[Lords] (By Order) Orders for Second Reading read.
To be read a Second time on Thursday 5 July.
Mr. Leighton : Is not the underfunding of the national health service for inflation one reason why the service is starved of cash? Is the right hon. and learned Gentleman aware of the financial crisis in the North East Thames region that has led to the postponement of phase 3 of Newham general hospital? It was promised in 1984, but has now been scrapped, and that has led to a sense of betrayal in Newham.
Is the right hon. and learned Gentleman aware of the growing and projected population moving into London's docklands and the need for health facilities for them, which have been mentioned by the district health authority and London Docklands development corporation in representations to his Department and the Department of Environment? Nothing has been done. Why? Will he do something about that? Will he review the position of health services in the London borough of Newham?
Mr. Clarke : The health service is not underfunded. Indeed, the resources available to it have grown so fast that we are now spending almost half as much again, over and above inflation, as the previous Labour Government were spending when they left office. This year, health authorities have at least an additional 4 per cent., ahead of inflation, in their coffers compared with last year.
Column 842I am aware of the postponement of the hospital in Newham. It is an unfortunate result of the fact that the North East Thames capital programme was racing ahead, partly on the basis of land sales in a booming property market. Those land sales have now slowed and the region has had to review its programme. I agree that it is a serious problem and, together with the regional health authorities, I shall continue to review the capital programmes, and especially that of the North East Thames region.
Mr. Michael Morris : Will my right hon. and learned Friend clarify a point recently announced in the press--that some districts will not be required to achieve a level playing field by the beginning of the next financial year? If that is the case, why should others suffer?
Mr. Clarke : No one is suffering, because it has always been a requirement that all parts of the national health service should live within the growing amount of resources available to it. All districts have always been expected to keep within those resources, and they are being urged to do so now.
I accept that one or two district health authorities may not manage to do that this year, but we will accept that only on the basis that they are well on course to eliminating the deficits as quickly as possible thereafter.
Ms. Harman : Will the Secretary of State make good the underfunding of Camberwell district health authority? Is he aware that tomorrow night that health authority will consider proposals to cut 106 beds and begin the reduction of its junior medical staff by up to 40 doctors? Does not he think that people in south London and throughout the country will be disgusted by the fact that, with hospitals in south London facing £3 million of cuts this year, he is prepared to spend £3 million of taxpayers' money on propaganda leaflets?
Mr. Clarke : The system of cash limits in the national health service was introduced by the previous Labour Government. It was a wise move, and I am sure that no future Government will remove cash limits from the national health service.
The cash limits for Camberwell or, indeed, anywhere else vastly exceed the levels expected when Labour was last in power. It remains a fact that all parts of the national health service are expected to deliver their services within the growing resources allocated to them. Sometimes they can cut beds and facilities and switch the money saved to more important parts of the service or use it to maintain the number of patient treatments at reduced cost. That is part of managing the health service and Camberwell, like every other district, sometimes has to face difficult decisions about how best to maintain high-quality services within the resources available.
Column 843The Minister for Health (Mrs. Virginia Bottomley) : Since 1979, the pay of hospital doctors has increased in real terms by 33 per cent.
Mr. Irvine : Does my hon. Friend agree that that encouraging answer provides clear evidence of the Government's commitment to the national health service? What is more, does not it provide clear evidence of their readiness and ability to back their commitment with hard cash?--[ Hon. Members :-- "No."] If she has them, will my hon. Friend give the comparative figures for the period 1974 to 1979, when Labour was in office?
Mrs. Bottomley : I shall answer only one question, and provide the information that my hon. Friend wants. Between 1974 and 1979, the pay of hospital doctors fell by 6.4 per cent., which contrasts with a 33 per cent. increase over the years that the present Government have been in power. That is a strong indication of our belief in the professionals who work in the health service as well as of our commitment to the patients whom we are all there to serve.
Mr. Skinner : Why does not the Minister tell the House about another 33 per cent. increase for last year only? I refer to the increase gained by company chairmen following a 28 per cent. increase the previous year. If it is good enough for company chairmen, bosses, and friends of the Tory party, why cannot hospital doctors, nurses and others who work in the health service receive the same kind of increase?
