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House of Commons

Tuesday 8 December 1992

The House met at half-past Two o'clock


[Madam Speaker-- in the Chair ]

Oral Answers to Questions


Royal Free NHS Trust

1. Mr. John Marshall : To ask the Secretary of State for Health what representations she has received about the work of the Royal Free NHS trust.

The Minister for Health (Dr. Brian Mawhinney) : We have received many favourable comments about the quality of patient care at the Royal Free NHS trust.

Mr. Marshall : Has my hon. Friend seen the annual report of the Royal Free trust which serves many of my constituents and which can boast of a 9 per cent. increase in the number of in-patients treated, a substantial reduction in waiting lists and additional facilities for the mentally ill, victims of AIDS and the elderly? Is that not a record of which the Government and the trust can be justly proud?

Dr. Mawhinney : My hon. Friend is absolutely right, and he will see that I, too, have a copy of the annual report which was issued this week. He will be pleased to know that I visited the Royal Free only yesterday and was able to learn at first hand of some of its successes as a trust. I endorse everything that my hon. Friend said, except that I would reverse the order--it is something of which the trust can rightly be proud and the Government also.

Ms. Glenda Jackson : Is the Minister aware that his previous reply will ring somewhat hollowly in the ears of my constituents in Hampstead and Highgate in the light of the news announced 10 days ago that operations at the Royal Free will have to be postponed due to the lack of funds from its central purchasing authority because of the news that the Royal Free will have to trim its budget by between 3 and 5 per cent., amounting to £4 million next year, which will mean that 16 beds will be lost to the national health service for ever? Far from solving a problem, trust status is creating a crisis.

Dr. Mawhinney : The hon. Lady's point is far from the truth. I am pleased to be able to tell her that those responsible for the trust were yesterday in much more robust form and were looking forward with far greater enthusiasm to the success that they will continue to achieve, building on what they have already achieved. The hon. Lady's constituents will be pleased that activity at the Royal Free last year increased by 10 per cent.

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Mr. McCartney : Why does not the Minister of State tell the truth, the whole truth and nothing but the truth about that particular trust? It has a hospital maintenance backlog of more than £18 million, two thirds of its staff accommodation fails statutory standards and it has legionella problems in the air-conditioning system, which have not been solved because of a lack of resources. By December, the trust will close at least three wards because of expenditure cuts in this year's budget, nurses are to be forced to work a 12-hour shift instead of an eight-hour shift because of the cuts, and vacancies will not be filled because of problems in the current budget cycle. In 1993-94 there is to be a 3 to 5 per cent. cut in the budget. That is a story not of success but of serious problems in the trust. The Minister should rethink and suggest real reasons why the trust is to be underfunded by £4 million next year.

Dr. Mawhinney : I do not recognise the Royal Free trust from the information that the hon. Gentleman tried to give the House

Mr. Skinner : And he never took a breath.

Dr. Mawhinney : It was a great performance.

The Royal Free trust has managed to increase facilities for the elderly, including a new ward. It has increased facilities for the mentally ill and the elderly and introduced new facilities for those suffering from HIV and AIDS. It is treating more patients than ever before and plans to treat even more next year. If that is the hon. Gentleman's definition of failure, I hope that many more NHS hospitals are failures by his standards.

Community Care

2. Mr. David Nicholson : To ask the Secretary of State for Health if she will make a statement on the latest progress towards the implementation of the Government's proposals for community care.

The Parliamentary Under-Secretary of State for Health (Mr. Tim Yeo) : Good progress is being made by most local authorities in implementing the new arrangements. Where there are difficulties, we are offering help in a variety of ways, including our community care support force.

