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House of Commons

Tuesday 10 November 1992

The House met at half-past Two o'clock

PRAYERS

[Madam Speaker-- in the Chair ]

PRIVATE BUSINESS

London Underground (Jubilee) Bill

Order for Third Reading read.

Queen's Consent, on behalf of the Crown, signified.

Read the Third time, and passed.

Llanelli Borough Council (River Lliedi) Bill

[Lords] Considered ; to be read the Third time.

Oral Answers to Questions

HEALTH

Occupational Health

1. Mr. Jim Marshall : To ask the Secretary of State for Health what plans she has to increase the time that medical students spend on occupational health issues during their training.

The Minister for Health (Dr. Brian Mawhinney) : Medical students already learn about occupational health medicine as part of the standard undergraduate medical curriculum. The General Medical Council has responsibility for the content of the curriculum and has recently issued a discussion document proposing changes. Those include proposals to increase our future doctors' knowledge of occupational health matters. The Government fully support the General Medical Council's proposals.

Mr. Marshall : I thank the Minister. On a personal note, it makes a change to have discussions other than during Northern Ireland business.

The Minister must realise that occupational health is not taught in seven out of 27 medical schools, and in many others it is treated casually. If the hon. Gentleman has discussions with the GMC, will he impress upon it the need to make occupational health a core subject rather than allow it to remain a peripheral subject?

Dr. Mawhinney : I reciprocate the hon. Gentleman's first remark. I take the hon. Gentleman's point. It was partially his concern that caused the GMC to issue its proposals. The hon. Gentleman is right to draw attention to occupational health being an important part of the medical undergraduate curriculum.

Dr. Goodson-Wickes : I welcome my hon. Friend's admission that occupational health has not always been


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taught as well as it might have been. Will he assure the House that when he consults the GMC, he will pay particular attention to comparative studies with the services offered by our Community partners which, in many respects, have a much more sophisticated system?

Dr. Mawhinney : I am grateful to my hon. Friend for that suggestion.

Mr. Morgan : Will the Minister, in his discussions with the GMC, also consider the effect of the present restrictions on hospital intakes on the quality of medical training? I quote a letter from the consultants at Llandough hospital, which serves my constituency--

Madam Speaker : Order. I am sorry to interrupt the hon. Gentleman, but we do not have quotations at Question Time. He may paraphrase briefly.

Mr. Morgan : A letter to me from consultants at Llandough hospital, which provides medical training for south-east Wales, refers to the fact that medical training is suffering because of the current restrictions on intakes. The dean of the medical school is concerned that, with no paediatric intake, no gyneacological elective operations and no waiting list in elective surgery, junior doctors do not have enough work to do and medical students are not being properly trained. What will the Minister do about that?

Dr. Mawhinney : I have no doubt that, if the hon. Gentleman wants us to take the matter seriously, he will be in correspondence with us and we shall look at the letter that he has received from his constituents. However, that matter goes much wider than this question.

Practice Nurses

2. Mr. Day : To ask the Secretary of State for Health how the number of practice nurses employed by family doctors has changed (a) since 1978 and (b) since 1990.

The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville) : In 1978, 888 whole-time equivalent practice nurses wereemployed by general practitioners. The number at 1 October 1990 was 7,698--a massive increase of more than 700 per cent. The latest figures available are to 1 October 1991, when 8,776 nurses were employed by GPs.

Mr. Day : I thank my hon. Friend for his answer, which I am sure that the whole House will welcome. Does he agree that that answer is evidence of a vast--indeed, record--increase in NHS resources? Will he confirm that, since 1979, nurses' pay has increased by 50 per cent. in real terms? Does he agree that that is a sign not only of increased resources but of efficient use of those resources, which is vital in the present climate of pressure on public expenditure?

Mr. Sackville : What my hon. Friend has said about nurses' pay is correct. Moreover, the total budget for family doctor services has more than doubled in recent years. The effect is clear : additional services are being offered, such as immunisation, and practice nurses are very popular with patients.


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Community Care

3. Mr. Legg : To ask the Secretary of State for Health what has been the response from local authorities to the announcement about community care finance she made on 2 October.