Mrs. Bottomley : It is exactly that type of contribution from the hon. Gentleman that makes all those who work in the health service fear the day that Labour ever achieves power. It is precisely that type of political mischief-making that so enormously depresses the 1 million people who work in the health service. The hon. Gentleman mentioned nurses. Their pay has risen by 43 per cent. while the present Government have been in power, which contrasts with a fall of 21 per cent. when a Labour Government were responsible for the service.
The Parliamentary Under-Secretary of State for Health (Mr. Stephen Dorrell) : We have not set any national targets. It is for individuahealth authorities to assess the numbers of speech therapists they require.
Mr. Squire : Is my hon. Friend aware that there is a national shortage of speech therapists, and that in the North East Thames region the shortfall is estimated at 35 per cent? The figure for my district is similar. Will my hon. Friend give his full commitment to increasing the supply of qualified speech therapists and to reducing the number of children who sometimes have to wait more than one year for an initial assessment?
Mr. Dorrell : We recognise the need to increase the number of speech therapists in the future. Perhaps the best earnest of our intention to do that is the 80 per cent. increase in the number of speech therapists in post since 1979. An important way of improving the flow of people into the profession is to ensure that pay and conditions are made properly flexible. That issue will be addressed as part of the review promised for this autumn.
Dame Jill Knight : Will my hon. Friend take this opportunity to pay tribute to the work of speech therapists, who do an exceptionally good job, often in difficult circumstances, for people who desperately need help?
Mr. Dorrell : My hon. Friend is absolutely right. Speech therapy offers an important release for people who would be unable to get as much out of life as they can with the help of a properly qualified speech therapist. As my hon. Friend will know, the Education Act 1981 was instrumental in identifying the major opportunities for improvement in individual circumstances that is offered by speech therapists.
Mr. Alfred Morris : Is the Minister aware just how seriously the current shortage of speech therapists is being felt by disabled children and their parents? In particular, is he aware that there are schools for such children, many with severe speech impairments, that now have no speech therapy at all and that this will involve lifelong consequences for the children affected? What action will he take to help them?
Mr. Dorrell : I have already said that I recognise the need for further improvement in the number of speech therapists. I should have hoped that the right hon. Gentleman would welcome the increase of 80 per cent. in the total number of speech therapists in post since he left office as Minister for the Disabled.
Mr. French : Will my hon. Friend issue guidelines to family practitioner committees to avoid the difficulty under the cost rent scheme when permission for a new doctor's surgery is first given and later withdrawn?
Mrs. Bottomley : My hon. Friend has a constituency case on which he has made diligent and persistent representations. I assure him that in his FPC area 63 schemes out of 86 practices have been approved. A letter was sent to FPCs six months before the new system started, and in the current statement of fees and
Column 845allowances clear guidance is again given. My hon. Friend the Under-Secretary will respond to my hon. Friend on his constituency case in the near future.
Mrs. Wise : Does the Minister understand the surprise that will be felt in the House on hearing that statement? One of the great fears of parents of mentally handicapped offspring is that when they die their children will have nowhere to go. Is he aware that there is wild fluctuation in the priority accorded to mental handicap services by different authorities? What is he doing to stop his right hon. Friends from exerting unreasonable pressure for cuts in local government spending which will certainly be felt in mental handicap services?
Mr. Dorrell : It is a funny way to cut services for the mentally handicapped. Since 1979 places in local authority homes and hostels for the mentally handicapped have increased by 57 per cent., places in adult training centres and day centres have increased by 30 per cent., and the number of local authority staff employed in residential homes and hostels has increased by 109 per cent. The facts simply do not accord with the hon. Lady's prejudices.
Mr. Favell : Life in the community for the mentally handicapped is one of the most important but least applauded reforms made by the Government. When I meet mentally handicapped people who have moved into the community I ask whether they would prefer to go back where they came from. I have never yet found one who would prefer to be back in hospital or in a home rather than in the community. It is a wonderful reform and it is about time the Opposition recognised it.
