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Mr. Hayes: I accept that the hon. Gentleman is totally sincere. However, I refer him to his suggestion that persons elected from local authorities should serve on health authorities and trust boards. That idea was declared unworkable by Nye Bevan, and the leaked document describes it as "barmy". I suspect that it was declared unworkable and barmy because, under the present system of appointment--there are many Labour and Liberal Democrat as well as Conservative appointees--party politics is buried once the parties are around the table taking decisions. That is good for health care.
Mr. Hughes: I know that the argument is not cut and dried. No one wants to see health authority policy hijacked for party political aims. I shall conclude my speech by suggesting how we can behave slightly more intelligently in that area than we have of late. We should not shout at each other across the Floor of the House. The people are not well served by party political appointees who seek to advance an imperfect manifesto. No one has the benefit of complete wisdom.
However, I do not accept that no one should be elected, and that all members should be appointed by the Government. Of course they will appoint people of different political persuasions in order to make it appear a balanced exercise, but at the same time they will continue to appoint their own people and those who are politically neutral. That gives the Secretary of State enormous power and leads to a lack of accountability to the patients, which is entirely inadequate in the case of a public service. The service is funded with taxpayers' money, and people expect to have some control over that expenditure.
Many problems remain in the family doctor service, including inadequate out-of-hours service and inadequate deputising services in many areas. Doctors cannot be recruited in many urban areas, and the quality of doctors is also an issue. People often find it difficult to register with a doctor, and they may be thrown off a doctor's list even though they have not found a replacement GP.We have not yet resolved the controversial issue of how often doctors should be allowed to dispense.
Doctors certainly believe that they are under increasing pressure. My colleagues have surveyed doctors around the country, and I shall refer to the views of doctors in three areas. My colleagues in Hazel Grove--an area south of Manchester, which I know well--conducted a survey of general practitioners in the autumn, and discovered that 70 per cent. of those who replied wanted to change profession or take early retirement. Eighty per cent.of GPs said that they were unhappy with the state of their profession.
Colleagues in Cornwall made a similar survey, and in Devon morale among GPs was so low that new jobs in Torbay are attracting only two out of three applications, compared with 40 out of 50 a few years ago. In Cornwall, the county of the hon. Member for Falmouth and Camborne (Mr. Coe), the local medical council chairman, Dr. Andy Stewart, said in response to a survey by the hon. Gentleman's prospective Liberal Democrat opponent,
Terry Jones, that 20 out of 320 GPs surveyed were receiving psychiatric care because of the stress caused by long hours and other work-related problems.
My colleague in Liverpool, who is a prospective candidate, also undertook a survey.
Mr. Malone:
Was it a similar survey?
Mr. Hughes:
Of course, and it comprised straightforward questions. I shall willingly show the Minister the results. When all the results are collected,I will let him have those because the issue is hugely important. Thirty per cent. of Liverpool's doctors are thinking of earlier retirement. Morale among GPs at the front line of the health service is severely low; that bodes ill for the future unless immediate action is taken to remedy it.
Mr. Sebastian Coe (Falmouth and Camborne):
I hope that the survey by one of the hon. Gentleman's colleagues in my constituency had slightly more intellectual and numerate rigour than the Liberal Democrat survey in Devon and Cornwall. Under scrutiny in a debate in this Chamber only a few weeks ago, the Liberal Democrats had to accept that the response rate barely bordered on25 per cent.
Mr. Hughes:
I am perfectly happy to deal with the figures. I remember that debate, and I have read it. Various surveys have been undertaken in large areas,if not throughout the country. The response rate varied.In some places it was one quarter, and in others well over 50 per cent. There is no secret--I can give the hon. Gentleman the figures. I hope that he shares my concern that the trend, which is identical or similar throughout, is for large numbers of general practitioners to say that they are overworked, over-stressed and thinking of retiring early, and cannot recruit to their practices.
A practice just around the corner from my house is having great difficulty recruiting. I asked another practice in my constituency today, so that I could not be accused of giving outdated information. It stated that it is under huge pressure because of lack of resources. It was told that there would be adequate resources for care in the community, but there are not.
The practice informed me, for example, about a lack of bathing facilities and care assistants. It knew of more than one person who has been waiting three years for a bath seat. Standards of care are often considerably reduced because there are not the people to deliver them.
I do not rejoice in that situation, but state facts rather than speak rhetorically. Those facts suggest that something is substantially wrong. We all have a responsibility to respond.
