Read the Third time, and passed.
The Minister for Health (Mr. Gerald Malone): Some 177,752 adult and 1,154 child patients were deregistered by dentists in the year ending 18 November 1994, but 1 million more patients were registered at 30 September 1994 than at 30 June 1992.
Ms Anderson: What advice would the Minister offer to my constituents in Haslingden, who have been told by their dentist, Gillian Burn, that, as a direct result of the Government's Green Paper, she is no longer able to treat them under the NHS?
Mr. Malone: Where dental services cannot be found from a local dentist, they are available through family health services authorities. Haslingden, which has a population of 14,000, is served by three dental practices, but NHS dental services are available in neighbouring villages. Service are available and we are monitoring the position closely.
Mr. Malone: My hon. Friend will be well aware that we published the Bloomfield report and the Green Paper that followed thereafter and that there have been consultations with the dental profession. Dentists have provided constructive opinions about moving towards a purchaser-provider relationship in the longer term. We are now dealing with other issues raised in the Green Paper and I hope that we can make some progress on that. We sent officials around the country to garner opinion from dental practitioners. It was a comprehensive and proper survey and we are now considering the results of that comprehensive test of dentists' opinion.
Column 126salaried dentists are available, but in my area, which has an establishment of four dentists, only one has been recruited. That is hardly surprising when the salary being offered is £15,000 a year. When will the hon. Gentleman open his eyes to the crisis facing people looking for dental treatment?
Mr. Malone: The fact that the hon. Gentleman must recognise is that, since 1992, adult registrations have risen substantially and the number of dentists practising within the NHS has also risen. He cannot say that a service where expenditure has risen by some 53 per cent. in real terms since 1979 is in decline; it is not. Of course there are concerns that must be dealt with--that is why we looked at Bloomfield, that is why we published the Green Paper and that is why we have had the most significant consultation exercise for dentists that has been undertaken in recent years.
Mr. Illsley: Is there not now a real crisis in NHS dentistry, with a rising number of areas in which NHS dentistry is not available even to existing registered patients? Bearing in mind that the proposals to which the Minister referred will take some years to come to fruition, how will he ensure that NHS dentistry is restored to those areas now?
Mr. Malone: The Government undertook, in discussions on the Green Paper and during the consultation period, to underpin the provision of NHS dentistry, and the profession as a whole has welcomed that. I hope that we can make progress so that we can get the total provision of dentistry back on to the stable footing that we all want. The hon. Gentleman is wrong--NHS provision is made by dentists who give NHS cover, by family health services authorities directly employed dentists or by community dental services in other areas. The service exists and it is working. Everyone who needs dental treatment under the NHS gets it.
Mr. Allason: Does the Department have a policy on deregistration? Is my hon. Friend aware of the suspicion that a large number of dentists are making any excuse to deregister their patients because of the lack of NHS remuneration? One constituent of mine was refused further treatment by a dentist when he failed to keep an appointment. Although that was obviously an expensive inconvenience for the dentist, it appears that no other dentist in the same FHSA is willing to take on that constituent.
Mr. Malone: If my hon. Friend will write to me with details of that particular case, I will be happy to consider it. The system of continuing care payments ensures that somebody remains registered for two years. I am not sure whether the case that my hon. Friend raised falls into the category of someone rolling out after the two-year period, which happens frequently.
Column 127of our health reforms. That is a further demonstration of our commitment to ensuring the proper stewardship, and the effective use, of NHS resources. Both my Department and the NHS always take the commission's reports seriously and ensure that, where necessary, improvements in practice result.
Mrs. Campbell: Has the Secretary of State taken any notice of the representations made to her by Councillor Janet Jones of Cambridgeshire county council about the underfunding of community care? Would the right hon. Lady like to follow her advice to Cambridgeshire county council and get her act together in respect of underfunding of community care? Will she make sure that Government policies are properly funded?