The Secretary of State for Health (Mrs. Virginia Bottomley) : Our decision to introduce a ring-fenced special transitional grant of £539 million in 1993-94, and to announce that and the grant for the following two years in advance of the general local government settlement, has been widely welcomed.

Mr. Legg : The sums that my right hon. Friend has won for the implementation of community care by local authorities are very welcome. Does she agree that, at a time of difficult choices in public expenditure, it is most welcome that priority is being given to community care? This is a long-awaited feature of Government reform.

Mrs. Bottomley : I thank my hon. Friend. Certainly, very difficult decisions must be made about public expenditure, but we believe that it is right to fund care in the community fairly. That is a long-standing policy. We introduced the legislation ; we have introduced the regulation ; now, we are fairly funding it. It is now up to local authorities and health authorities to make care in the community the success that all intend it to be.

Mr. Kevin Hughes : Does the Secretary of State believe that those funds will be safe after the Chancellor's statement on Thursday? It is possible that he will remove the money that has been made available through her good offices, by way of the back door. In reality, no extra funds may be available for community care.

Mrs. Bottomley : I have made it clear that we have maintained our commitment to fund care in the community fairly, and I am sure that the hon. Gentleman will recognise that, when all the consequences of the autumn statement are understood. It is now up to local authorities to accept a responsibility that they have long sought and to ensure that when they provide services the users of those services, rather than their own narrow or partisan interests, are at the forefront of their minds.

Dame Jill Knight : Does my right hon. Friend anticipate that, under the new arrangements, the excellent work carried out by drug rehabilitation centres such as Turning Point, in my constituency, will be allowed to continue? Is she aware of the grave concern that is felt about that matter?

Mrs. Bottomley : I am happy to reassure my hon. Friend on that point. Drug and alcohol rehabilitation units are carrying out excellent work. A substantial sum is involved and detailed discussions have taken place with the providers of drug and alcohol care to ensure that all the proper regulations are in place. I can reassure my hon. Friend that there is a direction on choice. There is also a requirement that a substantial amount of the money must be used in the independent sector--the voluntary and private sectors--and that agreements with health authorities must be in place. I believe that, given all those safeguards, no anxiety need be felt on behalf of drug and alcohol misusers, but the


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Under-Secretary of State--my hon. Friend the Member for Suffolk, South (Mr. Yeo)--is engaging in further discussions to ensure that all aspects are fully considered.

Mr. Hinchliffe : Apart from the £300 million shortfall identified by local authorities, do not the funding formula and the requirement for 75 per cent. of the money to be spent on independent provision demonstrate that the Government have completely abandoned one of the fundamental principles of the community care reforms--the avoidance of unnecessary institutional care? Is it not apparent that they are being prevented from developing a proper community care policy by irrelevant free market dogma? Is not their treatment of the private care sector in marked contrast to their complete ditching of previous commitments to protect drug and alcohol projects?

Mrs. Bottomley : I am afraid that the hon. Gentleman has misunderstood the position. On the day that I announced the ring-fenced money, my understanding was that, only the day before, the hon. Gentleman had said that no news on money would be available until at least the end of October or the beginning of November. We have fairly discharged that responsibility.

As ever, the hon. Gentleman, who is sponsored by the National Union of Public Employees, thinks always of the public sector providers and not of the voluntary and private sectors. We have made it clear that money must be spent by the independent providers if we are to safeguard choice. Choice always means very little to the Labour party. [Interruption.] If the hon. Gentleman cares to listen, I am able to inform him, and others, that after consultations with local authorities we are amending the requirement relating to the percentage to be provided by the independent sector. That will now be 85 per cent. of the transfer element, but the additional 35 per cent. over and above social security money will be distributed normally and can be used in the way that local authorities choose.

Mr. Sims : Does my right hon. Friend recall the pleas made by the Social Services Select Committee, many organisations and hon. Members on both sides of the House that the transfer of funds from social security to community care should be both adequate and ring-fenced? I thank my right hon. Friend for accepting both those pleas. Is not a high proportion of the income support provided by social security already spent in the private sector? Does it not make sense, therefore, that the vast majority of the funds to be transferred should similarly be used in the private sector?