Mr. Nicholson : My hon. Friend will be aware that there is a general welcome from all parties for the ring fencing of the substantial grant given for the implementation of care in the community. He will also be aware that Somerset has been especially singled out by a recent Audit Commission report for making excellent progress, in collaboration with the health authority, in preparing to implement the proposals. However, is my hon. Friend also aware of a matter about which I am in correspondence with him and other right hon. and hon. Friends, which is that Somerset feels that it has lost about £1.3 million of grant for having followed Government guidelines in giving the private sector proper scope in the administration of care in the community? Do I have my hon. Friend's assurance that he and his colleagues will carefully examine that matter?

Mr. Yeo : I am grateful to my hon. Friend for his welcome for ring fencing, which ensures that the very generous resources that the Government have provided for local authorities to deliver community care will reach their targets. My hon. Friend is a most vigorous champion of the interests of Somerset in all respects. I am, therefore,

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aware of the particular difficulty to which he alludes. When Somerset county council entered into arrangements to ensure maximum participation by the independent sector in Somerset, it was aware of the likely arrangements for funding the new policy from next April. I shall continue to look into the matter most carefully.

Ms. Jowell : Will the Minister confirm the guidance given by civil servants last week to health service managers that trusts are to be regarded by local authorities as part of the independent sector in purchasing community care? Will he make it clear to the House that he agrees that care for many elderly people will not now be free at the point of use and that their health care has been privatised by stealth?

Mr. Yeo : There is absolutely no question of privatising the health care of any person, whether elderly or otherwise. As the hon. Lady really should know, a distinction has always been drawn between health care needs, which are met free of charge at the point of delivery to patients, and social care needs, for which we have never guaranteed that services would be delivered free. It is proper that all local authorities should make a charge for social services to those families who can afford to pay for them.

I gladly confirm that, as part of our general programme of maximising participation by the independent sector and of giving all local authorities the best opportunity to meet the requirement that 85 per cent. of the transfer funds must be spent in the independent sector, NHS trusts will qualify as being part of the independent sector because they are not controlled, managed or owned by local authorities.

Dame Jill Knight : Does my hon. Friend agree that the Children Act 1989 laid on social services departments the duty to take care of and to watch over children aged 16 who have left care? Is he aware that that is not being done and that children of 16 are not capable of managing by themselves? Will he look into that problem?

Mr. Yeo : I am aware that, in terms of implementing the provisions of the Children Act--which require local authorities to prepare all children, from the day they enter care, for the moment when they leave care, and to befriend children up to the age of 21 after they have left care--and in terms of the powers they have to help children where necessary not only with cash payments, but with advice and general counselling, there has been some variation in the performance of local authorities in the year since the Act came into force. We are studying the matter and we have a research programme at Leeds university. We are also carrying out a careful survey of all local authorities to see exactly how they are implementing the Act. We shall study the information submitted to us and we shall include it in the report that we make to Parliament in the new year, as required by the Act.

Mr. Hinchliffe : Has the Minister fully considered the implications of requiring a set quota of next year's community care funding to be spent in the independent sector, bearing in mind that independent sector domiciliary care is non-existent in many areas and that local authority domiciliary care faces cuts in 87 per cent. of councils, according to the directors of social services? Are

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we not in danger of seeing more rather than fewer elderly and disabled people ending up in unnecessary private institutional care?

Mr. Yeo : Absolutely not. I very much regret the fact that the hon. Gentleman continues to adhere to his party's traditional hostility towards the private sector in any form. What the policy will deliver, by replacing the awful alternative of a local authority monopoly in the provision of all social services, is higher standards and better value for money. Local authorities will have to contract with private and voluntary organisations, not only for the provision of residential or nursing home care but for domiciliary and day care services. We have an initiative in hand that is designed to encourage local authorities to work with the independent sector to develop innovative methods of delivering domiciliary care.

Hip Replacement Operations

3. Mr. Knapman : To ask the Secretary of State for Health how many hip replacement operations were carried out (a) in 1979 and (b) in 1991.

The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville) : The number of hip replacements climbed from 28,788 in 1979 to 44,477 in 1990-91, an increase of 54 per cent.

