House of Commons Hansard Debates for 21 Feb 1995

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certain objective which was not achieved because they failed to take into account something which could have been pointed out by the person who was supposed to receive the service.

It is most disappointing that the Minister does not feel that the health authority should be asked to make arrangements for securing advice from the users of health care. The community health council has an important role and a different experience from the people who use health care.

To give yet another example, the most difficult health care to deliver is in the most deprived areas where unemployment is high. It is a major challenge in health promotion to establish structures and strategies that will improve health in those areas. Indeed, health promotion in deprived areas all over the country is disappointing. If it is to be successful, health promotion must involve local people to find out how best screening can be provided or how best people may be persuaded to take advantage of health promotion programmes. I would not want the Minister to think for an instant that I think that such promotion would permanently improve health, because it is related to poverty. There will be ill health as long as there is poverty. However, within the remit of health promotion, it is obviously important to ensure that it is used effectively among groups that do not currently take advantage of it, for whatever reason. The health professionals need to consult more extensively and understand why that is happening. Whether as users of health care or not, the health professionals must be consulted.

I am concerned about the fact that the Minister has not included that important user group. To use that over-used word "partnership", the professionals are part of the partnership for delivering a health strategy in a locality. Health authorities, trusts, local authorities and the users of health care are all involved in that partnership. I was also surprised that the Minister said nothing about consulting local social services departments. Although such consultation occurs at officer level to a large extent, there is an enormous variation across the country. The local authority has a prime role in delivering health care through the public services and as an employer. In addition, with the health authority, it is a joint health care purchaser of services for elderly people.

Although the Government have made some welcome gestures towards consultation, it would have been more welcome if they had included the users of health care, and perhaps local authorities, to underline that partnership and the value of the role of health users and of the local authority as a health provider.

Mr. Malone: I shall address briefly some of the points that have been raised during the debate. I am grateful even for the grudging response from several Opposition Members who I thought looked at me sceptically in Committee and probably thought, "He'll never bring a detailed amendment before the House on Report." However, I am delighted to honour the undertaking that I gave in Committee. I understand that the amendment does not go far enough. It was not designed to address concerns about board membership and making that prescriptive. It is therefore hardly surprising that I am going to fail the

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expectations or wishes of the hon. Members for Doncaster, North (Mr. Hughes) and for Morley and Leeds, South (Mr. Gunnell) on those points.

Opposition Members raised several important points about the detail and structure and I draw their attention to the draft guidelines which have been issued for consultation. No fewer than seven principles should inform local arrangements by health authorities for involving professionals. These will vary widely across the range. It is not right to say that the rather rigid and formalistic structure which is not going to be reiterated in the Bill means that it will be a case of come one, come all, and a loose arrangement.

According to the principles, there must be an emphasis on outputs in the arrangements. They must be timely, relevant and authoritative, and they must improve patient-client care. That is a very important area for professionals to be involved with. There must be clarity about who is to be involved and what is expected of them. There will be an agenda for professionals to follow. The system will not be haphazard.

There must also be a strong personal commitment to the intended outcomes by those involved. The professionals involved must accept the need for their input to be firmly based on research evidence where that is appropriate. Any old point of view will not do. There will have to be the clearest indication that soundly based evidence is brought to bear.

There is an underlying principle that those involved must be given access to all relevant available information, including any relevant research- based evidence which may be needed to underpin discussions. It will not be a case of the uninformed talking to the well-informed. There must be a proper sharing of information with professionals. I am sure that the House will welcome that.

I now come to the real change between those arrangements and the uni- professional activities that were undertaken before. There must be multi- professional, multi-disciplinary teamwork which addresses both the primary and secondary care aspects of any issue. That part of the guidance is the nub of what is intended. Teams must be brought together for specific purposes and they must look across the board at the implications of what they are discussing. There must be good communication between those working on an issue and any other related work by the health authority.

That covers a broad spectrum of what the professionals should consider. It is right to set those points out in guidance and guidelines instead of being entirely prescriptive. It would be wrong to do anything other from the centre than lay out the principles. We do not want to place the health authorities in a straitjacket. We must address the important principles that will underlie the vital matter of consulting professionals.

