry into the circumstances surrounding their deaths ?

Mr. Bowis : I am sure that the hon. Gentleman, from his experience in Northumberland, will acknowledge that the inspectors of social services have recorded that a very good start has been made there. That is a great tribute to Northumberland's director of social services.

The hon. Gentleman rightly referred to one particular point about young people. I am aware of the problem affecting them--it is solvent abuse. I am also aware, as he is, that a special group has been set up to look into the problem. It will report to the health authorities, which can then take appropriate action.

Mr. Heppell : Does the Minister accept that carers of people with psychiatric disabilities need respite as much as, if not more than, other carers ? How does he account for the fact that although 25,000 psychiatric beds have been lost from hospitals, only 9,000 additional places have been provided in day centres ? Why is there such a disparity ?

Mr. Bowis : The hon. Gentleman raises an important point and I fully accept that carers need a break. The whole House would pay tribute to the contribution of carers to care in the community and community care. That is one reason why, in this year's financial settlement for local government, we incorporated an additional £20 million for respite services for carers. We want to build on what has been achieved.

The hon. Gentleman is right to say that it is important that health authorities, when planning their services, take account of the need for respite care in psychiatric cases as well as the need for acute services. I am sure that he is

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pleased about the recent report from the Carers National Association, which shows that of those surveyed who had had an assessment, 78 per cent. had received some form of respite in the previous year.

Mrs. Lait : Will my hon. Friend ask East Sussex county council how it justifies the Lib-Lab policy of referring all respite care cases to county council homes, at a cost to the council taxpayer of £100 per week more than the cost in the private sector ? Does he agree that that is a waste of public money--some £3.5 million a year--and will he please tell the council to stop it ?

Mr. Bowis : I shall certainly pass on my hon. Friend's words to East Sussex county council. I cannot answer for Labour or Liberal policies in that area ; I doubt whether the House could understand them even if the parties explained them themselves. It is right to say, however, that if authorities fail to use the range of provision available, including the whole of the independent sector--private and voluntary--they will not get the best service for those in need in their areas. I imagine that the Audit Commission, when it does its surveys, will have something to say about that.

Mr. Waterson : Does my hon. Friend agree that this would be a good moment to remind local authorities, including East Sussex county council, that the 85 per cent. figure for funding in the independent sector is a minimum, not a maximum ?

Mr. Bowis : My hon. Friend is right. That 85 per cent. represents the continuation of the 100 per cent. provision for support for community care in the independent sector under the old social security system. The purpose of the 85 per cent. figure is to give stability to the voluntary and private sectors during this period of change--and, indeed, stability for the residents in the homes. It is also to give authorities and the private and voluntary sectors time to diversify so that they can make an even greater contribution to community care.

Mr. McCartney : Would the Minister like to be a bit more candid about the issues raised in the report of the Carers National Association ? Did not 93 per cent. of respondents say either that services had not improved or that they had worsened since the introduction of community care ? Perhaps the Minister could be a bit more open about the problems affecting both funding and access to services. That would help the Opposition to come to terms with many of the problems that carers now face- -the greatest of which is the Government's disastrous policy of trying to write off the Civil Rights (Disabled Persons) Bill. Can the Minister give us some indication of whether his Department will provide more time for that Bill, so that it can become law ?

Mr. Bowis : I suppose that the hon. Gentleman has read the report to which he referred. I certainly have, but, having listened to the hon. Gentleman, I suspect that he has only read the press release that accompanied it. He would learn most by reading the entire report, and I commend it to him.

If he had indeed read the report, the hon. Gentleman would know that the survey was carried out just a few months into the new community care system. More important, he would have read that 72 per cent. of carers interviewed said that they had found the assessment thorough, 75 per cent. said that they had received a break,

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92 per cent. said that they encountered no difficulty in obtaining services at weekends and 92 per cent. said that they felt that their position was at least as good as it had been before, if not better. We care about carers. We recognise the contribution that they make, and we are intent on working with them and continuing to improve care for people in need in our community.

Madam Speaker : We must be brisker.

Rev. Martin Smyth : I welcome some of the positive advances that have been made, but will the Minister bear in mind early-day motion 1176, which reveals some anxiety in the House about the concern expressed by the Carers National Association in regard to needs still to be met ?

Mr. Bowis : We shall continue to work with carers, and with the hon. Gentleman, if he brings any specific matters to our attention. I cannot say off the top of my head that I am acquainted with the early-day motion that he mentioned, but we shall examine the issue carefully with the carers. As the hon. Gentleman said, progress is being made ; we look forward to further progress in the future.