Mrs. Bottomley: One difficulty faced by local government is the regrettable change of political control of many social service departments. The responsible stewardship to which we had become accustomed from Conservative county councils is sadly lacking among many hung or Labour- controlled councils. The county councillor in question has failed to point out that Cambridgeshire had a 20 per cent. increase in funding for personal social services this year--an extra £10 million. Next year, it will increase by another 13 per cent. If Labour-controlled councils are unable to exercise responsible stewardship, it looks bad for the future of local government, and that is the message of the Audit Commission.
Mrs. Roe: Does my right hon. Friend agree that, thanks to Government reforms, NHS expenditure is now subject to the careful scrutiny of the Audit Commission's external auditors? Is that not particularly important, given the substantial extra money that the Government are giving the NHS? When will my right hon. Friend be in a position to detail how that money will be allocated between different health regions next year?
Mrs. Bottomley: I endorse my hon. Friend's comments. The substantial increase in NHS funding is recognition of the priority that we attach to the service. A £1.3 billion cash boost will be available, and much better value for money will be achieved because of the measures in hand. I am pleased to tell my hon. Friend that I am placing in the Library and in the Vote Office today details of allocations to regions of next year's extra funding. Her region of North Thames will receive an additional £153 million.
Mr. Hinchliffe: Does the Secretary of State recall that the Audit Commission report "Finding a Place" made specific reference to problems arising in the allocation of resources for community care? Is she aware that at least 12 local authorities controlled by various political parties have run out of care funding, with four months still left before the end of the current financial year? Is it not a disgrace that pensioners are having to go to court to obtain basic care services? Should not the Secretary of State, rather than local councils, be in the dock?
Mrs. Bottomley: It is extremely irresponsible to exploit old and vulnerable people's fears about the discharge of the responsibilities that, as the hon. Gentleman knows full well, local government wanted to take on. This year, local government has an extra £1.2 billion for community care. Those are very substantial sums indeed. Next year, the increase will be 10 per cent.
Column 128So, overall, local government spending on social services will have doubled in four years. Every local authority in the country has extra money for personal social services this year, but all of them must learn the message that the health service had to learn--that each year contains 12 months, not nine. Running out of money after nine months and frightening old and vulnerable people is irresponsible. Good stewardship is the only way in which to get the trust of the public.
Mr. Whittingdale: Is my right hon. Friend aware that the Audit Commission estimated that some £50 million could be saved if general practitioners prescribed just 20 generic drugs? Will she take further steps to encourage generic substitution, and in particular, measures such as the institution of a tick-in system on the prescription form?
Mrs. Bottomley: My hon. Friend makes a further suggestion on how we can curb the rising costs of prescribing. A particularly succesful measure has been the introduction of GP fundholding. The prescribing increases of GP fundholders are going up by 3 or 4 per cent. less than those of non- fundholding GPs. There are many measures to be considered. It is quite clear that, with the extra money that the taxpayer has made available to the health service, we have a duty to ensure that we root out waste and use the money saved in that way as effectively as possible for the benefit of patients.
The Parliamentary Under-Secretary of State for Health (Mr. John Bowis): We have put in place a range of measures on research into the causes and triggers of asthma, and on the care and education of asthmatics, including the chronic disease management programme run by general practitioners.
Dr. Howells: Given that there is no cure as such for asthma and that many people who suffer from that illness must take expensive cocktails of drugs for the rest of their lives to stay alive, will the Minister take the advice of the Select Committee on Health and undertake a review of prescription charge exemptions?
Mr. Bowis: We always look at the cases for prescriptions. We provide the inhalers and drugs for nebulisers on GP prescription, and the nebulisers come on prescription from hospitals. However, the hon. Gentleman is quite right to point out that there is, as yet, no cure. Research shows that the causes are probably of a genetic predisposition, followed by triggers which start off asthma attacks. It is important to put money into research. The good news is that, this year, we have been able to put an additional £5 million into research into respiratory and related diseases.