I hope that I have gone some way towards convincing Opposition Members that, although the guidelines are not as prescriptive as former arrangements, the principles are very firmly in place and I am sure that they will be broadly welcomed on both sides of the House.

Mr. Gunnell: The seven principles are set out in the document relating to the involvement of the professionals. That document is out for consultation. The principles

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appear to be sensible, but there will presumably be a response to those principles and thoughts about how one involves the 17 different professional groups identified.

Mr. Malone: That is right. The principles are not set in concrete. As I said in Committee, and I repeat it tonight, we are talking about draft guidelines. However, the general thrust of the guidelines is clear. While there may be some modification around them, they are very important principles to which we will adhere. There is no suggestion that, as a result of consultation, we will suddenly say, "All these principles should simply be scrapped and we will set this out on a half-page of A4." That is not the Government's intention. I was keen to come to the House on Report to honour the commitment that, whatever guidelines are agreed after consultation, they will be give statutory force in the sense of the general obligation to take professional advice. It was right to do that at this stage. The hon. Member for Stockport (Ms Coffey) said that the amendment should be extended to take account of user groups. I said in an intervention that the interests of user groups are partly catered for by CHCs which do extremely important work. I again confirm to the House, as I explained in Committee, that that work will continue under the new arrangements.

However, that is not all that happens when we take account of the views of consumers and carers. The hon. Member for Stockport specifically and rightly referred to that point. I remind her that the national users and carers monitoring group advises the Department, particularly with regard to the implementation of community care. The Department listens to that very important group, and the interests in that area to which the hon. Lady specifically referred are brought directly to the Department's attention.

Ms Coffey: I understand that, but surely the Minister is aware that the problem is that there are no national criteria for the delivery of community care locally. There is an enormous variation in terms of criteria in respect of who is going to be accepted for care by a health authority and who is going to be paid for by a social services department. Although a national monitoring group is welcome, it does not address the problem of the local issue and the particular local criteria.

Mr. Malone: As the hon Lady might anticipate, the purpose of informing nationally is not so that that can be done, everyone goes home and nothing happens. What happens on the ground is influenced in the new structure set out in the Bill. That will involve the regional officers who will ensure that best advice is given through health authorities and so on. There is a flow down from such national advice and, as I said in Committee, guidelines to be published in due course will clarify a number of matters to which the hon. Lady referred. In conclusion, I am delighted to be able to bring the amendment to the House on Report. There has been much discussion outside the House about increasing the weight of professional involvement from a range of people whose advice perhaps was previously honoured more in the breach than in the observance. A combination of the statutory power with the guidelines which we will issue once the consultation has been concluded will put that

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right, and will assure all those who are concerned with the best possible delivery of health care and with the performance of health authorities that their voice will be heard, and heard effectively. I commend the amendment to the House.

Amendment agreed to.

Schedule 1

Amendments

7.30 pm

Mr. Morgan: I beg to move amendment No. 5, in page 6, line 27, at end insert--

`(2) The Secretary of State shall be under a duty to give directions to such Health Authorities as may be established in Wales, requiring them to act so as to secure--

(a) the promotion of common standards in the purchasing of equipment for, and design of capital works by, those authorities, (b) the publication from time to time of such information, including annual performance targets and details of defective or deficient work by contractors, as is necessary to enable progress towards the achievement of such common standards to be evaluated, and

(c) the organisation of clinical and non-clinical services on an all-Wales basis where that represents the most efficient and cost-effective means of providing such services.'.

I am pleased to be able to speak to an amendment that deals specifically with some of the problems pertaining to the application of the Bill in Wales. When one thinks of past major political figures from Wales such as Lloyd George and Aneurin Bevan and the contributions which they made to the development of the NHS, it is right that we should have a debate on Wales. No doubt The Sunday Times will run a story next week alleging that Lloyd George and Aneurin Bevan were Soviet agents with the code names of "Snow White" and "Taffy", or some such invention in which it specialises. There are areas where we are somewhat dissatisfied with the application of the Bill to Wales. The Bill should probably have solved more problems than it does. It comes forward with a raft of measures which try to bridge the long -standing gap between the purchasing of secondary and primary health care. It tries to reflect in statute the equalisation of status between GPs and the primary health care which they represent on the one hand, and the consultants and hospitals on the other--the historic prima donna-shopkeeper split within the medical profession--by merging the health authorities and the family health service authorities. That is okay as far as it goes.