General Practitioners' Contract --

5. Mr. Oppenheim : To ask the Secretary of State for Health what representations she has received about the general practitioners' contract.

The Minister for Health (Dr. Brian Mawhinney) : We have received various representations on aspects of the general practitioners' contract. We welcome the continuing and constructive discussions with the profession, and others, that have resulted.

Mr. Oppenheim : Will my right hon. Friend cast his mind back to what was said when the GPs' contract was being introduced ? Did not both the doctors' trade union and the Opposition go around frightening the sick and the vulnerable, telling them that cytology and immunisation would decrease and doctors' lists would massively increase ? Given that the result of the contract has been a significant improvement in services, how can we trust any pronouncement from the Labour party, which was prepared to use the sick and the vulnerable as pawns in its own political game ?

Dr. Mawhinney : My hon. Friend is absolutely right. The Labour party was against the contract and against deprivation payments ; through its spokesman, it said that the immunisation levels were too heroic for GPs to attain. In all respects, indeed, the Labour party has been as wrong as it was about Jennifer's ear. I extend that deprecation to all on the Opposition Benches--apart from Offa, whose last Health Question Time this is. I wish her a long, happy, peaceful and politics-free retirement.

Ms Lynne : Can the Minister assure the House that under the new GPs' contract that is currently being negotiated, which would allow GPs to stop night visits other than in exceptional circumstances, other services such as night surgeries will be in place before any GP night visits are curtailed ? Although I understand the reason for the changes, I think that patients' needs must be protected.

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Dr. Mawhinney : The whole House will be disappointed that the hon. Lady did not rise to apologise to the pensioners of Portsmouth, and those in need on the Isle of Wight, for her party's policies. I am happy to confirm, however, that 24-hour cover, home visits and GPs' responsibility for their patients have been retained, and that over time primary care centres will be developed, providing an additional option for patients.

Notifiable Diseases --

6. Mr. French : To ask the Secretary of State for Health what is her policy in respect of additions to and subtractions from the list of notifiable diseases.

Mr. Sackville : The notification system is one of the methods by which health authorities are alerted to the need to prevent further cases of a communicable disease. It also assists in the planning and valuation of long-term preventive strategies, such as immunisation campaigns.

Mr. French : Is my hon. Friend aware that the streptococcal infection known as necrotising fasciitis--a galloping gangrene-type disease, which can eat human flesh at the rate of an inch an hour--is not on the list of notifiable diseases ? Does not he feel that the definition of "notifiable" ought to be revised to include conditions that are rampant and lethal and in respect of which early diagnosis and recognition of the symptoms may make the difference between life and death ?

Mr. Sackville : I can assure my hon. Friend that if notification in any way contributed to the treatment of the individual patient or to the prevention of the infection spreading to other patients, I would certainly recommend it. I am aware that a number of severe streptococcal infections become necrotising fasciitis. It is extremely rare that there is a cluster of such cases such as that in his area, which is being investigated urgently by the Public Health Laboratory Service. I am advised by leading public health experts that, except for the Gloucestershire cluster, the pattern and number of those cases is not out of line with what is normally expected. However, I assure the House that we will continue to do everything possible to find the source of those infections and ensure that there are not further incidents.

Mr. Blunkett : I do not think that the House or the country will be at all satisfied with that reply from the Under-Secretary. Is not the cluster in Gloucestershire completely out of line with previous experience ? Will the Under-Secretary tell the House not only what the PHLS is doing but what steps he and the Secretary of State intend to take to allay understandable fears by indicating how the infection is being tracked and what preventive measures are being taken across the country to ensure that this extremely worrying development is laid to rest ?

Mr. Sackville : I can tell the hon. Gentleman that the literature on the subject reports that there has been only one other case of a cluster of such infections, which was in Norway. We are leaving no stone unturned in trying to locate the reason for the cluster and find the connection between the cases, some of which, tragically, have been fatal. The Public Health Laboratory Service is investigating and is giving every assistance to the local national health service staff in Gloucestershire. That process will continue until we have some answers.

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Mr. Knapman : My hon. Friend will be aware of the real concern and anxiety that exist in Gloucestershire, especially in my constituency. My hon. Friends and I met the chairman and the chief executive of the local national health service trust recently and they are doing all that they can. Will my hon. Friend assure the House that the Department of Health will do its very best to try to find a cure to this awful disease at the earliest possible date ?

Mr. Sackville : It appears that, when the infection reaches the stage of necrosis, the only answer is surgery. We will ensure that those cases, if they continue to appear, are treated with all dispatch.

General Practitioners --

8. Mr. Mandelson : To ask the Secretary of State for Health how much, on average, general practitioner fundholders spend on purchasing health care in the private sector.