Mr. Congdon: Given the dangers that asthma presents, does my hon. Friend welcome the fact that 90 per cent. of GPs are now signed up to the chronic disease management programme? Is he aware that, if that is to be a success, he will have to ensure proper liaison with the Department for
Column 129Education, to ensure that teachers participate, and co-operate fully, in allowing children to use their inhalers in school?
Mr. Bowis: My hon. Friend makes two important points. Some 90 per cent. of GPs are signed up and participating in the chronic disease management programme. That is an enormous step forward, but it is no less important that schools work alongside school nurses and take their advice, because it is given not only to the children who unfortunately suffer from this condition, but to the teachers who can help them.
Mrs. Helen Jackson: Is the Minister aware that a survey of children's health carried out in Sheffield three years ago showed that no fewer than 26 per cent. of school children in the area had suffered from asthma at some time in their lives? Does he accept that a major cause of that worrying increase is the rundown of good-quality public transport in Sheffield and elsewhere, and the consequent increase in private car use? What is the Minister doing--in consultation with his colleagues in the Department of Transport--to ensure that urgent action is taken to upgrade public transport?
Mr. Bowis: As the hon. Lady may know, I am the first to advocate good public transport. Traffic does not cause asthma, although it may well be one of the factors that exacerbate it. It is interesting to note that New Zealand--where pollution and traffic jams are not a problem--has high asthma levels.
We need to look more widely, and to take account of all the household effects: central heating and double glazing, for instance, have produced more dust mites. We should also consider working conditions. Some people work in a dusty environment. Above all, we should try, between us, to send a message to pregnant mothers begging them not to smoke; smoking by pregnant mothers is one of the main causes of asthma in very young children.
4. Mr. Carrington: To ask the Secretary of State for Health what assessment has been made of the progress of general practitioners in meeting their targets under the general practitioner contract in the North Thames region.
Mr. Malone: I am pleased to be able to tell my hon. Friend that, as at April 1993, 88 per cent. of general practitioners in North Thames achieved targets for childhood immunisation, 83 per cent. for pre-school booster and 93 per cent. for cervical cytology. This represents an improvement since 1990 of more than 10 per cent. for childhood immunisation and the pre-school booster, and 25 per cent. for cervical cytology--an excellent record.
Mr. Carrington: I am grateful to my hon. Friend for his answer, which shows a most impressive record against the targets. One of the problems facing general practice in west London, however, is the large number of single-doctor surgeries. Will my hon. Friend take measures to enable doctors to come together, so that they can become fundholders as a group?
acknowledgement of the successful figures. I hope that the hon. Member for Livingston (Mr. Cook) will pass on
Column 130to the right hon. Member for Derby, South (Mrs. Beckett), who is sitting on the Opposition Front Bench, the fact that, when we set them, he said that the targets would never be attainable. General practitioners are now attaining them all over the country. I can tell my hon. Friend that we encourage single practitioners to combine to form fundholding practices where we are able to do so. We give them other benefits such as allowances specifically geared to ensure that they can manage their practices more easily and co-operate. We have also announced a range of measures to encourage fundholding, not least a community fundholding threshold for lists of 3,000. The position will improve, as my hon. Friend will discover when he visits the Library and finds that his region has an additional allocation of £153,385,000 this year.
5. Mr. Miller: To ask the Secretary of State for Health what arrangements she has in place to ensure that money saved from the closure of mental hospitals is spent on the needs of the mentally ill; and if she will make a statement.
Mrs. Virginia Bottomley: The NHS executive has written to regional general managers to make it clear that the resources released from the closure of a long-stay hospital should be reinvested in community-based services for the same client group. The number of beds available for mentally ill people has remained at about 80,000 for the past 10 years, but there is now a wider range of accommodation in the community.
Mr. Miller: Twice this afternoon, the Secretary of State has referred to stewardship of moneys by local authorities. In that context, does she agree that--in the light of her answer--it would be inappropriate for the Tory-Liberal alliance in Cheshire county council to continue its policy of charging for mental health day-care places?