The Bill gives power to the Secretary of State to come back later and to merge those authorities geographically as well, and that is also okay as far as it goes. It would have been better to have some way of debating that now. The amendment attempts to tie down the duties of the Secretary of State further, because there is a plain failure in the way in which the Bill has been drafted, to cover a lot of things which would have been covered had this been proper, competent and timely legislation.

There should have been coverage of a unified complaints authority, and we try to deal with some aspects of that in the amendment. There should have been some reference to the future of the two special health authorities in Wales. Either merging them or doing whatever it is that the Secretary of State intends to do would at least mean

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that we could debate the authorities. We have also covered that issue in the amendment in the best way we can to ensure that there is some form of debate on the issue.

Finally, we need to clarify the role of the newly merged health authorities in relation to GP fundholders and other providers, hospital providers and the Welsh Office. It is an eternal triangle between the Department allocating the budget, the GP fundholders and health authorities as purchasers and finally the provider units such as trusts or directly managed hospital and community health care units. Those involved in that eternal triangle--in which the Secretary of State is the hypotenuse--must work out their relationship in an entirely new ball game.

We have attempted to clarify that matter by giving the Secretary of State a set of duties. The Bill gives the Secretary of State all of the fun, and none of the duties. The fun is that he can decide without much debate after the Bill has reached the statute book how many health authorities there will be in Wales and what their function should be. Of course, he can announce the annual allocation of the budget, but he will not have any duties. We have injected duties into the amendment, so that the Secretary of State can impose duties on the purchasers and providers in the new health care system.

The Bill, as has been often emphasised by Ministers, is a part of the final piece in the jigsaw of the health care reforms of 1990 and the establishment of trusts and GP fundholders. The effect of all that has been to break up the NHS in Wales into some 200 small businesses, which can buy their own equipment and services and manage their cash flow and capital expenditure, and which are able to save money by more astute purchasing. We have to decide--as taxpayers--what leeway those units will have to deal with that money.

The Secretary of State must decide how much leeway he wants those 200 small businesses to have in how they spend their money, particularly when they can squeeze some cost savings out of the providers of health care and not spend all of the money that they been given through their capping formula. It is a difficult area for hon. Members. We are responsible to the taxpayers for the way in which the money has been raised, but we must assure taxpayers back in our constituencies that we are sure what has happened to their money.

The breaking up of the NHS in Wales has led to the creation of 200 small businesses. If we apply that across Britain, we would be talking about several thousand small businesses. We cannot be sure what is happening to all of the money, and that is why we are trying to establish a set of duties for the Secretary of State to try to co-ordinate a system after the Government have broken the NHS into pieces.

I shall give a simple example of the duties which we want to establish. The Welsh Office has produced documents relating to the general practitioner fundholders steering committee--there is an oxymoron if ever I heard one. The whole purpose of fundholding is to break up the system and allow GPs to do their best to buy health care with their own money; but, as soon as they set up as fundholders, they almost immediately form a steering committee to bring them back together again and to tell them what they ought to be doing. From the documents it is obvious that, in the coming financial year, GP fundholders are expected to make savings of some £10 million, and that will be free money for them. If we gross that up for the whole of Great

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Britain, we are talking about £200 million of free money for GP fundholders to spend in ways which we cannot account for. That is why fundholders buying equipment should do so under a direction from the Secretary of State.