Mrs. Bottomley : As ever, my hon. Friend is extremely well informed and authoritative on these issues. The Select Committee took the view over many years that the money should be ring-fenced. We gave an undertaking not only that it would be available and be seen to be fair but that it would be transparent. Local authorities are now in a good position to take forward that policy.

My hon. Friend is also absolutely right about income support. At present, it is spent entirely in the voluntary and private sectors. That is why today's announcement is important : that 85 per cent. of the money that comes over from social security will be spent in the independent sector. However, the 35 per cent., over and above, will be spent in the way that the local authority wishes.

I think that the Labour party has singularly failed to understand the significance of what I am saying. The


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announcement means that a lesser, not a greater, percentage of the total amount for community care is to be spent in the independent sector. It is only the transferred money, not the 35 per cent. additional money, that is involved. I suggest that the Labour party should try to understand the policy a little better.

Mr. Blunkett : The Secretary of State has just made a statement. She has not answered the question. Her statement has changed completely from the previous position. The amount of money announced by the Secretary of State on 2 October has changed from a 75 per cent. allocation to the private sector to 85 per cent.--a very significant change in the amount that will now be available to other sectors of care. Will she confirm that, in the intervening six weeks, something has happened to change her mind? Can she tell the House what has changed her mind and why the sum has changed?

Mrs. Bottomley : I am only too happy to tell the hon. Gentleman. We have been consulting local authorities and have listened to their comments. Unlike the Labour party, which is in the pockets of NUPE, we listen to and work with local authorities. What I am trying to explain, in the most elementary way that I am able to do, is that the upshot of this announcement is that the amount to be spent in the independent sector overall will fall from 75 per cent. to 64 per cent. It is 85 per cent. of the transferred money from social security, not the 35 per cent. of extra money, that is coming through. We listen. We work in partnership. We treat local authorities fairly. Community care will be a great success.

Mr. Nicholas Winterton : I recognise the substantial sums of money that have been transferred to local government to deal with community care, but does my right hon. Friend accept the increasing reports from the professions that responsibility for mentally ill people should lie primarily with the medical profession and not with social services? Will she assure me and the House that there will be sufficient resources in local government to allow it, as the authority primarily responsible for social care and community care, to provide medical care to deal with mentally ill people?

Mrs. Bottomley : My hon. Friend and I do not always see eye to eye on every issue, but we very much see eye to eye on the priority to be given to mentally ill people. That is why it is so important. It is one of the key areas in "The Health of the Nation". It is a targeted area not only in community care but in "The Health of the Nation". We have introduced the mental illness specific grant, which last year rose to £30 million. Above all, we have now established a task force in the NHS, led by David King, to ensure that we have a genuinely seamless service. It is no good people leaving long-term institutions without a long-term programme of care. Like my hon. Friend, I am absolutely determined to see that the standard of care for mentally ill people improves and is consistent throughout the service.

Accidents and Illness at Work

4. Mr. Gareth Wardell : To ask the Secretary of State for Health if she will encourage health promotion departments in hospitals to distribute information on the prevention of accidents and illness at work.


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Mr. Sackville : The NHS is already widely engaged in health promotion at work. Following up the commitments in the "The Health of the Nation" White Paper to develop that, we have launched the health at work initiative. A specialist workplace task force has been established to develop an action programme covering workplaces generally. That task force includes members of our wider health working group and representatives of employers, occupational health professionals, the Trades Union Congress, the Confederation of British Industry, the Health and Safety Executive, the Health Education Authority and the Departments of Employment and of Health.

Mr. Wardell : How much money has the Department made available to district health authorities and hospital trusts this year to enable them to promote campaigns to prevent accidents this year--the year of Europe--when Europe is specifically considering safety, hygiene and the protection of workers at work?

Mr. Sackville : We expect managers to spend adequately on protecting their employees. I recently launched a handbook called "Handling of Patients", produced by the National Back Pain Association and the Royal College of Nursing designed to offer good practice and to prevent nurses from the accidents to which they are so vulnerable.

Mr. Jessel : In view of the large number of nurses suffering from back pain from lifting patients, to which my hon. Friend referred, can he ask health departments to ensure the widest possible distribution of their booklet on handling patients, published by the National Back Pain Association, whose recent conference my hon. Friend was kind enough to attend?