Mrs. Bottomley: The Conservative group on Cheshire county council will be wanting to point out that Cheshire has 15 per cent. more money this year--£13 million more. I hope that it will also welcome the increases in the mental illness specific grant, particularly the recent allocation in the hon. Gentleman's constituency. It may be that, on charging, it will have considered the report of the Commission on Social Justice, which made it clear that there is a distinction between health care and social care and that it is reasonable to expect a contribution towards social care from those who can afford it if we are to
Column 131extend the quality and quantity of care for all who need it. I suspect that, in that respect, the Commission on Social Justice had much to offer.
Sir Giles Shaw: I welcome my right hon. Friend's commitment to the fact that the consequences of selling or closing large mental institutions will result in ploughing back money into health funding. Will she confirm that she is satisfied that there are adequate facilities for care in the community for those discharged from mental hospitals and that there is proper doctor control for those who are having to be transferred?
Mrs. Bottomley: My hon. Friend makes a vital point. We need to tighten up the care of those who are discharged from hospital and are severely mentally ill. Unless or until it is safe to discharge people from hospital, they should not be discharged and for those in the community who have severe problems we have introduced supervision registers and new guidance. I hope that all hon. Members will support the new power of supervised discharge to ensure that the minority who get into difficulties have better support and better care and are better watched over in the community. I hope that that reassures my hon. Friend.
Mr. Alex Carlile: How can the Secretary of State be satisfied with a situation in which people discharged from mental hospitals are finding themselves in inadequate accommodation with inadequately funded social services support and without the necessary housing provision? What are the Government going to do to improve that?
Mrs. Bottomley: It is extremely important that health and social services give the necessary priority to mental health. There has been a dramatic increase in resources for mental health services with about £2.5 billion being spent. I am surprised that the hon. and learned Gentleman should not be aware of the new £10 million mental illness specific grant, let alone the £1.3 billion for the NHS next year which will allow health authorities to give mental health services the priority that they deserve. Report after report suggests that better co-ordination, better management and better monitoring are also required.
Mr. David Atkinson: Will my right hon. Friend acknowledge the valuable work of those who run halfway hostels for the discharged mentally ill? Does she agree that there are still insufficient numbers of such hostels to make community care for the mentally ill a reality? Will she encourage social services authorities to use their ring-fenced grants more for that purpose?
Mrs. Bottomley: I can affirm my hon. Friend's comments. We need comprehensive and coherent mental health services. There is much good practice and we have to ensure that there is greater coherence in every community and that it is targeted on the severely mentally ill.
Mr. Malone: The total financial value of all contracts placed by the national health service with the private sector is not known. The NHS has been a substantial purchaser from external suppliers since its inception.
Mr. Burden: Is the Minister aware that he is at least being consistent? In answer to a written question that I tabled last week, the Under-Secretary also said that Ministers did not know the number of patients being treated in the private sector, the costs or even how many were involved. Does the Minister agree that the Opposition have perhaps been a little unfair in accusing Ministers of knowing the cost of everything and the value of nothing, and that Ministers in the Department of Health know neither?
Mr. Malone: The hon. Gentleman obviously seeks an answer, and if he had tabled the right question, he would have got one. If he is interested in the private health care that is purchased from the NHS, I can tell him that in the South Birmingham health authority in 1993-94, the total was £2.3 million. The national figure for 1992-93 was £267 million. I wonder whether we are seeing part of the dinosaur Labour party--the Leader of the Opposition is perfectly content to break down policy boundaries and use grant-aided schools. Are we seeing some sort of division between health care in the public sector and in the private sector? If the hon. Gentleman looks at the glossy brochure published by the Labour council in Hammersmith and Fulham, he will find private health care advertised there. Clearly, people in Hammersmith and Fulham are well ahead of the hon. Gentleman.
Dame Jill Knight: Does my hon. Friend agree that it does not matter whether NHS contracts are placed with the private sector so long as patients are being treated? Will he deplore the blind dogma of the Labour party that it does not matter whether patients wait a long time for treatment or are a long time being treated, but a partnership between the NHS and the private sector must not happen?