If GP fundholders next year--when they will only be responsible for some 40 per cent. of the patients in Wales--have £10 million to spare, they will have made what is known as efficiency savings, although I do not think the word ` efficiency' is used. That is free money, available to GPs to spend as they wish on capital equipment. They can extend their surgeries or buy additional physiotherapy or chiropody equipment. We have no way of registering the equipment, or of telling them that some forms of capital expenditure may benefit their pensions. When a GP retires at 65 or 70 and sells out his share of a practice, his pension may be enhanced by taxpayers' money. We need control over the process by which money which we have approved as taxpayers becomes eligible for savings simply by prescribing cheaper drugs or by forcing a harder bargain out of providers. We all want them to try to do that, but not necessarily in such a way that benefits their pension when they, as GPs and self-employed contractors to the health service, retire and sell out to a younger partner. If the practice has been extended three or four times, it will be worth a lot more when the GP sells up at 65 than it would have been if the taxpayer had not enabled him to have the ability to spend on capital equipment.

The fact that the matter has perplexed the Government is shown in the general practitioners steering group documents. The matter is obviously causing the Government considerable problems in terms of the accountability of GP fundholders for the money that they draw out of the system by extracting "savings". Strangely, non-fundholders make the same savings but do not have the right to spend the money as they want on improved services. That money still belongs to the family health services authorities and is part of the traditional allocation from taxpayers' money. If it is not spent, it returns to the Treasury; if it is spent, the same amount plus an allowance for inflation is allocated the following year.

The difference in treatment of fundholders and non-fundholders is not logical as there is no evidence that GP fundholders gain more in efficiency than GP non-fundholders. But they are given the benefit of spending taxpayers' money as though it were their own. I admit that they must spend it on patient care but it can be spent in a way that makes a considerable capital gain throughout a GP's career. Given that, next year, "free money" will amount to £10 million in Wales and £200 million in Great Britain, we must know what the Minister has to say about it, particularly in the light of all the questions that have been asked in the general practitioners steering group, which was set up by the Welsh Office to try to restore order to the chaos that it created. It is totally bewildering that the Government never foresaw that problem when they proudly set up the GP fundholders scheme in 1990 and announced the creation of those wild cards, which would float freely and be able to negotiate their own bargains.

The amendment also seeks to provide that, as well as enabling powers that determine how many authorities we need, health authorities should have annual performance targets for themselves and suppliers of equipment, buildings or whatever. That links with the point about the

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need for health professionals to be involved, through local medical committees, in advising on the purchase of X-ray equipment, sterilisers and various aspects of the health services' purchasing functions. There should be a professional input, and we hope that annual performance targets will help.

In that process, a function exists for at least one all-Wales special health authority. We have tried to frame the amendment to fit in with the enabling pattern of the Bill. Sub-section (c) implies that, ultimately, the Secretary of State has discretion in that matter. It would be nice to have the whole Bill before us so that we could see the detail of all the practical implications. The enabling style of legislation that is becoming increasingly common makes debate at this stage far more difficult than in the past. The amendment seeks to oblige the Secretary of State to set out clearly for those in the health service what the performance of an all- Wales health authority should be. There are two such authorities at the moment, but we do not say whether there should be one or two. We say that, where the benefit of having an all-Wales health authority is evident, the Secretary of State should not be held back by a dogmatic aversion to an all -Wales health authority such as we have now. At present, dogma seems to drive the exercise.

At the last Welsh Grand Committee but one in June last year, the Secretary of State told the Committee that he did not like the structure of the Welsh Health Common Services Authority, which has clinical and non-clinical aspects. At that time, 1,000 people worked in the non-clinical part at the new headquarters building at Cardiff bay. The Secretary of State said that he would market test the non-clinical part of that outfit.

Market testing is Government policy, and the Government do not require the House's authority to carry it out. But having announced that he would market-test the authority, the Secretary of State engaged not in market testing but in his own version of market testing--a game of "heads I win, tails you lose". The aspects of the authority which he wants offered up to the private sector are not allowed to compete against the private sector. People in those jobs have been told that it is not market testing in the usual sense. It is a new phoney version of market testing in which they are not allowed to make an in-house bid.

The staff are extremely upset about that, because they were led to believe that the authority would be market-tested. A subsequent ministerial instruction appears to have been given to the Welsh Health Common Services Authority that there can be no in-house bids. That has not happened with the authority of this House. We have not come across that framework or any legislative backing for a "market testing exercise"--those are not my words but the words of the Secretary of State in the Welsh Grand Committee last year when that policy was announced--but it has subsequently been introduced by the actions of the Secretary of State, who says that his version of market testing involves no in-house bids.

