Order for Second Reading read.

Mr. Speaker

Before I call upon the Minister, in view of the rather late start to the Bill and the large number of right hon. Members and hon. Members who wish to participate, I appeal for short contributions.

4 pm

The Minister for Health (Mr. Tony Newton)

I beg to move, That the Bill be now read a Second time.

On 25 November I announced publication of the Government's White Paper on primary health care, "Promoting Better Health". The White Paper set out the Government's strategy for primary health care and our key objectives. These were to make the services more responsive to the needs of the consumer, to promote health and prevent illness, to raise standards of care and to improve value for money.

The Bill, which was read the First time on the same day, paves the way for the implementation of some parts of that strategy, others of which do not require legislation. The Bill goes wider than primary health care, for example, in giving health authorities new powers to generate additional income for patient care in various ways. I shall comment on those provisions later.

First, I should like to say a word about the context of the primary health care provisions of the Bill, which I suspect are those on which much of the debate will focus. As the primary health care White Paper stated, expenditure on family practitioner services has risen by £1.5 billion, or 43 per cent. in real terms, since 1978–79 and our existing plans provide for additional expenditure by 1990–91 of over £0.5 billion more in real terms.

The proposals for promoting better health, taken together, will require sizeable additional resources. Subject to the progress and nature of negotiations with the professions, I expect expenditure on the family practitioner services by 1990–91 to be substantially in excess of £600 million in real terms more than it is today. It was against that background, as I emphasised in my statement on the White Paper, that we concluded that it was reasonable to secure some of the additional resources going into primary care services by asking those who can afford it to meet something more of the overall cost of their health care, with the provisions in the Bill concerning dental charges and eyesight tests, about which I shall have something to say at the appropriate part of my speech.

Mr. Eric Forth (Mid-Worcestershire)

I apologise to my hon. Friend for intervening so early, but will my hon. Friend consider looking more widely at our Health Service and consider the French approach, where people are asked to make a contribution whenever they consult the health services? This would broaden the principle he is outlining and upon which he will expand. Is he prepared to look at it on the same basis, because it might give us more resources and may have a wider beneficial effect than the measures he is proposing today?

Mr. Newton

I note my hon. Friend's suggestion. He will note that there is no proposal along those lines in the Bill. I would not wish to be drawn to comment on that today.

As the House knows, our principal aims, through those proposals, are to improve the standards of care, in particular in the inner cities, and to give greater emphasis to the prevention of ill health. We believe that more can be done for the family doctor service through the practice team by vaccination, immunisation and screening for cervical cancer. The White Paper outlined our plans in those areas for what might be called prevention targets. The intention is that doctors have targets for each of the main preventable diseases and the action taken to prevent them. We shall relate remuneration to the achievement of those targets and encourage greater provision of more general advice on keeping healthy, not only by doctors but by other members of the practice team. We shall introduce a sessional fee for health promotion sessions.

We emphasise also—it is an important point in the broader context of this debate—that vulnerable groups such as elderly people should be properly cared for. In recognition of those needs, higher capitation fees are paid already for each patient over 65 and 75. We propose to discuss with the profession what sorts of additional services should be provided for elderly patients. The routine screening of mobility, sight, emphysema and hearing, and keeping in touch by one means or another with elderly patients, particularly those who live alone, are the sorts of services we have in mind.

The effective development of this approach depends not only on the doctor but on a strong practice team. It is this which lies behind clause 13 of the Bill. We propose to release more funds to enable practice teams to take on extra skills and to carry out the sorts of task I have just described. That may mean, for example, additional practice nurses or the extension of services provided by a practice to include the care that can be given by people such as counsellors, physiotherapists or chiropodists. In inner-city areas, or other areas where a similar problem arises, some practices may wish to recruit interpreters under this heading to help people of ethnic minorities whose command of the English language is limited. Subject to negotiations with the profession, more money will be made available for those purposes.

We also intend to abolish the current central constraints on the type and number of team members whose salary costs can attract direct reimbursemment. Clause 13 substitutes a more flexible system, which rests on giving the local family practitioner committee or health board freedom to determine need and allocate priorities within a budget. Clause 12 will strengthen practice teams by clarifying and extending the scope for reimbursing the training costs of staff. For example, subject to the passage of the Bill, we intend to arrange for general practitioners to be reimbursed for the training costs of practice nurses and for financial recognition to be given to those general practitioners who provide clinical training for undergraduate medical students. Both changes, which have been widely welcomed by the profession, would help to improve the quality of primary care.

Mr. Dafydd Wigley (Caernarfon)

Welcome though it may be that physiotherapy, chiropody and other GP services will be extended, how will the Government ensure that minimum standards are retained and that we do not have a patchwork of standards which vary considerably from area to area, withour any guarantee being imposed on the GP services?

Mr. Newton

That is precisely why we think it right to move to the allocation of budgets to family practitioner committees and health boards, so that they can have a say in determining the priorities for expenditure in those areas and seek to achieve a better spread and balance of services than we have at the moment. This is something that sometimes affects rural areas, which may be what the hon. Member for Caernarfon (Mr. Wigley) has in mind. More often it affects inner cities and deprived areas, which have been the more common focus of attention.

The more flexible approach reflected in those clauses also affects clause 13, which provides for financial assistance for practice premises through improvement guarantees or under the cost rent scheme to be controlled locally under a cash-limited system. This picks up the hon. Gentleman's point; it enables locally set priorities to be determined and makes it easier to direct funds to the areas where they are needed most. Quite apart from practice team support, it is often the case that the premises of family doctors are at their worst in the inner city and other deprived areas, and we wish to direct extra resources to their improvement.

Family doctors can also be helped to buy surgery premises by obtaining Government-guaranteed loans from the General Practice Finance Corporation. The White Paper announced our intention to seek powers to change the constitution of the GPFC to allow maximum use of private sector funds. We propose that the corporation should become a statutory company under the Companies Act and a trust should be set up to represent the medical profession on the board of the new corporation. The exact shape of the new arrangements will depend on discussions with the corporation and with the general medical services committee of the British Medical Association, as well as with potential investors. Clauses 1 to 3 would provide powers to enable such changes to take place. They would provide also for the GPFC to have greater access to private sector funds in the period before reconstruction.