Mr. Malone: My hon. Friend will not be surprised to hear that I agree with her. She highlights the dogma of the Opposition, who are more interested in who treats patients than in whether patients are treated. I thought that as the Labour party's clause IV on nationalisation of the means of production was being reviewed there might be less infatuation with who was treating whom in the health service and that whether people received better care might be the main issue.
Mrs. Beckett: How can the Minister agree with his hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) and, indeed, how can she assert that it does not matter whether patients are treated in the public sector or the private sector when we know from the Government's waiting lists initiative that it costs five times as much to treat patients in the private sector? The Secretary of State is always bleating about value for money. Surely that means, ultimately, that fewer patients will be treated for the same money because the
Column 133Government are dogmatically insisting on sending them into the private sector. Is that not a waste of money and a denial of care?
Mr. Malone: No, it is not. I am aware of the figures from which the right hon. Lady selectively quotes. If she considers the figures procedure by procedure, she will find that people who were treated in the private sector were treated at a far better cost. Would she say to her constituents that they should wait for treatment rather than be treated in the private sector? I suppose that she is endorsing that sort of dogma today.
Mr. Malone: Yes. The whole point about health service reforms--not just those involving competitive tendering--is that the benefits and savings go directly back into patient care.That is why there has been a substantial increase in activity for given amounts of taxpayers' money since the reforms were put in place.
Mr. Prentice: Does the Minister appreciate that people will be dismayed by that answer? in saying that, I speak not only for my hon. Friends the Members for Burnley (Mr. Pike) and for Rossendale and Darwen (Ms Anderson), but for the community health council, the Royal College of Nursing and many others. Was not what happened at Burnley Healthcare NHS Trust an utter fiasco, with macho management, no accountability and no transparency? Is it not clear that an independent inquiry is needed to prove that what happened there is not symptomatic of the new market-driven NHS, where the first duty of doctors is, allegedly, to the organisation and not to their patients?
Mr. Sackville: I agree that there have been uniquely regrettable incidents, but a new chairman and a new chief executive are in post. If the hon. Gentleman is interested in the welfare of patients and staff, which I sometimes doubt, he will want to ensure that the trust returns to a period of stability, with no further allegations or counter-allegations.
Mr. Nigel Evans: Does my hon. Friend agree that it is shameful for Opposition Members to try to play politics with this issue? Burnley has had a local difficulty, but recognition should be given to the fine record that the Burnley Healthcare NHS Trust achieved in 12 months, with nine five-star and five four-star ratings in the summer performance league tables. It was the first trust in the north-west to have no patients waiting more than 12
Column 134months for treatment. Opposition Members should concentrate on those things and not just rubbish the NHS trusts.
Mr. Sackville: I congratulate the trust on maintaining its excellent standards during these difficult times. I hope that the hon. Member for Pendle (Mr. Prentice) and his hon. Friends will help the trust to get back to normal.
Mr. Nicholas Brown: I am sure that the Minister will accept that rows of this sort are debilitating for health care workers. Will he also accept that they are turning out to be increasingly expensive for the NHS? The latest £250,000 pay-off will be seen by many people as an inappropriate use of public funds, particularly when set alongside criticisms of the Minister's Department from the district auditor, the Audit Commission and the Public Accounts Committee in investigating similar incidents. Has it occurred to the Minister that the source of misuse of public money might be the reforms themselves, which are turning out to be more expensive and less efficient and, are in fact, encouraging conflict and corruption?
Mr. Sackville: The performance of the trust--what it has done for patients--speaks for itself. I remind the hon. Gentleman that the payment made was in accordance with the former chief executive's contract.
Mr. Ian Bruce: My hon. Friend will know that I stood as a candidate in Burnley almost a decade ago, when there was a great deal of disquiet about the length of time that people were waiting for treatment. Will he confirm that many more patients are being treated now, due to the adoption of trust status, than when I stood in Burnley?