Mr. Knapman : Does my hon. Friend agree that those excellent figures are testimony to the improvements in the national health service over the past decade? Will he comment on the citizens charter where it is suggested that no one should wait more than 18 months for a hip replacement operation?

Mr. Sackville : I can confirm to my hon. Friend that a target of 18 months has been set and that regional health authorities tell us that they are on target to meet that by April next year. I certainly agree that the operation is wonderful and that it has improved the quality of life of hundreds of thousands of people over the past 20 years.

Ms. Abbott : Is the Minister aware that if he and his colleagues go ahead with the closure of London hospitals outlined in the Tomlinson report, waiting lists in inner London for elective surgery such as hip replacements are bound to grow? Is he aware also that the statistics quoted by the Secretary of State at the Dispatch Box about an excess of beds in London have proved to be unfounded? In the context of the Tomlinson report, is he further aware that London's general practitioners have come out unanimously against the closure of those great teaching hospitals?

Mr. Sackville : I can only tell the hon. Lady that the evidence of the increase in efficiency with which hip operations are carried out all over the country is there for everyone to see. The number of orthopaedic surgeons has increased and the number of staff specialising in orthopaedics has increased from 2,000 to 2,400. It is a success story.

Mr. Lidington : Will my hon. Friend congratulate the orthopaedic teams at Stoke Mandeville hospital in my constituency on the increased treatment that they are providing for patients in my area? Will he also assure the House and my constituents that when the £20 million capital programme proposed for Stoke Mandeville reaches

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his Department, it will be treated sympathetically and with speed so that top-quality NHS treatment can be assured for my constituents?

Mr. Sackville : I can confirm that. The temporary problems have been matched by a very sharp increase in activity at the hospital over the past year, including in orthopaedics.

NHS Staff (Pay)

4. Mrs. Jane Kennedy : To ask the Secretary of State for Health if she will make a statement on the future of the pay review bodies dealing with the pay of NHS staff.

The Secretary of State for Health (Mrs. Virginia Bottomley) : The remits for the review bodies have been amended for next year. Pay restraint will help us to improve services to patients. The review bodies have been asked to resume their full role for 1994-95.

Mrs. Kennedy : Does the Secretary of State accept that that answer will be a great disappointment for those members of staff whose pay is subject to the decisions of a pay review body? The House will recall that in 1984 the then Chancellor of the Exchequer imposed a 3 per cent. pay limit on the public sector. Notwithstanding that pay limit, the nurses' pay review body recommended a 5 per cent. pay increase. The Government recognised the special case made for nurses and awarded that pay increase. Will the Secretary of State reassure the staff who are concerned about the matter that she will honour and respect the independence of the pay review bodies, fully restore their independence and allow them to make recommendations next year, based on the circumstances of the staff whom they look after?

Mrs. Bottomley : The review bodies will have a continuing role. This Government introduced the review bodies for nurses and for doctors. Nurses had little to look for from the Labour party which was dominated by members of the National Union of Public Employees like the hon. Lady. When Labour was in power, nurses saw their pay cut by 3 per cent. in real terms. Their pay has been increased by 52 per cent. since this Government have been in power.

Mrs. Roe : Will my right hon. Friend join me in paying tribute to all the regional health authority chairmen and district and family health services authority chairmen in some areas who have volunteered for a pay freeze next year? Does she agree that that sacrifice to help patients should be warmly applauded?

Mrs. Bottomley : I certainly join my hon. Friend in paying a warm tribute to all of those regional chairmen who have agreed to take no increase in pay next year and the growing number of regional chairmen who have told me that their district health authority chairmen and FHSA chairmen have agreed that, as an act of leadership, they will take no increase in pay. Sir Donald Wilson, the chairman of Mersey regional health authority, is one such chairman who has made an act of commitment on his part and on the part of his chairmen.