I have referred to premises in inner cities and to support for general practitioners in those areas. A striking feature of the inner cities is that they have an above average number of elderly doctors—some of them are very elderly— who too often practise on their own.

The responsibilities of family doctors are extremely exacting and we would expect them to become more exacting following the implementation of the proposals that I have outlined. We have come to the conclusion that it is not reasonable to expect doctors to continue to work beyond the age at which they can carry out their responsibilities properly under NHS contracts.

Clauses 5 and 6 are intended to change the present system. They would give powers to introduce a compulsory retirement age for general practitioners and would end the so-called 24-hours retirement, whereby doctors over the age of 65 years can retire, draw their pension and return to practice a day later without any reduction in either pay or pension. Our proposals were widely supported in consultation and by the Select Committee on Social Services. We would expect and hope that the places of retiring doctors would be taken by younger, vocationally trained doctors who are genuinely keen to work in group practices and as members of primary care teams. That we see as contributing to the improvement in the standard services that we wish to see.

Mr. Tam Dalyell (Linlithgow)

Dentists often own their own businesses, which means that compensation would have to be paid. Any rapid decision to make dentists sell would depress prices, and perhaps mean they would be treated unfairly.

Mr. Newton

The hon. Gentleman has raised a fair point. If he reads the White Paper he will see that it contains passages on compensation for goodwill. That is something that we have in mind and it will be considered in our negotiations with the professions.

I have referred to the £170 million overall that we expect our proposals in respect of dental charges and eyesight tests to contribute to the £600 million-plus of additional expenditure on primary care services that we expect over the next three years.

I shall turn directly to the issue of dental charges and to clause 8, which is concerned with them, because I know that this is a matter of some concern to the House. The House will know that we propose to move to a proportionate charge for dental treatment and to extend that system to dental examinations that are now free. Existing powers already permit proportionate charging for routine dental treatment. Clause 8 is required to enable such charging to cover dentures and bridges and to permit charges for dental examinations. It follows that we intend to move to the new arrangements in stages.

Under existing provisions, regulations will be brought before the House at the appropriate time to provide for proportionate charges from 1 April 1988. The regulations will also specify fixed charges for dentures and bridges at or about the same percentage of cost. Bearing in mind that the current average of the proportion of treatment charges that is met by the patient is 65 per cent. and that there has been no increase in dental charges since 1985—in other words, by next April they will have been unchanged for three years—we expect to set the figure at 75 per cent. At the same time, the maximum charge—I know that the British Dental Association has been concerned about this—will be increased from £115 to £150.

Subject to the passage of the Bill, we would at a later stage move the charges on bridges and dentures to the same fully proportionate system for routine treatment and introduce the proportionate charge for the dental examination. The House will be aware that the principle of moving to proportionate charges for treatment has been widely welcomed and pressed for by the profession. In saying that, I intend only to associate it with the principle, not with a particular rate.

I think that it is generally acknowledged that the present system is difficult for the public to understand, difficult for the profession to administer and difficult for anyone to defend as fair. For example, the present charges for dentures, bridges and crowns vary from 25 per cent. to 93 per cent. of the cost. The cost of routine treatment ranges from 100 per cent. to less than 50 per cent.

I wish to emphasise the need to consider our proposals as a whole. The move to proportional charges will reduce substantially the costs of much routine treatment. For example, on current figures a 75 per cent. charge would cut the cost of a clean, polish and two small fillings from £14.20 to £10.65. I acknowledge readily that that saving will be offset by the proposed 75 per cent. examination charge, which on current figures would be £2.93. Even after allowing for that, the cost of examination and treatment in the case that I have mentioned would be £13.57 compared with £14.20 for the treatment alone on the basis of current charges. We estimate that some 2 million courses of treatment, including the proposed examination charge, will cost less than they do currently. The charges for extensive and more expensive treatment will generally be higher, and the net result of that will be, in our view, to set the signals much more clearly in favour of those who attend a dentist regularly and take proper care of their teeth.

Sir Barney Hayhoe (Brentford and Isleworth)

My hon. Friend has talked about regarding the Government's proposals in the round. Does he recognise that some of us who are generally very supportive of the main provisions in the Bill, and who will be voting for the Bill's Second Reading this evening, are sharply opposed to charges for sight tests and dental examinations? We are extremely concerned also about the mounting and increasing difficulties that are facing many hospitals and district health authorities, which have been spotlighted by the important statement of the three royal colleges which has been reported today. Does my hon. Friend recognise that clause 4, which refers to giving greater freedom to district health authorities in raising income, is superficial and peripheral to the fundamental and central problems that have been highlighted by the presidents of the royal colleges, which demand the urgent attention of DHSS Ministers and my right hon. Friends the Chancellor of the Exchequer and the Prime Minister? That should be the message from this House.

Mr. Newton

My right hon. Friend has referred to the proposals in clause 4, with which I shall deal later in my speech, and generally to the proposals which I have been outlining, which are perhaps not related directly to hospital and community health services, and described them as peripheral. It is clear to anyone who examines the pressures on the Health Service that it would be wrong to ignore or dismiss any reasonable source of enhancement of the resources that we can put into health care as a whole. That is what I have had in mind—I hope that this will be the view of the House generally—in judging these proposals. We all know that the potential for spending on health is literally infinite. Therefore, we all have a duty to consider every legitimate way of garnering resources to spend on health services.

Mr. Peter Fry (Wellingborough)

My hon. Friend has referred to those who are able to pay. Will he accept that there are many pensioners whose income is slightly above the supplementary benefit level who will find it extremely difficult to meet the new charges that are embodied in the Bill? Will he undertake to examine the present exemptions from charges and give consideration to whether they could be widened to take account of the difficulties that will be faced by those on very modest incomes?