Mr. Sackville : I attended the annual general meeting of the National Back Pain Association at my hon. Friend's request. I intend shortly to lunch with the president thereof. The matter of back pain was mentioned in our White Paper and we attach much priority to it.

Mr. McCartney : The Under-Secretary was rather complacent in his response to my hon. Friend the Member for Gower (Mr. Wardell)--

Mr. Oppenheim : Stand up.

Mr. McCartney : I am standing up. It is not true that Conservative Members have clumped together to buy a high chair for my debut at the Dispatch Box.

The figures on occupational health are staggering : 20 per cent. of hospital accident admissions are work related, 2 million people suffer from work-related illnesses and a huge number of days are lost each year due to illness at work--a staggering 29 million. Despite that, the Government have set no targets or objectives in the White Paper. Will the Minister state clearly when he intends to introduce targets and objectives to reduce workplace injuries and matters related to occupational health?

Mr. Sackville : We attach a high priority to that. It is for that reason that the Health Education Authority has set up a workplace project covering 4 million private and public sector employees in England, including many of the health authorities' employees.


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GP Fund Holders

5. Mr. Bryan Davies : To ask the Secretary of State for Health what proportion of general practitioner fund-holding practices are projecting overspends in the current financial year ; and if she will make a statement.

Dr. Mawhinney : That information is not held centrally, but I have no reason to believe that fund holders will be any less efficient in managing resources than they were last year.

Mr. Davies : Are not regional health authorities having to bale out those GP fund holders who are overspending? Is that to save the Government embarrassment over the failure of the scheme? Should not the resources be used for better and fairer purposes in the health service than baling out fund holders?

Dr. Mawhinney : I am sure that the hon. Gentleman will be pleased to know that, last year, overall savings were about 4 per cent.--that is to say, GPs came in at about 4 per cent. below budget. As a result of imprecision in the setting of some budgets--which I recognise and on which work is being done--a few GP fund holders needed to ask regional health authorities for special help and that was given, as the rules allow. Nevertheless, the fund holders' record in treating their patients is an enviable one for the rest of the profession to follow.

Mr. Jacques Arnold : Are not fund-holding practices now getting value for money and, above all, obtaining treatment for patients faster, co -ordinated for the convenience of those patients?

Dr. Mawhinney : My hon. Friend is absolutely right. Next April, the percentage of the population being served by GP fund holders will increase from 14 per cent. to, probably, just over 25 per cent. and, anecdotally, it is suggested that the fourth wave in the following year will be very large indeed. That reflects the attraction of the scheme not only to GPs but to their patients.

Mr. Blunkett : Would the Minister care to comment on the article in The Times this morning which suggests that 100 GP fund holders are to form a consortium with a budget of more than £20 million, which will aim to match the purchasing power of district health authorities? Does the Minister agree that not only does that not square with the district health authorities' accountability for health care planning and strategy but that it runs contrary to the ethos of GP fund-holding practices as set out by the Government, which is that they should buy individual contracts for individual patients? Does not this whole sorry story show that the Government's reforms are in a terrible mess? Is it not time that they agreed to start again and put patients first?

Dr. Mawhinney : I am happy to respond to the wisdom of the National Union of Public Employees. However many GPs enter GP fund-holding schemes in a given area, their share of the budget is only 20 per cent., so their purchasing power will not in any sense be comparable that of the district health authority. The Kingston GPs mentioned in today's edition of The Times are thinking of joining forces because, in their judgment, that is the best way to deliver the best services to their patients. If I have


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to choose between those GPs' judgment of what is best for their patients and the hon. Gentleman's judgment, I shall side with the GPs every time.

Mr. Paice : Is it not indicative and encouraging that many GPs, including some in my constituency, who were opposed to the principle of fund holding at the time of the NHS reforms are now applying to become fund holders because they have seen the benefits to patients of existing GP fund holders?

Dr. Mawhinney : My hon. Friend is absolutely right. The fact that 600 GPs are to join the scheme next April gives substance to his remarks. GP fund holders, through their initiatives, have been in the lead in developing better services, not just for their own patients but for all patients in their community. That should be welcomed by hon. Members on both sides of the House.

Dental Services

6. Mr. Lewis : To ask the Secretary of State for Health what measures she intends to take in order to ensure that NHS dental services are universally available.