8. Mr. Jon Owen Jones: To ask the Secretary of State for Health in what circumstances one patient's treatment in hospital can be counted under Department of Health statistical rules as more than one finished consultant episode.
Mr. Sackville: A patient's treatment in hospital may comprise more than one consultant episode if a hospital patient is transferred from the care of one consultant to that of another, or if a patient is discharged and then subsequently readmitted.
Mr. Jones: In other words, there is double and triple counting. When do the Government intend to use reliable and accurate figures for patient numbers rather than inaccurate and inflated figures? Or do they prefer to use fiddled figures rather than the real values?
Mr. Sackville: What the hon. Gentleman has said is an insult to all the people who work in the national health service, including the statisticians. They agree with Dr. Edith Korner who, in the 1980s, chaired a committee which concluded that patient activity was best measured by the numbers of consultant episodes and that the
Column 135number of deaths and discharges, which had been used previously, was not the correct way to measured hospital activity.
Mr. Harry Greenway: Does my hon. Friend accept that some patients do not wish to be treated in mixed wards and are determined to stay in single- sex wards? Can he give a guarantee that if a patient chooses to be treated in a single-sex ward he or she will be placed in one?
9. Mr. Michael: To ask the Secretary of State for Health what reassurance he can offer to practitioners in herbal medicine and their clients about the impact on them of changes to the Medicines Act 1968 consequent on European directive 93/39.
Mr. Michael: The Minister seeks to reassure people, but does he accept that his reassurances are meaningless because they can be challenged in the European Court and shown to be worthless? Why is it that, although Ministers tell us that they are not willing to be pushed around by Europe, we are rushing headlong into this legislation while Germany is delaying it by 10 years? Would it not be better to withdraw the statutory instrument and introduce one that gives specific assurances in respect of herbal medicines?
Mr. Sackville: The hon. Gentleman has chosen wholly to misunderstand the situation. On 20 October, I made it clear in a series of interviews that we would not be pushed by the Commission or anyone else into clearing the shelves of medicines or anything else. By 11 November, I was able to announce that the herbal medicines which were currently exempt would continue to enjoy that exemption under the directive; and on 16 November I wrote to all hon. Members to confirm that. I am glad to be able to say that only yesterday the British Herbal Medicine Association confirmed that it was happy to support the Government's conclusions.
Mrs. Ann Winterton: Is my hon. Friend aware of the continuing belief of many hon. Members and their constituents that stronger protection is required in respect of herbal medicines, stronger than that which he has identified and which he has accepted could be overturned by the European Court? Will he therefore refrain from introducing the statutory instrument until the European Commission can give the guaranteed protection that herbalists and their patients demand?
Mr. Bowis: That is a matter for local decision. However, I understand that discussions are taking place locally to identify the most appropriate type of development and funding arrangement, and that negotiations to acquire additional land are in hand.
Mr. Bennett: I thank the Minister for that reply, but does he share my nausea at the number of health service officials and medical experts in Stockport who are prepared to produce survey after survey to demonstrate how much poor health and ill health there is in Brinnington, but who, when asked to provide practical help by enlarging the health centre so that poor health can be prevented or treated, seem totally incapable of taking action? Will the hon. Gentleman urge those people to get a move on and to enlarge the health centre as soon as possible?
Mr. Bowis: I understand that representatives of the Stockport trust are talking to the general practitioners in the two practices concerned, and that progress is being made. I understand the hon. Gentleman's concern for progress. He will know that the North West region has been developing its programme of primary care resource centres, and I understand why he wants his local service to be on a par with that excellent health advance for the area. The good news is that for the coming year the general medical service allocation for the North West region is to increase by 8 per cent. to £86 million, so perhaps good news for the hon. Gentleman will follow.
Dame Elaine Kellett-Bowman: If the Brinnington health centre is to be extended, will my hon. Friend confirm that its patients, like my constituents, will be able to use the excellent herbal remedies that have been saved by his fellow Under-Secretary of State as such remedies are efficacious against eczema and asthma while ordinary medicine is not?