Mr. Ray Whitney (Wycombe):
We all want facts, not rhetoric. Does the hon. Gentleman have any comparable statistics of that claimed low morale in the medical profession during the Lib-Lab pact, when morale was distinctly low? I do not have any such figures, but it would be interesting to compare them. Is the hon. Gentleman aware that, in the past 10 years, the average GP list has been reduced by 9 per cent, which is difficult to square with the high stress to which the hon. Gentleman referred.
Mr. Hughes:
I was not here in the time of the Lib-Lab pact, but I remember the issues and debates. The former
There will be no bottomless pit, no matter which party is in government and who is Secretary of State, any more than there is now. The Secretary of State was right to point out that there will always need to be rationing of health care, and we would be fools to ignore that fact. Rationing has always happened--at some times by long waiting lists, at others by clinical choices. We owe a duty collectively to our citizens to resolve three questions--as the hon. Member for Broxbourne (Mrs. Roe), who chairs the Health Select Committee, knows.
First, what are the health service's boundaries of responsibility? The original legislation and current legislation do not accurately define them. The right hon. Member for Sutton Coldfield gave an example of care in the community, where free service at the point of delivery may no longer be available. We may enter the area of community care or social services. Redefinition is a difficult debate, but we must address it.
Secondly, we must address how we make choices among competing priorities for funds that will always be insufficient to meet the needs to which the NHS would like to respond. We may need to be rigorous about eliminating work that does not have proven clinical value. If I may be controversial, the famous case of Jennifer's ear was probably an example of work that did not have proven clinical value.
Thirdly, we should seek to agree the minimum public funding needed to guarantee a comprehensive health service in all four countries of the United Kingdom that is free at the point of delivery and accessible to all our citizens.
Those difficult-to-answer questions are ideally suited to the exercise of that which, from this week, I am required to call partnership politics. The people--patients, actual and prospective, professionals and politicians--should begin a dialogue to reach agreement. Just as there used to be bipartisan agreement on pensions policy, if we are to hold on to a national health service we will require a bipartisan or multi-partisan agreement on health service policy.
Mrs. Marion Roe (Broxbourne):
I am pleased that the House has the opportunity to debate the state of the national health service because I want to draw attention to the work
How the disabled elderly are to be cared for and who is to pay for that care is a question that affects us all potentially. Last November, the Committee published the results of phase 1 of its inquiry, which considered the implications of Department of Health guidance on NHS responsibilities for meeting continuing health care needs. That report was unanimous, and I thank all my colleagues on the Committee for the constructive way in which that topic was discussed. It was a very good advertisement for the Select Committee system. We are now well into phase 2 of our inquiry, which is considering the potential demand for long-term care in the future and the possible consequences of funding arrangements.
I shall begin by outlining the main conclusions in our report and the main points of the Government's response, which was published yesterday. The Select Committee has not yet had an opportunity to discuss the response, so I shall give my own personal view. I will also touch on the main issues that we are considering in phase 2 of the inquiry.
The Select Committee was pleased that the Department of Health had recognised the need to clarify NHS responsibilities for continuing health care services. We commended the Department for the extent to which it was able to accept views expressed during its consultation period. Nevertheless, there were some areas where we thought that further clarification would be helpful for the NHS, for local authorities and also, of course, for the users of those services.
The guidance calls on health authorities to develop local policies for purchasing continuing health care services. All the members of the Select Committee were struck by the desire of witnesses that health authorities should not focus solely on the important question of defining eligibility criteria for NHS continuing health care, but should also ensure that the full range of high-quality continuing health care services is available to support people in their own homes for as long as possible. I am pleased to note that the Government strongly agree with our sentiments.
The Select Committee shared the concerns of many witnesses who argued that locally set eligibility criteria might create unacceptably wide variations in the provision of NHS services. We recognised that the Department of Health's guidance provided a framework which went some way towards meeting those concerns, but on the grounds of equity we recommended that the nationally set framework should include eligibility criteria for long-term care so that it is absolutely clear what the NHS, as a national service, will always provide.
I am also pleased that the Government, in their response to our report, agreed that the current variation in continuing health care arrangements needs to be addressed. The Government have also committed the national health service executive board to reviewing, during the coming year, how eligibility criteria are operating in practice and to issuing further guidance on priority issues relating to eligibility criteria, which may, in effect, lead to the national criteria that we called for in our report.