8. Mr. Hicks : To ask the Secretary of State for Health how many representations she has received expressing concern about the provision of dental services within the national health service ; and if she will make a statement.

Dr. Mawhinney : Since 1 April this year, the Department has received some 6,000 letters from hon. Members, dentists and others about the provision of NHS dental services. In the same period, there have also been some 120 parliamentary questions on dentistry. NHS dental services remain available throughout England. Family health authorities will assist any patients experiencing difficulty in obtaining NHS dental treatment.

Mr. Lewis : Does the Minister accept that that answer will fall very flat in Irlam in my constituency, a town of 17,000 souls who do not have a national health service dental facility? With reference to choice which the Secretary of State mentioned earlier, does the Minister also accept that a pensioner in Irlam in my constituency has received a letter from her dentist after being under his wing for a long time telling her that she could no longer be treated on the NHS? She must choose whether to pay or to travel eight miles down the road to another dentist.

Dr. Mawhinney : I am very happy to tell the hon. Gentleman that the application of the FHSA to appoint a salaried dentist which was received last week was approved today. There will be an NHS salaried dentist in Irlam.

Mr. Hicks : Is my hon. Friend aware that over half the dentists in Cornwall are refusing to take new NHS patients? Does he agree that that is both confusing and annoying? When can we expect tangible evidence to correct that unsatisfactory situation and not have to depend on temporary expedients such as the employment of mobile dentistry facilities?

Dr. Mawhinney : I certainly share my hon. Friend's concern about the fact that a number of dentists in Cornwall and in his constituency have decided to withdraw from offering NHS dental services. My hon. Friend will be aware that the local FHSA has appointed two salaried dentists who are mobile precisely because the


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nature of my hon. Friend's constituency and others is such that they need to be able to move around. Given his concern, I will be very happy to draw his remarks to the attention of the FHSA in case it decides to make further application.

Miss Lestor : What action is the Minister taking to safeguard the school dental inspection service? Is he aware that that service is being threatened or severely curtailed in some areas which means that children will no longer have annual dental inspections? If that happens, it will have a serious effect on children's teeth in future.

Dr. Mawhinney : I hear what the hon. Lady says. However, she will also be aware that under the new dental contract there was a significant focusing of dental attention on young people and on children. I hope that she will welcome that development which should be set alongside the school dental programme.

Dame Peggy Fenner : When might we expect the results of the review on remuneration of dentists in the NHS?

Dr. Mawhinney : Sir Kenneth Bloomfield has been asked to report by Christmas and I have no reason to believe that he will not be able to fulfil that request.

Tomlinson Report

7. Mr. Cohen : To ask the Secretary of State for Health if she will make a statement on the time scale for the implementation of the Tomlinson report.

Mrs. Virginia Bottomley : We will carefully consider the proposals put forward by Sir Bernard Tomlinson and his team. No decisions will be taken without full consultation with those institutions that are affected. We shall set out our detailed proposals for change in the new year.

Mr. Cohen : Will the Health Secretary confirm the report in "London Health Emergency" that in the past six months the four regional health authorities covering London have drawn up plans to axe 9,000 beds over the next five years? Is not the presupposition in Tomlinson's and the Government's thinking that London has too many hospital beds an absolute myth? Has there not been a cut of 8,000 beds in the past decade and have not hospital waiting lists in the capital increased 30 per cent. in the same period?

Mrs. Bottomley : If the hon. Gentleman studies the Tomlinson report, he will see that London already has many more beds than other parts of the country. It has 3.9 per thousand compared with 2.5 per thousand elsewhere. The waiting lists in London have come down by 10 per cent. over the past year and that is an achievement.

The real point is that Tomlinson has identified a problem of long standing which has been recognised by 20 reports in the past 100 years. With 45 hospitals, 12 teaching hospitals and eight postgraduate hospitals, London must have an enormous overhead infrastructure, but does not provide the proper primary care services that are needed. It is time for us to take those decisions, which we shall do on the basis of improving health care for Londoners while safeguarding research and teaching.

Mrs. Roe : Has my right hon. Friend seen the report in last Friday's Evening Standard of a study conducted by two health experts which concluded that general


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practitioners in London tend to be elderly with large practice lists and often without adequate back-up staff? Does not that report clearly make the point that action and change are needed to improve primary health care services in the capital?