Mr. Dorrell : My hon. Friend is absolutely right. He speaks with some authority. I happen to know that he is the president of Stockport Mencap. The line that he takes is supported by patients and the professionals who look after the patients and it should be supported by the House.
Mr. Tom Clarke : Is the Minister aware of Mencap's concern about the absence of services for mentally handicapped adults? Does he accept that his figures confirm that there is a shortfall of 22,000 places--25 per cent.--in adult training centres? How did he respond to Sir Brian Rix's letter to Members of Parliament which said that if that shortfall continues there will be a lottery leading to empty hours, empty days and empty years for some of society's most vulnerable people?
Mr. Dorrell : What the facts confirm, to pick up the hon. Gentleman's phrase, is that there has been a 69 per cent. increase in real expenditure on facilities for the mentally handicapped in the community since 1979. That hardly makes out the case for additional protection for expenditure by local authorities on the mentally handicapped.
Column 846government finance? Does he suspect that the Opposition's enthusiasm for such grants illustrates their lack of confidence in Labour-controlled councils' spending priorities?
Mr. Dorrell : It also squares ill with the repeated allegations of the Opposition that the Conservative party wants to centralise power that properly belongs to local government. It is a proper exercise of local discretion.
12. Mr. Flynn : To ask the Secretary of State for Health what representations have been received from local authorities regarding the costs of implementing the Government's proposals on community care.
Mrs. Virginia Bottomley : We are having discussions with local authority associations in the usual way. The local authorities have produced an estimate of those costs which they believe will be necessary in the implementation of care in the community.
Mr. Flynn : Does the Minister agree that the Government appear to be having extreme difficulty understanding the argument? It is not a question of centralising power ; it is one of a shortfall in finances. Does the Minister agree that by 1994 social services depts will be facing a shortfall of £500 million? The projections are that the fall in Government funding and increasing costs will mean that the social services departments will have the greatest difficulty implementing the Children Act 1989 and care in the community. What do the Government propose to do about it?
Mrs. Bottomley : The hon. Gentleman is right that local authority social services departments are already implementing the Children Act as well as carrying forward plans for care in the community. Social services departments have seen an increase in their spending of about 37 per cent. over the past 10 years. Of course, they will have to seek good value for money and meet the most important priorities in carrying forward their plans. We have always made it clear that adequate resources will be made available for implementing care in the community.
Mr. Nicholas Winterton : How can my hon. Friend assure the House that there will be adequate funds for community care after April 1991, bearing in mind the fact that it is almost inevitable--I have it from the highest level of government--that there will be additional capping next year? How can my hon. Friend and my right hon. and learned Friend the Secretary of State guarantee the House that the most vulnerable groups of people--the mentally handicapped, the mentally ill, the elderly and the disabled--will get the sums of money that are allocated to them under the present system when capping will take a major part of next year's local government financial allocation?
Mrs. Bottomley : There were those who believed that local authorities should not be entrusted with the important task of care in the community. I am not one of those people. Had the health service undertaken that responsibility, it would have become a directly managed service. Local authority responsibility involves local accountability. Where a particular need has to be addressed, a limited specific grant is appropriate, and for that reason last week my right hon. and learned Friend the
Column 847Secretary of State introduced the popular ring-fenced grant for drug and alcohol-related difficulties. We have made it clear throughout that adequate resources will be made available for the implementation of care in the community.
Mr. Kennedy : Does not the Minister appreciate that in addition to the problems faced by local authorities, as outlined by the hon. Member for Macclesfield (Mr. Winterton), the health authorities are offloading people into the community far more rapidly than was ever envisaged when care in the community gained all-party support? They are forced by the squeeze on their budgets to release property on to the open market or to release patients back into the community without adequate back-up care. When will the Minister make sure that one arm of government is working in conjunction and harmony with other arms of government so that people do not fall through the net? That is precisely what is happening at the moment.