Mr. Wigley : Notwithstanding the pay restraint which the Government regrettably find necessary to impose, can the Secretary of State give an absolute assurance that such

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restraints will not preclude the Government from meeting any recommendations for the dental service to get the service out of the total chaos in which it finds itself?

Mrs. Bottomley : As I am sure the hon. Gentleman knows, this year the dentists received an increase of 8.5 per cent. from the review body. In addition, the system has overpaid an average of £5,000 a head. The review body was also able to agree an increase in expenses of 11 per cent.

A review of dental remuneration is under way. We will consider that review carefully once it has been published. At the same time, the 1.5 per cent. overall envelope applies to dental practitioners as well as to others this year. It will be for the dental rate study group to decide how to translate that 1.5 per cent. into fees.

The Health of the Nation"

5. Mr. Fabricant : To ask the Secretary of State for Health what progress has been made in the regional health authorities in taking forward the strategy outlined in "The Health of the Nation".

Mrs. Virginia Bottomley : The NHS is making excellent progress. Managers and professionals in hospitals, health authorities and primary health care teams are working together to achieve health improvement in the key areas and other local priority areas. The NHS is setting the pace for other organisations to follow.

Mr. Fabricant : Will my right hon. Friend join me in congratulating the Mid-Staffordshire group of hospitals on getting trust status? Will she confirm that being a trust means that no one in my constituency who goes to that group of hospitals will need to enter a building that is more than 10 years old? How does she intend to expand the scheme so that other parts of the country may enjoy trust status hospital treatment?

Mrs. Bottomley : I certainly congratulate my hon. Friend. Like many other Members of Parliament, he, on behalf of his constituents, is seeing the benefits that trusts can bring. I am pleased to tell him that today I have accepted a further 121 expressions of interest in the fourth wave of NHS trusts. If all those applications are successful, 95 per cent. of hospital and community health service provision will be in the hands of trusts. That is good for the NHS and for the health of the nation.

Ms. Lynne : Will the Secretary of State explain how the guidelines laid out in "The Health of the Nation" White Paper relating to mental health patients can be seen to be implemented when people such as Dr. Loucas, who was the subject of a "Cutting Edge" documentary on Channel 4 last night, are still allowed to practise? Despite repeated warnings from the Mental Health Act Commissioner about his activities, he still practises. Will she give an assurance that there will be a full inquiry and that the results of that inquiry will be made public?

Mrs. Bottomley : The hon. Lady asked about the guidelines in the White Paper on mental health. Last year, 71 million working days were lost as a result of mental health problems. That is 14 per cent. of sickness absence,

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and it accounts for 23 per cent. of the drug budget. The problems of mental illness that the nation faces are very serious and are certainly a priority.

In relation to the case raised by the hon. Lady, the Mental Health Act Commission made it clear that progress had been made at the special hospital. As to the further allegations about Riverside health authority, further investigations and assurances are on their way.

Mr. Sims : The successful implementation of the proposals laid out in "The Health of the Nation" involve not only my right hon. Friend's Department but a number of other Government Departments. What mechanism exists to ensure co-ordination between Government Departments? To what extent is that co-ordination reflected at regional and health authority level?

Mrs. Bottomley : I assure my hon. Friend that there is a Cabinet Committee, under the chairmanship of the Lord President of the Council, which oversees progress in meeting the targets in "The Health of the Nation". That committee met last week, and further progress was made. At regional level, there is a particular officer to take progress forward, and it is subject to the management review.

There will be a series of regional conferences in the new year to ensure that all parties to a healthy alliance are able to contribute. Only by different agencies working together will we achieve the real improvements in health that underlie our health strategy.