Mrs. Virginia Bottomley : General practitioner fundholders can purchase health care from whichever hospital best suits the needs of their patients. In 1992-93, fundholders spent just over 1.5 per cent. of their budget with non-NHS organisations. In doing so, they have improved waiting times, convenience and standards of service for patients.

Mr. Mandelson : Is not it a scandal that the draining of public funds from the national health service to private medicine has doubled since 1991 and that the national health service has been denied much-needed cash as a result of that policy ? Is not it also a classic illustration of the two-tier health system that the Government are creating ? Is not it now time for Ministers to impose a strict limit on that diversion of public funds to private health care ?

Mrs. Bottomley : The hon. Gentleman may think that 1.5 per cent. is a substantial sum, but I have to disagree. As ever, he is scaremongering and speaks as the political apparatchik that he is. His obsession with the ownership of the means of production shows him to be the clause 4 socialist so typical of the Labour party. He failed to tell us that no patient in his constituency waits more than 12 months for treatment and that a maternity unit there recently received a quality award and has won "Heartbeat" awards. There have been a great many developments, in addition to the further initiatives pioneered by fundholders, from which all patients benefit.

Mr. Forman : Did I hear my right hon. Friend say 1.5 per cent ? Does not that represent exceptionally good value for money for patients and for the health service ? What proportion of general practitioners are now in fundholding practices ?

Mrs. Bottomley : Yes, my hon. Friend is exactly right. A modest amount is now spent in the independent sector, but we are motivated by patients, not by the means of providing care. We want to look for ever- better value for money that provides quality and quantity of patient care. Just over 35 per cent. of the population benefits from GP fundholding practices, but we want to extend the benefits of fundholding as far and wide as we possibly can. Fundholding has changed the balance of power in the NHS and changed it in favour of the patient.

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Ms Primarolo : Is the Secretary of State aware that £268 million--a not insubstantial amount--was spent in private hospitals in 1992 -93 ? Is she also further aware that one fundholding practice in Colchester spent 90 per cent. of its funds at a local private hospital ? Does she agree that it is unacceptable that taxpayers' money should be used to subsidise private hospitals and private profit when national health service hospitals are running out of money and turning patients away ? When will she protect the NHS against private medicine--a move which would benefit patients ?

Mrs. Bottomley : Now you see them in their true colours, Madam Speaker--a party dominated by the public sector unions. Patients will not trust the Labour party until its spokesmen renounce their National Union of Public Employees sponsorship. The Labour party is dominated by the interests of the public sector unions, not the interests of patients. I recall Barbara Castle's comments on her decision to abolish pay beds. She said that it was

"an essential political sweetener for the unions."

A recent document again revealed the vendetta against the private sector and the private bed. Our prejudice is in favour of patients.

Mr. Congdon : Does my right hon. Friend agree that fundholders have introduced innovation in their approaches to patient care, which have demonstrated the benefits of devolved budgets ? Is she aware that GP fundholders not only spend under their drug budgets but spend less than non -fundholders ?

Mrs. Bottomley : My hon. Friend identifies precisely why GP fundholding has been so successful. GP fundholders prescribe around 4 per cent. more cost effectively than non-fundholders. That is one of many examples of the way in which GP fundholders have used the resources at their disposal cautiously and effectively, acting as good stewards so that they can extend the quality and quantity of care. GP fundholders are not given more money, but do more with the money that they are given. We want to level up a top-tier service.

Asthma --

9. Mr. McFall : To ask the Secretary of State for Health what is the estimate of the number of individuals suffering from asthma in each of the past five years.

Mr. Sackville : A recent estimate suggests that there are 2.5 million in the United Kingdom.

Mr. McFall : Does the Minister realise that asthma is now the health scandal of the 1990s ? There are more than 3 million sufferers, and one in seven of all children suffer from the disease. In addition to the human suffering, there is an economic cost. Does he accept that any preventive medical programme should take that into consideration ? When will the Government start doing something about the increasing number of asthma sufferers ?

Mr. Sackville : The hon. Gentleman shows his total ignorance of the fact that the new doctors' contract includes a chronic disease management programme, which means a call and recall system for asthma sufferers to ensure that their management of the disease is properly organised, that they are monitored and that they are aware of all the medication and of all the other action that can be taken.

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Mr. Jenkin : Will my hon. Friend undertake to re-examine "The Health of the Nation" and to think about setting targets for asthma prevention, as I understand happens in Scotland ?

Mr. Sackville : Yes, but we believe that we shall make a great deal of progress on asthma treatment now that we have a proper monitoring programme within primary care.