Mrs. Bottomley : I do not underestimate the difficulty of implementing care in the community. It will take 10 years to achieve the care for the frail and vulnerable that many of us hope to see. One such difficulty is not the narrow question of resources that my hon. Friend the Member for Macclesfield (Mr. Winterton) mentioned. The key is persuading the different groups to collaborate and to plan together to ensure that those who require the help receive it. My right hon. and learned Friend the Secretary of State spoke of the increase in resources to the health service. I have made it clear that there has been a substantial increase in funding to local authority social services departments, quite apart from the vast resources that are given through social security. The key is to make those substantial resources work effectively in the best interests of the frail and vulnerable.
Mr. Wilshire : When my hon. Friend responds to representations from local authorities, will she resist the pressures to support ring fencing of budgets? Does she agree that hon. Members who support wholesale ring fencing of local government budgets are in favour of destroying local government as we know it?
Mrs. Bottomley : I entirely endorse my hon. Friend's point. Ring fencing of substantial sums of money undermines local accountability. Those who believe in local government should welcome local accountability. Plans will have to be made for community care. My right hon. and learned Friend the Secretary of State will have powers of direction and there will be appropriate safeguards.
Mr. Robin Cook : What advice on the cost of community care did the Minister and her colleagues give the Secretary of State for the Environment before he capped 19 social services authorities? Is she aware that in the past month, as a result of that capping, North Tyneside has had to cut its social services budget by a tenth, Derbyshire by £2.5 million, and Fulham by £1.5 million and that Barnsley is having to shut old folks' homes and introduce charges for home helps of £5 a week? Is not she concerned about the effect of those sharp cuts and savage rises on elderly and disabled people in our community? What is the point of her lecturing local authorities to
Column 848provide more community care when her colleagues in the Government penalise the local authorities that provide the most?
Mrs. Bottomley : The hon. Gentleman constantly identifies with the producer interest rather than with those who must pay the community charge. I am well aware that elderly and disabled people and others must pay the community charge. They welcome the fact that they have been protected from the excessive spending of their local authorities by my right hon. Friend the Secretary of State for the Environment. It is right for local authorities to make proper plans, but that does not involve spending £1 million on a publicity department for Derbyshire county council.
19. Mr. James Lamond : To ask the Secretary of State for Health when he next intends to meet representatives of national health service junior doctors to discuss their terms and conditions of service.
Mrs. Virginia Bottomley : I shall next meet the representatives formally later this summer to discuss the first report of the working group that we have set up with the key parties involved to discuss the problem of junior hospital doctors' hours.
Mr. Lambie : I am disappointed by that reply. I should have thought that the Minister would seek an immediate meeting with the junior doctors. Is she aware that the British Medical Association is carrying out a survey of junior hospital doctors on industrial action over hours of work? The junior doctors want only a reduction in their hours of work to a maximum of 72 hours a week instead of the 92 hours that they are working at present, with no more than 36 hours of continuous work. In the best interests of patients and the national health service, will the Minister grant those fair demands?
Mrs. Bottomley : I have had a series of formal and informal meetings with junior doctors, and I hope shortly to meet the new chairman of the hospital junior staff committee. For the first time, we have called together all the key players who affect junior hospital doctors' hours--the royal colleges, consultants, junior hospital doctors and management. We are determined to have further action and will take all possible steps to achieve it, but it is very much for the profession to demonstrate commitment and to make the necessary changes with us to ensure that we put an end to unreasonably long hours for junior hospital doctors.
Mr. Lamond : Is not the Minister's answer a little unconvincing when we recall that her Department has found time wholly to reorganise the health service, to disrupt the relationship between the general practitioner and his patients and to pull the rug from under the national health service hospitals, while this simple problem, which has been known about for years, has still
Column 849to be tackled? Junior doctors, who are an essential link in the health service, are expected to work, on average, more than 90 hours a week.