Mr. Newton

I note what my hon. Friend says. I was about to emphasise that all existing exemptions — I know that this does not meet his point directly—from treatment charges will extend to examination charges. In other words, neither will be paid by children, students, those on low incomes, including the elderly, expecting and nursing mothers, and certain other groups. We are talking primarily about those on supplementary benefit or income support.

I recognise the reasons why my hon. Friend has introduced that point. Let me say, in general terms, that the objective of the Government's policy in relation to those over retirement age—which is clearly reflected in the measures that my hon. Friends concerned with social security have been introducing and carrying through in recent months and years — is to build on what has already notably occurred in recent decades: a steady improvement in the general standard of living of those over retirement age, not least with the development of occupational pensions.

I believe that the proper strategy of Government policy — and it is the strategy of our policy — should be to continue to build up the capacity of people in retirement to make choices and decisions for themselves, and thus enhance their independence. It follows from that that when public resources are to be applied by way of exemptions or special concessions, it is right to focus them on those who have not the advantages of, for example, the development of occupational pensions, and are — by definition—too late to benefit from what we are now seeking to do. That, I believe, is the right approach in this and other matters.

Mr. Robert McCrindle (Brentwood and Ongar)

While I accept what my hon. Friend has been saying about the desirability of encouraging those who are able to contribute to do so, will he take on board that many of us who will be voting for the Bill's Second Reading this evening for that very reason nevertheless feel strongly that, if it is impossible for the individual to make a contribution towards health care and only the Government remain capable of providing adequate resources, we should look to them progressively to do so in the weeks and months ahead? Many Conservative Members would be forced at this point to endorse the call by the presidents of the royal colleges this morning.

Mr. Newton

Let me say for the third time that I note what my hon. Friend has said, and ask him to note what I said to my right hon. Friend the Member for Brentford and Isleworth (Sir B. Hayhoe) a few minutes ago. I also ask him to recognise that it is too simple by half to associate all the pressures faced by the expanding Health Service solely with demand for additional financial resources.

I thought that one of the weaknesses of the statement issued by the presidents of the royal colleges last night was that it contained little or no serious discussion of the complex causes of some of the difficulties, including, for example, the nursing shortages which have been acknowledged recently in the Birmingham area —[Interruption.] The hon. Member for Derby, South (Mrs. Beckett) says that that has to do with money. But the cardiac clinicians who wrote to my right hon. Friend the Prime Minister at the beginning of last week, in a letter that gained some publicity in the press, made it clear that they felt that they could afford to pay intensive care nurses more within their existing budgets. They did not suggest that it was an overall resource problem; they suggested that it was a question of the structure of pay. We are tackling that through the so-called clinical grading review, on which I hope negotiations are nearly completed. That will give us a basis, through the subsequent recommendations of the review body, to tackle the problem in the way in which it needs to be tackled—in relation to the pay and grading of nurses.

Mr. Jerry Hayes (Harlow)

My hon. Friend is absolutely right to say that we must examine the restructuring of nurses' pay. However, let no one be deceived into thinking that it is just because of pay that 30,000 nurses are leaving the profession. They are leaving because they are demoralised.

Mr. Newton

My hon. Friend is oversimplifying matters in the same way as the statement by the presidents of the royal colleges. As was made clear in the debate in the House the week before last, no one suggests that there are not problems and pressures in the Health Service—as there have always been—over meeting demand. I do not try to dismiss those problems, any more than I did in that debate, or during the past few minutes. I ask in return only that my hon. Friend accepts that they are complex problems, which are often reduced to excessive simplicities by some of the statements that are put out.

Clause 7 of the Bill broadens the scope of the community dental service, and gives health authorities discretion to redirect the service's resources away from the routine treatment of children—who can be, and for the most part are, looked after in the general dental service —and towards providing health education for children in schools. We are also looking for new contractual arrangements, such as a continuing care, contract and capitation, which — subject to negotiations with the profession—will enable general dental practitioners to devote more time and resources to preventive work with their child patients.

I am bearing in mind, Mr. Deputy Speaker, the injunction from Mr. Speaker about brevity. In conjunction with the profession, we shall be launching a dental health testing campaign to promote dental awareness and regular attendance. The campaign will be directed in particular at young people in inner-city areas, where the standards of dental health are still some way behind those in the rest of the country. We shall also be taking a step designed to enhance the quality of treatment—one step among many, but a legislative step. Clause 9 provides increased powers for the Dental Estimates Board to survey and research norms and standards of treatment, and to deal with dentists whose work appears to be at variance with those standards. The White Paper also referred to our intention to consult the profession about a new counseling and monitoring service of dental practice advisers, which we hope will contribute to the improvement of services.

Mr. Dalyell

Why does the Minister think that the British Dental Association has circulated among many of us a powerful memorandum opposing examination charges for adults? Does he agree that charges will mean that people will go to the dentist less regularly, and that, ultimately, the expense will mount?

Mr. Newton

I do not find it surprising that the British Dental Association has circulated such a document. However, I disagree with its assessment of the effect of the proposals, especially against the background that I emphasised, possibly at excessive length. The net result is likely to be the provision of significant ranges of treatment — even with the examination charge — at lower costs than are now incurred; and, therefore, greater incentives for people to visit the dentist regularly while they still need modest treatment, rather than leaving huge problems to build up.

Clauses 10 and 11 relate to the general ophthalmic services. The first confines free National Health Service sight tests to groups which we have specified: children, those on low incomes, young people in full-time education and those who are registered blind or partially sighted. Those groups account for an estimated 30 per cent. — nearly one-third — of such tests. For the remainder, however, free NHS sight tests will cease to be available.

I should make it clear that there is no question of the Government setting or imposing a particular charge. The figure of £10, which has been quoted fairly widely, is simply the amount that we currently pay for such a test by an ophthalmic optician. For a test by an ophthalmic medical practitioner, it is rather less—just over £6, In the light of experience—following the end of free NHS glasses—with vouchers being provided for the priority groups whom I have mentioned— we can sensibly expect that the extension of competition, which has both reduced prices and notably increased consumer choice for spectacles, will restrain charges. Given that even those who already need glasses visit the optician only once every two or three years, I see no reason to suppose that people will be deterred in the way that has been suggested.