Mr. Blunkett : Will the Secretary of State accept that her answer this afternoon about the revelations made by The Independent and the Channel 4 "Cutting Edge" programme about Dr. Kypros Loucas shows that the Department is unwilling to act on a series of

recommendations made by, first, the Mental Health Act Commission and, secondly, interested parties who have expressed grave concerns to the Department and Ministers about the activities of Dr. Loucas not merely at Broadmoor but at Horton general hospital and subsequently as an employee, at present at Wormwood Scrubs? Is the Secretary of State telling the House this afternoon that hormone experiments of a kind practised by Dr. Mengele, the application of electro-convulsive therapy without anaesthetic and the overdosing of patients' drugs are practices which her Department is willing to countenance? In what way does the right hon. Lady recommend that the powerless in our society protect themselves from the powerful in high places?

Mrs. Bottomley : I have already informed the House that the Mental Health Act Commission commented on the position at Broadmoor in 1989 ; at that stage, it said that progress had been made in the matters to which the hon. Gentleman referred. That was the year in which the doctor involved left Broadmoor. We are carrying out further investigations with Riverside health authority into the subsequent events at Horton general hospital. We have also drawn the attention of the General Medical Council to the programme.

Fund-holding Practices

6. Mr. Booth : To ask the Secretary of State for Health what plans she has to meet representatives of the National Association of Fundholding Practices to review their progress.

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Mrs. Bottomley : I met representatives of the National Association of Fundholding Practices on 18 November when we discussed the significant benefits that fund holding is bringing to patients. I am pleased to be able to tell my hon. Friend that I shall also address the second annual conference of the National Association of Fundholding Practices tomorrow.

Mr. Booth : Will my right hon. Friend welcome the success of the fund-holding practices and in particular the way in which they have played their part in reducing waiting lists throughout the nation? Will she welcome the way in which we have brought down waiting lists since 1979?

Mrs. Bottomley : I certainly warmly commend the fund-holding practices and the national health service generally for the progress that they have made in reducing waiting lists. The Labour party said that we would never meet the targets for waiting lists, just as it said that we would never meet the targets on immunisation or cancer screening. We have met all those targets and, indeed, beaten them. But the contribution of fund-holding practices goes much wider than tackling waiting lists ; it concerns the quality of care, the integration of primary and secondary care and the dramatic progress in bringing down the cost of drugs.

Mr. Burden : Given what the Secretary of State has said, what advice would she give to my constituent, Mr. Kitching, whose general practitioner referred him for an appointment because he might require surgery to his knee, in which he had arthritis? He was told in January this year that the waiting list for an appointment was about 91 weeks. Last month, he received a further letter telling him that he might have to wait another 13 weeks. Would the Secretary of State say to Mr. Kitching that that is an appropriate or reasonable time to wait? If she would, why is she also considering shutting the royal orthopaedic hospital in Birmingham, which could provide Mr. Kitching with the treatment that he needs?

Mrs. Bottomley : All are agreed that there is more for the national health service to do. All are agreed, I hope, that remarkable progress has been made in reducing long waiting times. We hope to set an out-patient target under the patients charter initiative. However, it is not by avoiding difficult decisions that further progress for patients is made. It is certainly the case that GP fund holders have pioneered innovative treatments and care of their patients which others have been able to follow.

Mr. Rathbone : Can my right hon. Friend give us an assurance on the way in which fund holders have improved the services that they offer to patients--rather than having to send them to hospital, for example--in analyses for diabetes or cholesterol?

Mrs. Bottomley : Indeed, there are numerous practical examples of the ways in which fund holders have developed new services, either by inviting consultants to undertake out-patient work at their practices--by way of a treat and teach model--by pioneering different ways to deal with diagnostic assessments, or by the organisation of a contract with the local hospital, which other general practitioners have followed. The point is that GP fund

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holders have been able to push forward the frontiers and to demonstrate new models of practice, which can then be spread widely within the NHS.