Mrs. Bottomley : I am afraid that the hon. Gentleman is not entirely correct in his facts. The junior doctors worked more than 90 hours a week-- 91 hours a week--when the hon. Gentleman's party was in power. However, under this Government, their working hours are down to 83 hours a week, with about 58 hours when they are actually working. It is a complex issue because there is a difference between being on call and working. We are determined to see further progress and I am pleased to be able to inform the hon. Gentleman that, by the summer, only around one in eight junior hospital doctors will be working more than one in three onerous rotas. That is substantial progress over two years and we are determined, with those directly involved, to see further progress.
Mr. Conway : Will my hon. Friend continue to emphasise the difference between being on duty and being on call? Does she accept that, before any radical change is made, all junior doctors--not necessarily just their representatives--should be consulted, because any shortening of the number of hours would have implications for the length of time that doctors must serve before registration?
Mrs. Bottomley : My hon. Friend is exactly right. There is a large distinction between being on call and working, which is why legislation is an irrelevance in the context. My hon. Friend also identifies another important point, which is the role of the royal colleges in approving the training places. We are at an opportune moment when, for the first time, the royal colleges, the consultants themselves--and there are, of course, 21 per cent. more consultants than there were 10 years ago--and the juniors are prepared to work with the NHS management to ensure that our junior hospital doctors can be alert as well as awake when on duty.
Mr. Forman : I welcome the obvious progress toward shorter hours for junior hospital doctors, but is my hon. Friend aware that many of us share a deep concern about the problem, especially when we read stories of such doctors falling asleep on duty? Where does the real difficulty lie? Can my hon. Friend tell the House about the obstacles?
Mrs. Bottomley : I share my hon. Friend's deep concern. He is addressing the point about continuous hours of duty. There is a difference between the cumulative hours worked in a week and having long, continuous hours on duty. In many cases, the juniors themselves prefer to have continuous hours on duty so that they can have long weekends off duty. It is for them to sort out with the consultants in their particular locations the best way of organising the work rotas. In many cases, a move towards a team approach rather than an individual firm approach makes a difference. In other cases, other members of the health care profession, such as nurses, can substitute for doctors. It is a complex and subtle matter on which all parties are determined to make progress. Progress is in the interests not only of the junior hospital doctors, but of the patients, who are entitled to be treated in hospital by doctors who have had a good night's sleep.
Mr. Galbraith : Does the Minister agree that any progress made so far has been modest and slow and that the average hours worked by junior hospital doctors are still 87 a week? Any improvements have been achieved simply by shifting work from one group of overworked junior doctors to another group of overworked junior doctors. Is not the solution, as the Minister in part suggested, to look at ways of shifting work, such as giving responsibility for intravenous injections and phlebotomies to nurses and, most of all, to increase manpower, especially consultant manpower, so that they can take over some of the duties?
Mrs. Bottomley : As I was able to inform the House a moment ago, the number of consultants has increased by 21 per cent. It is important that some of the new consultants should be prepared to cover. If the new consultants refuse to cover for the juniors, the difficulty of the juniors' hours will persist. The working practices of juniors, consultants and management alike are involved. But there has been much more substantial progress than the hon. Gentleman suggests. The number of junior doctors working such hours has fallen from one in four to one in eight over two years, and regions that have shown real determination have cut by a half the number working onerous rotas. I would mention in particular South West Thames regional health authority, Northern regional health authority and South Western regional health authority.
Sir Robert McCrindle : Like the hon. Member for Strathkelvin and Bearsden (Mr. Galbraith), I have recently been on the receiving end of the valuable services of junior hospital doctors. Will my hon. Friend take on board the suggestion that one way of relieving to some extent the burden to which junior hospital doctors are subjected would be to try to give them some clerical and secretarial assistance? In my recent experience, junior hospital doctors spend a great deal of their time engaging in such activities, which, arguably, could be dealt with by somebody else.
Mrs. Bottomley : The discussion will soon be taken up by the working party that I have established, on precisely this subject. As my hon. Friend said, clerical skills may well play an important part. The work requirements of the consultants are important and, as my hon. Friend the Member for Shrewsbury and Atcham (Mr. Conway) said, the training requirements of the royal colleges are also involved. In many cases, a shift system could be introduced and in others juniors could be used to cover for other specialties in which they have had appropriate experience. In addition, in certain cases units can be amalgamated so that the junior can cover. What is clear is that all those involved are determined to take the necessary constructive action to bring an end to what I regard as an unacceptable problem.