Mr. Robin Cook (Livingston)

Let me remind the Minister that when the House last discussed the matter the previous Secretary of State for Health and Social Services, the right hon. Member for Sutton Coldfield (Mr. Fowler), said: we also believe that the access to a free sight test is important in detecting serious eye disease." —[Official Report, 20 December 1983; Vol. 51, c. 295.] What medical advice—I stress the word "medical"—has the Minister received that has encouraged the Government to change their view, and no longer to believe that that is important?

Mr. Newton

I shall comment on screening in a few moments. However, I must point out to the hon. Gentleman that we have been seeking to expand and develop our health services as a whole and that we have placed great emphasis on the primary care services. We have rightly kept that policy under review. We launched the primary care consultation, and we have now published the primary care White Paper and this Bill. We have come firmly to the conclusion that we wish to undertake further development of these services in the interests of the general promotion of good health and the prevention of ill health. In the context of furthering and continuing that development, we have thought it legitimate to bring this proposal before the House. It will contribute to the resources that we need to carry out the other developments that we believe are worth while. I make no apology for the fact that we have done that.

Mr. Cook

I repeat my question: what medical advice did the Government receive on that point?

Mr. Newton

I repeat that I shall say something about screening in a few moments.

Clause 11 safeguards competition, which has had a significant effect by reducing the price of spectacles and increasing choice. We believe that that will restrain the cost of sight tests. We propose to safeguard competition by requiring the optician after a sight test to give the patient a prescription, if glasses are needed, so that he or she can shop around for glasses, as can be done now.

I am aware—the hon. Member for Livingston (Mr. Cook) echoed this point in his interventions — that suggestions have been made that our proposed changes will diminish the role that is played by sight tests in screening for other conditions. The extent to which that argument stands up at all depends on expecting people to be deterred from seeking eye tests. There is no reason to expect that to happen. Sight tests will continue to be conducted at least to the same standards, although opticians may decide in practice—partly because of the competitive pressures to which I have referred—to offer a wider range of tests than is available under the National Health Service. It is a professional requirement of the General Optical Council that the optician should refer a patient to a doctor if he detects glaucoma or diabetic retinopathy. That arrangement — clearly on medical advice—will continue.

Dame Jill Knight (Birmingham, Edgbaston)

If opticians are to be encouraged to conduct different types of tests, with some being not quite so thorough as others, who will be responsible if, during a less than thorough test, early signs of diabetes are missed? Will the optician be responsible, although he has been encouraged by the Government to carry out a less than thorough test on his patient, or will the Government be responsible?

Mr. Newton

I think that I shall carry my hon. Friend, who knows a great deal about these matters, with me if I acknowledge that the extent of the tests that are carried out by opticians already varies from one practice to another. If it is felt that further steps should be taken either to tighten up the procedures or to impose precisely what should be done, that could be considered. I do not dismiss my hon. Friend's point, but I am uneasy about the apparent willingness to rely for the screening of some conditions, in particular diabetes, on the chance that people go to their optician. Our proposals for general practitioners are designed to encourage, particularly in relation to the very young and the elderly, the systematic overall health screening of those who are most likely to be at risk. It is worth considering whether that is a better and a more sensible approach to these problems than to rely on people going to their optician.

Mr. Richard Holt (Langbaurgh)

Will my hon. Friend accept that I have a typical diabetic condition that was found when I went for an eye test? I am not elderly and I am not a child. In those circumstances, would I have had the benefit of a sliding scale option? How much would the minimum charge have been and would the optician have given me that option at the beginning or at the end of the diagnosis?

Mr. Newton

I am not, I am afraid, absolutely sure that I have understood the last part of my hon. Friend's question. The charge will depend on what the optician decides to charge. My view is that the pressures of competition, which have significantly reduced the price of spectacles, will similarly restrain, and possibly entirely eliminate, the charges for eyesight testing. However, that is for opticians to decide within a much freer market than exists now. I believe that it will have the same beneficial effect as the move to vouchers has unquestionably had.

Mr. Holt

Am I to understand that each optician will be able to choose what charge he makes, that that charge could be nil, if he so chooses, and that the reimbursement by the Government will be according to a sliding scale that the Government will fix at another time?

Mr. Newton

I have already emphasised that there is no question of the Government setting or prescribing particular charges. We shall continue to discuss with the profession the arrangements for reimbursing opticians for eyesight tests that remain free NHS eyesight tests —according to current figures, about 30 per cent. Where there is no question of a free NHS eyesight test —roughly the other 70 per cent. — it will be for the optician to decide how much he wants to charge. I make no secret of the fact that my guess is that in many cases the charge will be rather less than the amount that is paid to opticians for carrying out those tests now. Indeed, it would be very surprising if that were not the case.

Mr. Robin Maxwell-Hyslop (Tiverton)

My hon. Friend says that he does not expect people to be deterred by charges for what was previously free. Since that is contrary to what any person would expect the consequence to be, on what objective evidence are his expectations, which seem to be so improbable to common reason, based?

Mr. Newton

My hon. Friend will accept that it can only be a matter of judgment, in the light of the experience that we already have of the abolition of free NHS glasses and the introduction of the voucher scheme. We were told that large numbers of people would be frightened and would not have spectacles. I know of no evidence that that has occurred. We were also told that opticians would never be able to provide spectacles that were as good as or better than the old NHS ones at the sort of price that the voucher values represent. One only has to visit one of the attractive spectacle stores that have now been set up to find that such establishments are offering a significantly wider range of much more attractive spectacles that come within the voucher values. I accept that it is a matter of judgment, and I hestitate to quarrel with my hon. Friend's judgment, but in this case my judgment differs from his.

Sir Peter Hordern (Horsham)

Is it not possible that the charges are most unlikely to be as much as £10 a visit, and is it not possible that more people will be encouraged to visit their optician? As for the complaints by the principals of the royal colleges, is it not a fact that there are now twice as many nurses and doctors as there were 20 years ago, when these eminent people first started in practice, and that if only they had run their hospitals better and achieved better savings, and if there were not so many hospitals, the Health Service would be a great deal better off?