Ms. Primarolo : When the Secretary of State speaks to the National Association of Fundholding Practices tomorrow will she make it clear that the House is appalled at the massive profits that GP fund holders are making out of the national health service? We consider it scandalous that practices can make £190,000 or £280,000 in profit from fund holding when cash-starved hospitals are freezing waiting lists. Will she ensure that that money is returned in full to the district health authorities, so that it can be spent on patient care, especially the care of those on long waiting lists?

Mrs. Bottomley : Yes, we see the two-facedness of the Opposition. They profess to believe in primary care, but when we find a way to mobilise it so that GPs can act on behalf of their patients, they say that they dislike it. I suspect that at the next election the Leader of the Opposition will say that fund holding is another policy with which he agreed, but that he did not think that he could face up to telling his party that he supported it. Fund holders are saving 4 per cent. in their fund-holding work. The point is that that money can be invested in the practice, to make further improvements in primary care.

Mr. Dunn : Is the Secretary of State aware that two practices in my constituency are now fund holding--at Longfield and at Dartford East--and that they are both working extremely well, to the benefit of patient care? Is she also aware that my Labour opponent at the last election is a general practitioner in a practice in Bexleyheath, which is in the fourth wave of applications for fund-holding status?

Mrs. Bottomley : I am delighted to hear that information from my hon. Friend. I very much hope that in spite of the mischievous and often wilfully misleading comments of the Opposition, sensible GPs who put their patients' interests first will see the advantages of fund holding for themselves and for the progress that it can encourage throughout the NHS.

Elderly Population

7. Mr. Milburn : To ask the Secretary of State for Health what estimates she has made of the impact of the growing elderly population on health expenditure ; and if she will make a statement.

Mr. Yeo : It is estimated that slightly under 0.5 per cent. growth in resources will be required in the hospital and community health services next year to take account of all demographic changes. That is much less than the estimated increase of at least 2.5 per cent. in hospital and community health activity which we expect the national health service to achieve as a result of the £1 billion extra funding announced by my right hon. Friend the Chancellor of the Exchequer.

Mr. Milburn : Why has planned spending on the NHS been cut by 2.3 per cent. in real terms for next year, when the Minister acknowledges that the growth in the elderly population requires an increase of at least 0.5 per cent. simply to stand still? Is it not a fact that his failure to take account of the growth in the numbers of elderly people

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when setting the health budget means that there will be real cuts in patient care next year? What is his message to my constituents, who face yet another year when health budgets will be squeezed as a result of his Department's failure to make available growth funding to my health authority in Darlington? When will the Government come clean about the real shortfall in NHS expenditure?

Mr. Yeo : I am sorry that after such a short time here the hon. Gentleman has succumbed to the Opposition obsession with inputs rather than outputs. The statistics of interest to elderly people are those that show what the health service is doing for them, such as the 54 per cent. rise since 1979 in the annual total of hip replacement or the 91 per cent. increase in the number of elderly people treated as in-patients.

But if the hon. Gentleman wants a battle about inputs, I remind him that spending on the health service has risen by 60 per cent. in real terms since 1979--up from 4.6 per cent. of gross domestic product to 5.7 per cent.--and that for the first time in British history, under the present Government, more taxpayers' money is being spent on health than on defence.

Mr. Dickens : Can my hon. Friend confirm that the elderly of today are most fortunate because they live under a national health service which has developed medical techniques unthought of years ago, with drugs beyond their wildest dreams being available? I look forward to immortality. I warn the Opposition of that.

Mr. Yeo : I am sure that, with the benefit of the NHS, my hon. Friend will achieve his goal of immortality. I agree with the points he makes, but there are others of importance too, not least the relevance of the patients charter to elderly people. That has now set maximum waiting times for hip replacements, knee replacements, cataracts and a whole range of other treatments which are of great relevance in delivering even higher quality health care to our elderly population.

Provider Units (Targets)

8. Mr. Gapes : To ask the Secretary of State for Health what steps she is taking to improve performance in those provider units that are not reaching targets specified in the patients charter.