7.45 pm

The staff are wondering what they should do. Should they simply resign and just give up? They have suggested that, if they cannot engage in a classic in-house bid, as

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would normally be the case in market testing, they could try to privatise themselves so that they could bid for their jobs against outside contractors. But they have been told that they can have no assistance for doing that.

Normally, the civil service and public agencies are allowed to employ accountants and legal advisers, but in this case they are being denied assistance and have been told that it will be strictly private contractors bidding for their jobs. That could result in no more than 100 people working at the Welsh Health Common Services Authority in 18 months' time. Indeed, I am told that that is the Government's estimate.

Another oddity that I should draw to the attention of the House, as it is relevant to subsection (c), is that among the people who have inquired about bidding for a large part of the Welsh Health Common Services Authority is W.S. Atkins and Partners, a company that is on a cautionary list published by the Department. The Welsh Office has told the authority that, except in exception circumstances for small jobs, it cannot use the company for hospital design work because it is responsible for the two major hospital design disasters of the modern Welsh health service, in Gwynedd and, before that, at the University Hospital of Wales, and it was required to make out-of-court settlements to the Welsh Health Common Services Authority with respect to those design disasters. Although it is on a cautionary list, sent on the Department's instructions to the authority, it is allowed to make an inquiry into buying the whole service and could take over hospital design services. That is the height of absurdity.

As we said earlier, we need a clear list of the minimum standards required within the health service. Contractors are used by health authorities throughout Wales, and they must abide by a minimum standard set by the Department. Nowhere is the need for standards more clearly illustrated than by the appalling case of the stillborn baby who was transported from Wrexham Maelor hospital to the University Hospital of Wales in Cardiff for pathological examination. It took sixteen and a half hours to travel by private courier from Wrexham to Cardiff. The firm did not say how long it would take to reach Cardiff or whether it would go direct, and the package containing the stillborn baby appeared to have been left outside in the rain. That is why the package partly broke open when it arrived in Cardiff.

How can it take 16 and a half hours for a package of that sensitivity to travel a journey that most of us know takes only four hours these days? That courier firm should not be on any private contractor list for any health trust, hospital or health authority anywhere in Wales. We need common standards and we need a clear complaints and public inquiry procedure to ensure that those matters are brought out into the open and not squashed.

Dr. John Marek (Wrexham): My hon. Friend referred to the incident concerning the stillborn baby in Wrexham. The health authority produced a good report, in which it admitted that it was at fault, but of course it did not explain the length of time that it took for the baby to reach Cardiff, how it went and the instructions that were given to the private courier firm. However, the health authority has said that it will not use private courier firms in future, which is a good thing.

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I asked the Welsh Office whether it would issue guidelines and at the time it said that it would not. Will the Minister reconsider that? If there is a case for issuing guidelines to hospitals in Wales, that surely must be it, and it is also a recommendation for amendment No. 5.

Mr. Morgan: I am grateful to my hon. Friend the Member for Wrexham (Dr. Marek) for using that argument, as the hospital is in his constituency and he has drawn attention to the need to set minimum guidelines. When one has an awful story of that type--

Mr. Richards: I wish to clear up that matter, as it obviously was a ghastly incident, which I am sure everyone in the House regrets. The trust has prepared a report about that unfortunate incident. That report is with my Department and we are examining it carefully. If anything can or should be done or needs to be done, obviously we will do it. I do not think that we want to go much further on that point.

Mr. Morgan: Obviously, something must be done; but it is not adequate for the Minister to say that he is considering it in the Department to discover whether anything needs to be done. Obviously something must be done; it is merely a matter of trying to decide exactly what it is.

From the point of view of amendment No. 5, it is obvious that it is now up to the Welsh Office to set minimum standards and not simply to leave the setting of standards to each hospital. As my hon. Friend the Member for Wrexham said, the Wrexham Maelor trust itself prepared a report. It was an internal report, but it has been placed in the Library of the House and we have been able to read it. It is evident that the report tends to skip the critical facts--the exact way in which the package got rained on and the exact way in which a package of that sensitivity could possibly be transported to Cardiff in such a way that it took sixteen and a half hours to do a four-hour journey.