The Select Committee felt that it was important that patients, together with their families and carers, should be left in no doubt as to the circumstances in which health authorities rather than local authorities will be responsible for purchasing continuing care services, especially nursing home care which, as the House will be aware, can be purchased both by health authorities and by local authority social services departments. We were not convinced that the Department of Health's refusal to provide information on the types of cases that might be expected to come within the eligibility criteria was justifiable. We therefore recommended that the Department of Health should prepare illustrative case studies and widely disseminate them.
I am pleased that the Government have recognised the strength of our case by accepting in their response that there is value in health authorities testing their eligibility criteria against case studies. I fear, however, that the members of the Select Committee will be disappointed that the Department of Health is still only considering whether it would be helpful to issue the kind of illustrative case studies that we call for. In our view, those are clearly necessary to help members of the public to understand their position.
Our report also recommended that the Department of Health should introduce a national long-term care charter, which would specify the minimum levels of provision that people could expect from health authorities, NHS trusts, GP fundholders and local authorities. It would also specify access to a named range of services, a minimum list of specialist equipment and home aids, time limits for assessment, and provision of services where need is identified.
The Government have told us that they have not reached a final decision on whether to issue such a charter, which would cover some of the ground already covered by the forthcoming local community charters, but that before April they will issue a national leaflet on long-term care. We look forward to seeing that.
The guidance issued by the Department of Health also deals with hospital discharge arrangements for patients who are assessed as not requiring further NHS-funded continuing health care. The Select Committee recommended that health authorities and NHS trusts should not discharge patients home without a package of care being prepared, which can be demonstrated to meet their assessed needs fully and, as far as possible, agreed in advance with them and their informal carers. We also called for NHS-funded patients entering a nursing home to have the right, subject to the necessary clinical and financial conditions, to choose their nursing home--a right which currently exists for local authority-funded patients in nursing homes.
The Select Committee welcomed the proposed establishment of independent panels to which patients being discharged from hospitals, who are not to be funded by the NHS, can appeal. Those panels will provide an extra safeguard for patients facing important and sensitive decisions about their future. We also urged the Department of Health to clarify the arrangements under which those panels would seek independent clinical advice. We also recommended that the right of appeal to the review panel should be extended to all patients
assessed as requiring nursing home care, wherever they live, when that care is not to be funded by the NHS, and that the right of appeal should not be restricted to those being discharged from hospital.
I am pleased that the Department of Health's further guidance on the review procedure makes it clear that patients, families and their carers have the right to request a second clinical opinion, which should be offered routinely before their case reaches the independent review panel. However, it is disappointing that the Department of Health has not clarified our concerns about how the provision of independent clinical advice to the review panel can be conducted fairly from the patient's point of view, if an opinion is to be given only on whether the clinical judgments made match the health authority's eligibility criteria, rather than on the clinical diagnosis, management or prognosis of the patient.
The Select Committee warmly welcomed the decision that implementation of the new guidance should be one of the six national priorities set by the Department of Health for the NHS over the next three to five years. We called upon the Department of Health to set firm target dates for the completion of NHS reinvestment programmes by all those health authorities whose reviews indicated a need for such a programme. We also considered that to aid public confidence in the equity of access nationally to NHS-funded continuing health care, the Department of Health should publish the outcome of its review of individual health authorities' policies and eligibility criteria and outline the action that it would take against any authority which significantly departed from the national framework. I welcome the Government's assurance that health authorities will have to publish plans clearly setting out the target dates for completion of any necessary reinvestment programmes; and the Committee will look to the NHS executive to monitor health authorities closely to ensure that the policies are fully implemented.
I should like now briefly to outline how the Select Committee is taking forward its work on long-term care in phase 2 of the inquiry. Many of our witnesses have commented on the need for the Government, Parliament, providers and the public to participate in a far-reaching debate about the future of long-term care provision and funding. We hope that our Committee is currently stimulating that debate. We are considering what models of care exist for long-term care services, and we are further examining the differing models of care which can meet future demand for long-term care.
Some of our earlier witnesses stressed the potential impact that health promotion might have on reducing demand, while others drew attention to the potential offered by further investment in rehabilitation services. We are also considering who should manage long-term care.
An aging population is a widely recognised phenomenon throughout most of the developed world, including the United Kingdom. The state of health of older people is also a key determinant of the need for, and hence the cost of, long-term care. We shall therefore be considering the cost implications of long-term care, given projected demographic trends, and whether talk of a demographic time bomb is realistic or alarmist.
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