Mr. Newton

I am not sure that I can vouch for my hon. Friend's statistics. Mine usually go back to 1979 for reasons about which the House will speculate. However, I confirm my hon. Friend's view. One need only consider the different periods of day surgery care from health authority to health authority, and, indeed, from hospital to hospital, the differing periods of time that patients spend in hospital following certain procedures or the relative costs of different hospitals and different clinicians to know that there is a good deal of room for improvement among all who are connected with the Health Service. I hope that doctors will reflect on that.

In addition to the contributions to the general improvement in health care services, especially screening and preventive services, with which we expect the resources released by the changes to assist, I should emphasise that the changes will enable us to extend other important services related to eye care. We propose to extend the voucher scheme to help adults who frequently break their glasses because of physical or mental disability. Negotiations will shortly begin with the profession about widening the National Health services to enable practitioners to provide a sight testing service to the housebound. I know that many people who are concerned with community care attach great importance to that point, which will be of real assistance to many elderly people. In addition, the value of vouchers that are available to those who require complex and expensive lenses will be given special consideration to ensure that that group of patients is not placed at a disadvantage.

I have already taken quite some time from the House and shall cover the remaining clauses briefly so that, at least, I shall have given the House some idea of what they contain. Some are principally technical measures to tie up loose ends that arise from earlier uncertainties.

Clause 14 anticipates the integration of the artificial limb and appliance services into the National Health Service in 1991. That has the effect of maintaining continunity of employment to civil servants who choose to transfer to the National Health Service.

Clause 17 confirms the legal basis of fees for licences that are issued under the Medicines Act 1971.

Clause 16 fills the gap in the limited powers of the Secretary of State to make grants for the training of local authorities' social services staff in England and Wales. That may sound a small point, but one aim is to enable us, at some appropriate moment, to put resources into improving the training of staff concerned with child abuse, for which we think we currently have inadequate powers.

Clause 15 removes the power of local authorities to charge health authorities for the services of social work staff. When the National Health Service was reorganised in 1974, local authorities were made responsible for employing social workers and health authorities for employing doctors and nurses. Resources were transferred centrally at that time from the health budget to local government grant arrangements to reflect that change of responsibility. There is no justification for retaining the anomalous powers for local authorities to make the charges. Subject to passage of the Bill, we intend that that should take effect at midnight on the day of publication, 26 November.

I return, as I said I would, to the issue of income generation by health authorities. The Bill is intended to assist health authorities in creating new opportunities to generate additional resources and, not least in connection with the points made during the past half hour by my hon. Friends on the Back Benches, to improve health care. The Bill gives health authorities new powers to supplement their resources by making, for example, better use of their facilities. They will be able to take greater advantage of opportunities to lease space to commercial outlets, such as shops or hairdressers. If they wish, they could sell advertising space in the hospital or at other premises. They will he able to consider providing completely new facilities such as health clubs, for which they can, quite sensibly and properly, make charges.

Several authorities have already made a modest start, for example, by charging taxi companies for the installation in hospitals of free taxi-phones for use by patients and visitors, or by recovering and selling the silver from used X-rays. The Bill is designed to enhance such opportunities and to make it clear, in the statute, that such activities can only be undertaken provided that they do not interfere, in any way, with the main duty, which is to provide services to patients under the National Health Service.

Mr. Holt

Will my hon. Friend give way?

Mr. Newton

Yes, but then I must get on.

Mr. Holt

I am grateful to my hon. Friend for giving way. If an entrepreneurial health authority holds bazaars and all sorts of events and raises a lot of money in the next year, will it suffer a deflation of its allocation by the regional health authority or will it be allowed to keep that money, in addition?

Mr. Newton

I intend to make it clear to regional health authorities, without attempting to dictate every detail of their allocation policy, that I expect them to ensure that district health authorities are not put in a position in which it does not seem worthwhile to engage in entrepreneurial activities because they fear that they will not gain or benefit from them.

Mr. Sam Galbraith (Strathkelvin and Bearsden)

Will the Minister give way?

Mr. Newton

Yes, but this may have to be the last time that I do so because otherwise many hon. Members will be unable to speak.

Mr. Galbraith

The Minister said that those other functions must not interfere with patients and subsection (5)(a) of clause 4 state that they should not, to a significant extent, interfere with the performance". Will he tell us how he will ensure that they do not interfere with performance?

Mr. Newton

The sort of schemes that we would be prepared to countenance will be a matter for monitoring by the Department and by regions. We intend to set up a central unit to distribute the information and to assist health authorities in such matters. I re-emphasise, because I do not want this to be misunderstood, that there is no intention of permitting activities that could be seen as detracting from the services provided under the Health Service to those to whom the health authorities have a responsibility. The purpose is to gain additional resources for the continued improvement of the National Health Service.

The clause gives health authorities much greater freedom as to the way in which they set charges for private patients. Currently, authorities can only recover through charges the costs of the services provided for private patients. We intend that in future they should be able to set charges according to the prevailing market conditions. That should enable authorities to increase their income from such services.

Partly because I have given way so much, I have taken rather longer than I would have wished and shall conclude briefly. In many important respects, the Bill paves the way for the implementation of significant improvements in primary health care in this country, for increasing consumer choice and improving the quality and quantity of services overall. It also provides those new powers that will make a useful contribution to the further development of hospital and community health services. In that sense, it will be a significant and useful step forwared in the continued development of policy for improving the Health Service in this country and, therefore, I commend it to the House.

4.47 pm
Mr. Robin Cook (Livingston)

Under this Government, the straightest way to the heart of any Bill is to turn to the financial memorandum. From the financial memorandum we learn that there will be no significant effect on public sector manpower, but that there will be significant net savings on public expenditure. I congratulate the Minister on his nerves of steel. Against a background of financial crisis in the Health Service, it takes a thick-skinned and impervious Government to come to the House of Commons to ask it to pass a Bill that will further reduce Government spending on the National Health Service.