Mr. Allan Rogers (Rhondda):I accept that the issue is extremely important, but I caution my hon. Friend not to labour the Welsh Office with tackling issues that would perhaps best be tackled at trust level. As long as the trusts exist, I should have thought that we should say to them, "Carry out your job properly."

I would hate to think that in future the Welsh Office, which has great difficulties in coping with its job at present, a fact of which we are manifestly aware, will start laying down standards for everything. That is one of the big problems that we should consider as regards the distribution of effort throughout Wales and the level at which it is carried out.

Mr. Morgan: That is the most backhanded compliment to the Welsh Office that I have heard in my time.

We have mentioned the question of the way that one provides a form of health service in Wales in which we try to give people incentives to improve their efficiency but not necessarily resulting in those people doing much better out of it financially than before. The Government have converted people into quasi small businesses in a quasi-market. We are not happy with that.

I think that some sort of warning system is being given to me, but I am not quite sure how it has been worked out. A new form of mathematics is being used in the timing mechanism here.

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The contrast could not be wider than on the issue of the blood transfusion service in Wales--an all-Wales service, which is run by the Welsh Health Common Services Authority. Uncertainty remains as to what will happen to it. The Secretary of State has said that, for the time being, it will remain under the care of the Welsh Health Common Services Authority, but when we are engaged in the process of primary legislation of that type, we do not want references to what the Secretary of State will do for the time being; we want to know what the Secretary of State will do.

The donor donates free of charge to the blood transfusion service. The costs that arise are simply the on-costs of the blood transfusion service itself, which governs what happens when the blood is passed on and processed or otherwise for use in operations. However, it is a free service. That is in total contrast with the increasing business and quasi market climate that the Government have created--a broken-up health service with everyone acting as their own business managers in a way that contrasts starkly with the ideas that Lloyd George and Aneurin Bevan originally had when they made a great contribution to the social system of the country by setting up the national health service.

That is why people in Wales feel especially strongly that the health service should remain a unified national health service, and that is why we have tabled the amendment. I commend it to the House.

Mr. Richards: First, I should like to reply to one or two of the arguments of the hon. Member for Cardiff, West (Mr. Morgan). The Bill does not deal with special health authorities, as those are established by order and are not affected by the measure that we are discussing.

Mr. Ted Rowlands (Merthyr Tydfil and Rhymney): Will the hon. Gentleman give way?

Mr. Richards: If I must.

Mr. Rowlands: As we are in Committee, would it not be a better idea for the Minister to listen to the debate first and listen to an expansion of the case by my hon. Friend the Member for Cardiff, West (Mr. Morgan) before trying to reply to it?

Mr. Richards: No; we are on Report. If I feel that I need to speak after the hon. Member for Cardiff, West makes a unique contribution to the Bill, I shall decide to do so at that time if it is appropriate.

Fresh powers are not needed to deal with the special health authorities, the Welsh Health Common Services Authority or the Health Promotion Authority for Wales. Indeed, I am fascinated that the hon. Member for Cardiff, West, who has a distaste for quangos, should wish to create what would, in effect, be a super health quango for Wales. It is not in keeping with his general distaste for health authorities.

Mr. Morgan: Can the Minister confirm that it would result in the saving of one quango, with all the board expenses that that involves?

Mr. Richards: It would not at all result in the saving of one quango. It would create a quango at least three times as large as the quango that we have already.

The proposals on the relationship between health authorities and GP fundholders will be worked up in the next few months in consultations among those involved.

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That work will consider accountability issues in detail, and the general practitioners steering group, to which the hon. Member for Cardiff, West referred, is part of that process.

The amendment is unnecessary to achieve the efficient and effective delivery of services. In the case of capital works, it would, in any event, not secure what the hon. Member for Cardiff, West seeks, as it does not acknowledge that the Welsh Health Common Services Authority, which is a special health authority, and NHS trusts have the key roles in contracts on capital works. In the case of capital works, it would add to the activities of health authorities and create a further tier of responsibilities, with additional bureaucratic costs cutting across the functions of NHS trusts. The design and implementation of capital works are subject to the law governing contracts between the NHS organisation concerned and the firm carrying out the work.