Mr. Alton : Is the Minister aware that of the nearly 2,000 people in Liverpool requiring speech therapy but currently denied it, 800 are children with special needs--partially hearing or disabled children? There are hospitals completely without speech therapy cover and there is no speech therapist to deal with the special needs of the deaf. Does the Minister agree with the view of the local area health authority chairman that the profession needs to be restructured and that improved resources and regrading are required? Does he further agree that the starting salary of £8,000 for a graduate is one reason why it is impossible to retain speech therapists within the service?
Mr. Dorrell : I agree that regrading would be desirable and we are committed to doing that in the autumn. I also agree with the conclusions of the Davies and Enderby study that, although pay and conditions are part of the problem, we must also look at patterns of work within the speech therapy profession to ensure that we make the best possible use of the skilled manpower available.
Mr. Wareing : Does not the Minister realise that the Government are regarding the problem with great complacency? A child of four in my constituency has been told that when his fifth birthday comes he will be able to obtain the speech therapy treatment that he requires only by going to a school in Warrington or Southport. Is not that disgraceful, and is not it about time that the Government gave real priority to the management of the speech therapy service so that conditions of service are such that speech therapists are retained in the service rather than being forced into other occupations?
Mr. Dorrell : I challenge the hon. Gentleman to find any part of the health service in which there was an increase of 120 per cent. in real expenditure during the Labour Government's four years in power. We have increased real expenditure on speech therapists by 120 per cent. and we have increased the number of therapists in post by 80 per cent. That is not complacency.
Mr. Rowe : Does my hon. Friend accept that, in places such as Liverpool, where the problem is acute, as it is in my constituency, there will always be a temptation for employers to look for people calling themselves speech therapists--which anyone can do--without guaranteeing the quality that qualification as a speech therapist ensures? Will he give the assurance that, in his tremendous efforts to solve those difficulties, he will not look for a cut in the quality of the service that is offered?
Mr. Dorrell : My hon. Friend is right to the extent that we must ensure that the people who offer those services are properly qualified to give them. Equally, we must not allow ourselves to regard the services as a mediaeval mystery. We must ensure that speech therapists are adequately qualified but not overqualified.
16. Ms. Short : To ask the Secretary of State for Health what further evidence has been made available to his Department regarding the effects of the introduction of charges on the numbers of eyesight checks undertaken.
20. Mr. Rees : To ask the Secretary of State for Health what further evidence has been made available to his Department regarding the effects of the introduction of charges on the numbers of eyesight checks undertaken.
Mr. Kenneth Clarke : We have received no new independent evidence on sight test demand since the publication of the independent national opinion poll report last month, which showed that the number of sight tests being undertaken is fully in line with past trends.
Ms. Short : I am shocked that the Secretary of State did not see the Which? report--he is not doing his job properly if he did not. That report showed that there has been a serious drop of 2.5 million in the number of eye tests. As the right hon. and learned Gentleman will know, one in 20 people are referred for serious sight and other health problems, which means that about 125,000 seriously ill people are being missed. Will he now admit that that is a disastrous move for people's health, apologise for misleading the House and the country, and scrap the eye test charge, because people's health is too valuable for them to miss eye tests?
Mr. Clarke : There has been no reduction in the number of eye tests as a result of the introduction of charges. All the evidence--not only our survey of 10,000 people but the MORI survey that was carried out for the Association of Optometrists, and even the telephone ring-round by the Royal National Institute for the Blind--shows that there has been no reduction in the number of eye tests compared with the tend that was established before the charging system was changed in 1987.
The Consumers Association, in its Which? magazine, has not explained the methodology that produced its rather startling conclusion. Most of the contrary claims are based on leading questions about whether people think that charges might deter them. All sensible surveys show that there has been no evidence of deterrence. The Labour party's only spending promise to spend £90 million to go back to the previous system is based on a mistaken assessment of the facts.