National Health Service Trusts --

10. Mr. Ainger : To ask the Secretary of State for Health how many NHS trusts have cut any senior executives' pay following the establishment of a remuneration committee.

Dr. Mawhinney : That information is not available centrally.

Mr. Ainger : That answer does not surprise me, but several independent reports and monitoring services have suggested that when trusts move from general management control within the NHS to so-called independence, the senior executives receive very significant pay rises. Moreover, the independent monitoring services have identified the pay rises for 1992-93--the latest year for which trust accounts have been published-- and found that some chief executives received increases in salary of 33 per cent. Is not it possible for the Government now to instruct the trusts to set up proper remuneration committees to ensure that that gravy train is ended ?

Dr. Mawhinney : I am sure that the hon. Gentleman's trade union friends will be pleased by that pat on the back. On 28 April, the Secretary of State announced codes of conduct and accountability that require NHS bodies to establish audit and remuneration and terms of service committees. That happens to be the case. I shall give the hon. Gentleman some information for which he need not look to monitoring committees : for every manager in the health service there are 26 doctors and nurses and senior and general managers represent 2 per cent. of the work force and 3 per cent. of the wages bill. What is most important, and what the Labour party has again demonstrated that it does not understand, is the fact that the health service exists to deliver more patient care, of higher quality, and at greater convenience, year on year. That is what is happening, and managers are playing their part in making it happen.

Mr. Hayes : Does my right hon. Friend agree that the perpetual scaremongering by the Labour party does appalling damage to morale in the health service, where there is really a hell of a lot of good news ? Is not that scaremongering nothing more than cynical manipulation of the fears of the elderly and frail ?

Dr. Mawhinney : My hon. Friend should understand that Labour scaremongering is really embarrassment and an attempt to cover up the paucity of Labour health policy. The truth is that for every 100 patients treated in the year before the reforms, this year we expect to treat 121--a marvellous record. When the Labour party was in power, 1 per cent. more patients, on average, were treated in the health service each year. Since our reforms, more than 5 per cent. more patients, on average, have been treated per

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year. That is a measure of the co-operation of the doctors, the nurses, the other professionals and the managers in developing more and better health care.

Mr. Blunkett : How the Minister knows that, when he does not collect the information centrally, is beyond all of us. In view of his original answer--that the information is not collected centrally--perhaps he will tell us why the Gloucestershire royal trust, in a letter to me dated 13 April, said that it would not answer any questions from Opposition Front- Bench spokesmen-- [Hon. Members :-- "Hear, hear."]--and would answer only to the NHS management executive ? And does not that "Hear, hear" from Conservative Members reveal that the Conservative party has abandoned even the least pretence of believing in democracy ?

Dr. Mawhinney : First of all, as the hon. Gentleman knows, the decisions of the trust are a matter for the trust. [Hon. Members :-- "Oh!"] The decisions of the trust are a matter for the trust. As the hon. Gentleman and Labour Members continually denigrate the work of those who work in the health service, it may be that the trust has decided to side with those who work in the trust providing more and better patient care, rather than pampering to the political ideology of the Labour party.

Practice Nurses --

12. Mrs. Roe : To ask the Secretary of State for Health how many practice nurses are currently employed by general practitioners ; and what the figures were in 1979.

Dr. Mawhinney : Many practice nurses work part time. Translated into whole-time equivalents, the number rose from 992 in 1979 to 9, 605 last year--an increase of nearly 900 per cent.

Mrs. Roe : Does not that figure show clearly the phenomenal development in primary care and general practice since 1979 ? Can my right hon. Friend confirm that the opportunity for GPs to delegate a wide range of tasks to practice nurses both eases their work load and makes a significant contribution to the achievement of targets on immunisation and screening ?

Dr. Mawhinney : As always, my hon. Friend has it exactly right. She will be pleased to know that in 1979 there were approximately 20,000 practice staff and in 1993, the figure had risen to approximately 54, 000. To put it another way, in 1979, we were spending £43 million on practice staff and last year, we spent £514 million on practice staff, which has enabled GPs to do precisely what my hon. Friend identified.

Mr. Bayley : Will the Minister agree to bring in a change to the funding of the health service so that the same capitation funding formula applies to fundholding and non-fundholding GPs, the two-tier system is abolished and the patients of both types of GP have an equal opportunity to benefit from practice nurses ?

Dr. Mawhinney : There no two-tier system, as the hon. Gentleman knows--there is a proper allocation of capitation resources to fundholders and non-fundholders. Indeed, I believe that I am right in saying, if he casts his mind back to the evidence that I gave to the Select Committee when he was a member of it, that some of the

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