Standards for the design of health buildings are published by NHS Estates and the Welsh Office and are common to England and Wales. Those include health building notes, health technical memoranda and health facility notes, which are used by designers, whether in the public or the private sector.

Mr. Rogers: With the health trusts themselves being responsible for the placing of contracts for capital works, is the Minister now saying that they are bound to stick to the designs and specifications as laid down in the standards that he has just said are appropriate for Wales and England?

Mr. Richards: The hon. Gentleman clearly did not listen to my first sentence. Standards are published by NHS Estates and the Welsh Office and are common to England and Wales. They include health building notes, health technical memoranda and health facility notes.

Mr. Rogers: Will the Minister give way?

8 pm

Mr. Richards: No, I will not give way to the hon. Gentleman; I think that I have made that point perfectly clear.

The documents are all available through Her Majesty's Stationery Office. If the hon. Gentleman wishes to study them, he is welcome to do so. Each development is project managed carefully. An evaluation is required for all capital projects which should identify important lessons in the planning, design, cost control and procurement of schemes, as well as in the use of the facilities.

The private sector undertook 30 per cent. of the contracts placed for design over the past five years. The vast majority comply with all conditions and, where performance of contractors is considered unsatisfactory, any failures are pursued in line with the contract in the first instance; that would include action to remedy defective or deficient work by contractors.

The Welsh Office is made aware of the conclusions of evaluations of all projects. That will continue whatever the outcome of the review of the EstateCare Group within

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the Welsh Health Common Services Authority. What the amendment seeks to achieve is already undertaken and, therefore, it is unnecessary.

Mr. Morgan: I think that the Minister has covered only hospital works. The departmental GP fundholders steering group refers in its document to the savings that GP fundholders can make. In paragraph 16, it says:

"Savings must be used for the benefit of the patients of the practice. This statutory requirement allows the purchase of equipment and improvement of practice premises."

The question of what happens to the "free money" that GP fundholders have-- it was £4.7 million in the last financial year, it is about £7 million this year and it will be about £10 million next year, and it can be spent on premises--applies also but, unfortunately, it is not covered by what the Minister has said.

Mr. Richards: I am astonished that the hon. Gentleman should speak in that way about savings that can be, and are, made by GP fundholders. He has said that any savings made--considerable savings can be made--should be used for the benefit of patients. Surely the hon. Gentleman welcomes any development whereby more resources are made available to patients. I know how the hon. Gentleman will reply; but before he says that premises should or should not be included, I remind him that even the development of premises can be beneficial to patients--particularly if it means that consultants can visit GP fundholding practices to consult patients.

Mr. Morgan: I am grateful to the Minister for giving way again. The amendment covers the way in which general practitioners extend their practices with the "free money". Unfortunately, there is nothing to oblige them to use the "free money". The departmental GP fundholders steering group document says:

"Holding large cash balances is seen by some as an unproductive use of resources".

They are the words of the Welsh Office. The document continues: "Is this the case and, if so, is there a risk that if this continues it will lead to criticism because it denies patients treatment?"

They are not my words; they are the words of the GP fundholders steering group.

Mr. Richards: With respect to the hon. Gentleman--I do not intend to pursue the point any further with him--I believe that that was a rhetorical question within the steering group document; it was not a statement.

The Welsh Office is currently consulting on proposals for the future management of three clinical services--the blood transfusion service, the artificial limb and appliance service and Breast Test Wales--currently managed by the Welsh Health Common Services Authority. The consultation document makes it clear that the proposals are aimed at ensuring that the services develop in response to patients' needs, and that improvements in efficiency are reinvested in patient care.

They also indicate that long-term programmes such as Breast Test Wales's contribution to the UK evaluation programme of screening as a means of treating cancer will be fully protected and that Wales will continue to co- operate with sister organisations elsewhere in the UK, for example, the blood transfusion service with the National Blood Authority. Assurances have been given about the continuing all-Wales requirements of the artificial limb and appliance service.

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