I saw the contrast between the needs of the Health Service and the priorities of the Government graphically illustrated yesterday on the front page of my Sunday newspaper. Side by side with the report of the death of baby Barber there was a report that the Chancellor of the Exchequer was considering a 2p cut in the basic rate of income tax next March, plus a cut of 10p in the income tax of top people. Apparently that is because of what is described as the "prosperous" state of Treasury revenues and the "negligible" need for public borrowing next year.

It costs £3 billion to reduce income tax by 2p, leaving aside the extra gilt for the top-rate payers. One third, or even one sixth, of that sum would transform the situation in British hospitals. If the Chancellor of the Exchequer has such money to spare, it is the duty of the Minister for Health to get it for the National Health Service. It is a function of Government to make a judgment between competing priorities for resources. However, only a Government who have abandoned all pretence of measuring social need could persuade themselves this winter that tax cuts should take priority over spending on the National Health Service.

The point was expressed yesterday succinctly by Philip Barber, who was interrupted at a marathon, sponsored game of pool to be told of his son's death, when he observed: There is something wrong in a society which needs me to play pool so that babies can have operations to save their lives Yet the Bill confirms that even the Ministers responsible for the nation's health have agreed to share the priority of cutting spending rather than meeting need.

Mr. Hayes

I am sure that the hon. Gentleman would not wish to mislead the House in any way. When he talked about the financial and manpower effects he talked about significant net savings, but he did not go on to say that that was because the General Practice Finance Corporation will be a limited company and will not be counted in the public sector borrowing requirement. I am sure that he would like to explain that.

Mr. Cook

The hon. Gentleman refers to clauses 1 to 3, to which I shall refer in a moment. If he re-reads the passage that talks of significant net savings in public expenditure, he will recognise that it refers to clauses 1 to 13, which go well beyond clauses 1 to 3.

Clause 13 is likely to be the most profound measure, because for the first time it extends cash limits to the family practitioner service. I noticed that the Minister said that that would be a more flexible system than the present one. We are surrounded by abundant evidence of what this flexible system of cash limits has done to our hospital service. The rest of the nation is appalled at the consequences of this flexible system on the hospital service, yet apparently the Government are so pleased with the results that they propose to extend the system to general practitioners. Clauses I to 3 promise considerable savings to the public sector borrowing requirement, never mind that The Observer tells us that the PSBR is also negligible. Apparently it is the first duty of the Minister for Health to find still more savings to make it even more negligible.

The savings arise from a proposal to privatise, not the family practitioner committees— the Government have not yet reached that stage — but the General Practice Finance Corporation. It was set up because GPs had difficulty in obtaining commercial loans to purchase property in areas of poverty and under-privilege; in other words, in areas where the banks were reluctant to lend. That remains the distinctive contribution of the GPFC. It is astonishing that in a package that we are told is designed to improve primary health care the Government should wash their hands of the major provider of funds for premises in inner cities, where there is the greatest need to obtain more premises and to modernise existing ones.

The Government considered privatising the GPFC in 1984 and rejected the idea. The Minister's predecessor came to the Dispatch Box on Report on the Health and Social Security Bill and positively preened himself on keeping the corporation in the public sector. He said: It shows what a flexible and non-ideological Government we are."—[Official Report, 2 May 1984; Vol 59, c. 366.] By the same token, we can only conclude from today's measure that we are faced with an inflexible and ideological Government. The savings from this bit of ideology are small beer, because the Government have already so reduced the borrowing limits of the corporation that it is allowed to spend only £10 million to £12 million a year. The Government will now receive 15 times that sum in increased income from the proposals on new charges for teeth and eyes.

I shall flag an anxiety raised by several members of the BMA about the breadth of clause 8. Mysteriously, reference to dentists and dental charges vanishes in subsection (2). When the Minister replies, will she clarify the scope of clause 8 and confirm that she is not giving herself powers to introduce by regulation charges on the services of general pracitioners? I shall wait in expectation of her reply when she is briefed.

What we know about the clause is bad enough. It provides for a new charge on having one's teeth examined. Since 1948 teeth have been examined free under the NHS as a matter of principle. The Government propose to raise £50 million by abandoning that free examination. One is bound to observe that they sell their principles cheaply—

Mr. Nicholas Bennett (Pembroke)

As the Labour Government did in 1951 with the introduction of prescription and dental charges.

Mr. Cook

With the greatest respect, no previous Government, of whatever colour, have introduced a charge for the examination of teeth. Nowhere are we favoured with an explanation of how it will help to prevent dental disease by deterring patients from going for a regular check-up, and deter them it will. I assert that with confidence because, thanks to the Government, we have experience of what happens when dental charges are hoicked up. In April 1985 the Government increased dental charges by 25 per cent. Over the subsequent year the number of fillings fell by 5 million, the treatment of gum disease fell by I million and root treatments fell by more than 100,000. By contrast, the number of patients opting for the cheaper treatment of extraction increased by 5 per cent.

Mr. Richard Tracey (Surbiton)

rose—

Mr. Edward Leigh (Gainsborough and Horncastle)

rose—

Mr. Cook

I shall happily give way when I have finished this point.

It need not surprise Conservative Members that increasing charges has that effect on demand. After all, they, more than anybody else, have put their faith in the market mechanism, and they should be gratified to learn that that faith is justified when patients respond to the pricing signal by staying away from surgeries or opting for the cheaper option of extraction.

Mr. Leigh

What happened to the nation's teeth when the Labour Government increased the cost of routine dental treatment by 150 per cent. in 1977?

Mr. Cook

I cannot answer that, but I can say what happened at the local elections, because I was canvassing on the night when that was announced. I can assure the hon. Gentleman that several colleagues and I resisted that charge when it came before the House, and if we had had the support of his colleagues we would have defeated it.