Mrs. Bottomley : I saw the report that my hon. Friend mentions. It comes from a report in the British Medical Journal. It recognises the point stressed by Tomlinson that London has poorer primary health care services than other parts of the country. It is absolutely vital that we invest in primary health care in London as we take forward proposals.

I give an absolute assurance that no decisions will be made until careful consideration has been given and until it is possible to guarantee the improvements in primary care that were so clearly identified by Professor Tomlinson.

Mrs. Roche : While the Secretary of State is considering implementation of the Tomlinson report, will she assure the House that members of staff who stand to lose their jobs if hospitals are closed will be redeployed, given that we have a waiting list of approximately 139,000 in London?

Mrs. Bottomley : I thank the hon. Lady for giving me an opportunity to say that some of the suggestions about the number of staff who would lose or change their jobs are ridiculous, irresponsible and scaremongering.

It is untrue and devoid of explanation that figures of the kind quoted by the Confederation of Health Service Employees could seriously be considered. The figures that have been quoted are enough to alarm and worry people in the health service in London at a time when most people want to explain and reassure.

The hon. Member for Sheffield, Brightside (Mr. Blunkett)--I give him credit --said that the status quo could not continue in London. Editorials in The Guardian, The Times, The Independent and New Statesman and Society have said that change must come. Of course, the needs and interests of staff will be very much in our minds so that we can find ways to redeploy them and make the changes as easy as possible.

Mr. Carrington : My right hon. Friend will know that there is great anxiety in my constituency about the proposed changes to Charing Cross hospital. Will she assure me that any changes made to health care in west London will improve the service to my constituents, rather than diminish it?

Mrs. Bottomley : I can give my hon. Friend that absolute assurance. As has been said in many independent reports, the problems in London are of long standing and complex. Increasingly, patients now wish to be treated in their home communities. As I have made clear, a great number of specialist services need to be rationalised. We need improvements in primary care and community services. There will be no question of decisions being taken before we can be sure that they will lead to improvements in care, better use of resources and a strengthened national health service.

Ms. Primarolo : Will the Secretary of State give an undertaking that she will conduct full public consultation with Londoners on the future of their hospitals? Will she guarantee that she has secured the additional funding that


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is necessary for primary and community care before she gives any further consideration to implementing the Tomlinson report?

Mrs. Bottomley : The House will know that my hon. Friend the Minister for Health is having discussions with the different institutions in London on the basis of the recommendations in the Tomlinson report. As I made clear at the time of the statement, it is advice to the Government and not Government policy. We shall discuss with all interested groups how we can take forward those changes to improve health care for Londoners. I give the hon. Lady and others a clear commitment that those changes are about improving health care for Londoners. That is the message from all the professional journals--from the Nursing Times and Nursing Mirror, General Practitioner, House, and the Health Service Journal. As far as money is concerned, in answer to an earlier statement, I seem to remember that the hon. Member for Wakefield (Mr. Hinchliffe) was busy telling people at a social services conference that money for community care would not be ring- fenced--the day before I was able to announce community care resources. People should take prophecies of doom from the Labour party with a pinch of salt.

Mr. Rowe : Will my right hon. Friend accept, from a Kent Member of Parliament who represents an area which historically has long been underfunded and whose patients have had to travel well over 50 miles for hospital treatment in London, that his constituents are exceedingly grateful that she is showing her determination to reorganise the London hospital service, so that services that have been overfunded there can follow patients out of London to areas like ours?

Mrs. Bottomley : I think that my hon. Friend speaks for many hon. Members. In the past year, the rest of the country supported London health care to the tune of £50 million. Sensibly, 20 per cent. of the money in the national health service cannot continue to cover 15 per cent. of the people. I am well aware that there is great pressure outside London for us to move swiftly. We shall move only as fast as we are able to safeguard health care for Londoners, but we shall do so on the basis of the long-term interests of the national health service.

West Midlands Ambulance Service

9. Ms. Estelle Morris : To ask the Secretary of State for Health when she will make a statement on the funding of the West Midlands ambulance service.

Mr. Sackville : I have no plans to do so.


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