Mr. Sackville : Regional health authorities are accountable to the NHS management executive, through contracts, for their districts' performance and for taking aciton to ensure that problems are remedied. It is for health authorities, as purchasers, to ensure that providers' performance on patients charter activity meet the standards set in contracts. Authorities must, therefore, take action where performance falls below standard.

Mr. Gapes : Is the Minister aware that there are in my constituency people who have been waiting for 54 weeks at King George's hospital and 66 weeks at Barking hospital for orthopaedic operations, while others have been waiting for up to 35 weeks to see a female gynaecologist? Is he further aware that since the present Secretary of State took office, 130 additional people per day have been added to waiting lists and that in the North-East Thames region there has been an increase of 2.1 per cent. in the number

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of people on the waiting list for up to one year and 3.9 per cent. in total? It is a disgrace that the Government should be doing nothing to reduce waiting lists.

Mr. Sackville : I ask the hon. Gentleman to remember that activity on in-patients has gone up by 32 per cent. in recent years in Redbridge, that it has gone up by 15 per cent. for day cases and that there is a £58 million hospital development at Goodmayes, the largest in the whole of the North East Thames region.

Mr. Tredinnick : In connection with homoeopathy, given the importance and popularity of alternative and complementary medicine, does the Minister agree that it would be an important addition to the patients charter to set standards for health authorities to implement ways in which patients might obtain those benefits? Does he recall that his predecessor, the present Financial Secretary to the Treasury, said that the alternative disciplines could be paid for through the NHS if the necessary powers were delegated and responsibility was taken by GPs?

Mr. Sackville : Under our system, purchasers, whether health authorities or fund holders, have greater opportunity to decide on the treatment that they consider to be appropriate. I have no doubt that complementary medicine will be given all proper consideration.

Mr. Turner : How does the patients charter relate to dermatology patients at the Royal hospital, Wolverhampton, who had to occupy their ward last weekend to prevent it from being closed at weekends to save cash? How does that relate to the rights of patients?

Mr. Sackville : The hon. Gentleman knows that health authorities must monitor the standard set locally by providers. They will all be required to publish annually a report showing how those performance standards have been met.

Fund-holding Practices

9. Mr. Hendry : To ask the Secretary of State for Health if she will make a statement on progress towards adoption by general practitioners of fund-holding status.

10. Mr. Gill : To ask the Secretary of State for Health what assessment has been made of how general practitioners' interest in the fund -holding initiative has changed since the scheme began.

Dr. Mawhinney : I am pleased to report growing interest and support for fund holding amongst GPs, who are realising the benefits that it brings patients. By April 1993, more than 1,000 practices will have joined the fund-holding schemes, covering one in four of the population.

Mr. Hendry : I am grateful to my hon. Friend for that reply. Is he aware that in High Peak every GP practice eligible for fund-holding status has achieved it or applied for it? Is not that a clear demonstration that even if the Opposition fail to realise the benefits of fund-holding status, doctors who are most in touch with their patients' needs clearly do?

Dr. Mawhinney : I am sure that my hon. Friend is right. It shows that GPs have been listening to their patients and probably also to their Member of Parliament.

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Mr. Gill : Notwithstanding the massive amounts of additional money which the Government continue to pump into the national health service, does my hon. Friend agree that the efficiency savings made by GP fund holders are extremely valuable because they free resources so that more patients may be treated?

Dr. Mawhinney : Of course, my hon. Friend is absolutely right. We are concerned that more patients should receive high-quality treatment from the record amount of resources made available. It is a matter of regret that others do not take the same view.

Mr. Cryer : Will the Minister assure the House that, in cutting down waiting lists, GP fund holders will not be able to get privileges for their patients by paying extra to NHS trusts and gaining access to hospitals? If he will not give that assurance, he stands convicted of establishing a two- tier system in the NHS, which is supposed to be a service open to all, free at the point of use. One tier will be for GP fund holders' patients and another will be for the rest.

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