Many will undoubtedly now stay away when they receive the reminder for a six-monthly examination. It is worth remembering that that examination has importance in health care well beyond sound teeth; the dental examination can reveal other medical conditions. To take one topical disease, it is likely that some AIDS carriers will first be detected through thrush of the gums when they present themselves to a dentist. It is important not only for them, but for the rest of the community, that they are not inhibited front obtaining early diagnosis of that condition.

There is also the wider issue of the structure of the charges. The Minister prided himself on the fact that some people will pay less under his new charges, and that may be so. I am prepared to concede that some people may have a smaller bill, but the Minister cannot stand at the Dispatch Box and pretend that that is some sort of general rule. After all, we know that he is budgeting to expect £85 million more in charges from those who visit the dentist, so, demonstrably, most will pay more. In particular, the 100,000 who at present bump against the ceiling of £115 on charges will now bump against the ceiling of £150 per charge.

The Minister said that the charge would be proportional to the cost, but no such proportion is set out in clause 8. On the contrary, clause 8 is drafted in alarming terms which would allow the Minister to recover the whole cost of the charge. I suppose that 100 per cent. may be passed off as a proportion of a sort, but it is hardly what most people understand by the use of the term. Clause 8 gives the Government the power to abolish by order all public support of NHS dental treatment. It puts the dental service on the slipway to an entirely private marketed service, and if anyone concludes that that is fanciful, I would ask who would have thought eight years ago that that is precisely where the NHS optical service would now be?

That brings me to the key proposal in the Government's preventive approach to eye care, which is to introduce charges for eye tests. The Minister said that it would not necessarily cost a tenner. A tenner happens to be approximately what optometrists are paid—£9.30 to be precise. Anything less than that would leave them out of pocket. The Government may argue, as the Minister argued, that they could opt for a lower income and therefore suffer a lower charge

The Minister referred to the market. Markets seek equilibrium when supply and demand are in balance. I should not have to point that out to such a disciple of the Prime Minister's economic philosophy. It would be a curious market which found it equilibrium at the point at which all demand was met. By definition, if the Minister is leaving it to the market to settle the charge, some demand will not be met because it cannot meet the charge. There was no hint in the consultation document of that proposal. There was not a breath of it in the Conservative party manifesto—a point of some relevance.

Mr. Ian Hunter, the general secretary of the Association of Optical Practitioners, told Conservative Back Benchers that most of them had voted for the Government. No doubt optometrists are men of strong political convictions who would have done so anyway, but it is a pity that the Conservative party did not trust them enough to tell them in advance what they were voting for.

The majority of optometrists' clients are pensioners, and pensioners need the eye test most, and they need it most often. Six million pensioners will not qualify for a free eye test. Many of them simply will not go, or will not go as often as they should. They may save a tenner, or perhaps a fiver if the market system operates, but they may also lose their eye sight. The eye sight test is a misnomer. Optometrists offer a full examination of the back of the eye, and they require specialist training and special equipment. They can detect serious health risks such as diabetes and hypertension.

My hon. Friend the Member for Aberdeen, South (Mr. Doran) was in contact with me over the weekend, following a visit from a constituent who visited an optometrist about three months ago. The optometrist examined the back of her eye and immediately arranged for her to see an eye specialist, who referred her to a neurosurgeon. Within a week of her examination, she was operated on for a brain tumour and was advised by the neurosurgeon that had she waited for another two weeks it is likely that she would have lost the use of her legs permanently. In that case a very serious medical condition was revealed by the eye test. I must add that the constituent in question was quite frank in saying that, on her wages as a cook, she would not have gone for that test if she had had to pay a tenner.

The damage that will arise from the introduction of charges is perhaps best illustrated in the case of glaucoma. Three out of four cases of glaucoma are detected by the eye test. I cannot do better than read the observations of the International Glaucoma Association, which says that it can only conclude that either the Government have not been well advised; or that they have deliberately decided to brush aside as of no consequence the certain increase in the number of people with glaucoma who will not be discovered until the disease is well advanced. I listened with interest to the interventions of the right hon. Member for Brentford and Isleworth (Sir B. Hayhoe) and of the hon. Member for Brentwood and Ongar (Mr. McCrindle) who are no longer in the Chamber. It would have been nice if they had stayed and participated in the rest of the debate, as they feel so strongly. They said that, although they would vote for the Bill, the Minister could not expect them to support the measure.

I have to tell those hon. Members that the Minister made a very interesting statement of particular relevance to Conservative Back Benchers who claim to disagree with his proposal. The Minister said that he believed that adults with means of their own should make up their own minds and make choices for themselves. I believe that that is precisely what those Conservative Back Benchers who are unhappy with the proposal must now do. It will not do for them to stand up in the House and say that they disagree with the Bill and then go into the Lobby and vote for it.

Clause 4 gives expression to the Government's latest fad, which they have termed income generation, and provides a new place in district management teams for a marketing director whose role will not be meeting health needs, but that of finding the sponsor who will pay most to get his name on nurses' uniforms — the Adidas solution to Health Service funding. It is not an optional course, which is being offered to managers as light relief from the stress of being unable to meet health needs. Clause 4 authorises the Secretary of State to direct health authorities to market their services. For good measure, it adds that it is their duty to comply with such directions.

The hon. Member for Langbaurgh (Mr. Holt) made a penetrating intervention, if I may say that without prejudicing his career, when he asked whether the Minister would allow health authorities to keep the fruits of their marketing. He received a particularly Delphic response. I have in front of me the words that the Minister used when he was asked an identical question at a press conference last week. His words on that occasion were slightly less Delphic. He said: Inescapably, we have to look at the totality of resources available from all sources. The hon. Gentleman feared that that meant that the Minister would deduct from the allocation to health authorities the revenue that they had raised from marketing. I have to warn the hon. Gentleman that it will be worse than that. After the Minister has taken his powers to direct health authorities to market the services, and after he has taken the power to oblige them to comply with those directions, he will assume that they are obtaining income from marketing the services, whether or not they are securing that income. It is a fraud on the House and on the nation to pretend that extra revenue will be available for patient care.

Let me make it clear where the Opposition stand on that matter. We believe that the test that has to be applied to marketing services is whether they will improve the service to the patient. If a spot of franchising provides greater variety in the cafeterias, that is well and good. If those cafeterias are run on the principle of a healthy diet, that is even better, although that rules out 90 per cent. of the fast food chains in Britain.

Mr. Holt

And in the House of Commons.

Mr. Cook

In the House of Commons, too. What is wholly dishonest is to pretend that clause 4 will unlock a chest of gold that will plug the yawning gap in hospital finance.

Last week the Minister objected to my description of this as tuck shop economics. Ken Grant, the manager of the City and Hackney health authority, who has done more than anyone else to generate income, expressed it in more blunt language than I dare use. He said: In terms of what the NHS needs, the money we are raising is peanuts. It's just that at the moment peanuts are bloody useful After three years the peanuts will amount to £70 million in a full year. To put that in perspective, it is less than half the £168 million by which the Government have underfunded nurses' pay in the past year alone. It is sheer effrontery for a Government who cheated the health authorities on that scale now to claim the credit for allowing them to raise half that money in the market. The basic reason why we are suspicious of clause 4 is that, eventually, the pressures on hospitals to make profit will make the patient pay. Nearly two thirds of clause 4 is about charging patients.

It might be salutary to recall at this point the crushing failure of the Government's previous intervention on charging patients, which encouraged hospitals to expand pay beds by one quarter over six years. Unfortunately for them, those six years turned out to be the same period in which the number of patients wanting pay beds fell by one third. The legacy of that colossal misreading of the market is a mountain of bad debt. Health authorities are writing off £500,000 in bad debt from private patients who slipped to the front of the queue into pay beds and failed to pay for them.

Despite that lesson of history, the Government now want to encourage health authorities to invest still more money in that loss leader. I have evidence of what the Minister has in mind. I understand that on Wednesday, or later in the week, at a press conference he intends to reveal a deal which the Government have struck with Bioplan Holdings to develop private day units in NHS hospitals. One of those is the Hope hospital in Salford, where Bioplan is to build a 12-bed new day centre unit. Another is the Churchill hospital in Oxford, where Bioplan is to equip an existing Health Service day surgery unit and provide 15 private beds. Those are the first two out of six such deals around the country. Each of them will have the capacity to carry out 10,000 operations.

That reflects the trend in America for fast in and out day surgery as the basis of private care—the "Kwik-Fit" approach to surgery. It breaks new ground in reducing health care to a market commodity. It will mean that NHS hospitals and private hospitals will occupy the same sites — in the case of the Churchill hospital, the same building. They will share common staff. It is not even clear whether consultants will operate in their own time or in the time paid for by the district health authority. They will share common laboratory staff—at any rate until such time as the Government privatise the laboratories.

The absurdity of the position is that the district health authorities will provide the sites, lend the staff, run the back-up services and must then pay Bioplan for the treatment of the patients. Of course, the deal has been stitched up behind closed doors, which is the very antithesis of market forces. There was no open tender here.

It is a flagrant case of favouritism — and what a favourite to have chosen. Bioplan shares its directors with the British subsidiary of the Hospital Corporation of America. The vice-president of that corporation has observed with engaging frankness: We try to maintain a low profile when we enter a country because we don't want it to appear that — here is a big American company to take over the health care system. With equal candour, two years ago the founder and controlling shareholder of Bioplan stated his health care philosophy at a Financial Times conference. He said: I don't apologise for being commercial—the bottom line to me means profit. How fitting that this Government should choose such a company as a partner. How perfectly that demonstrates where we are going with clause 4 and the joint priorities of that company and the Government.

Meanwhile, back in the state sector, every day we see more clearly the reality of the Government's commitment to the NHS. In Birmingham the reality of health care under the Government is a charity appeal for £500,000 to cover a corridor from the operating theatre so that ill babies need not be wheeled through the mud. In Leeds the reality is parents clubbing together to fund a registrar's post in a children's cancer ward.

At the weekend it was the turn of the royal colleges to issue an unprecedented joint statement. I have not been charged with the health portfolio for as long as the Minister has, but even if I had the years of experience that he has I hope that I would not presume to tell the presidents of the three senior royal colleges that they had not grasped the complexity of the issue. The three presidents said: In spite of the efforts of doctors, nurses and other hospital staff, patient care is deteriorating. Acute hospital services have almost reached breaking point. That statement is a damning indictment of the state of our hospitals this year. The statement demands a response from the Government that matches the magnitude of the crisis that it depicts. That response will require vision and clear-headed choices between priorities. It will require a readiness to square up to providing the resources to do the job adequately. Instead, the House is offered this tawdry Bill about putting petrol pumps in hospital forecourts and charging the elderly to have their eyes examined.

The measures are objectionable enough in themselves. The Bill that contains them is doubly objectionable because it is a pathetic and fatuous irrelevance to the real crisis in the Health Service. We will vote against it tonight with contempt.

5.13 pm
Sir David Price (Eastleigh)

Following Mr. Speaker's injunction to make brief speeches, I hope that the hon. Member for Livingston (Mr. Cook) will forgive me if I do not immediately answer some of his important points, especially the latter ones. I hope to take up some of them during my brief contribution.

I am the only member of the former Select Committee on Social Services, which spent most of last year examining primary health care, who is present for this debate. I thank my hon. Friend the Minister for agreeing, at least in principle, with most of the recommendations in our report. It would be churlish of me not to extend similar thanks to the Goverment for their White Paper. It is important for us to realise the commitment that they have made. In the preface to the White Paper, the four Secretaries of State say that we must shift the emphasis in primary care from the treatment of illness to the promotion of health and the prevention of disease. To succeed, that shift will require extra resources. Illness will not just vanish because we decide to work for a healthier nation.

In the long term, if we place more emphasis on the prevention of illness and immunisation, it will be reasonable to expect a reduction in known ailments, with known causes where they are known to be preventable. Former killer diseases such as smallpox, scarlet fever, diphtheria and tuberculosis have been nearly, if not completely, eliminated through public health campaigns, immunisation and the development of antibiotics. Thus, there is an historical basis for the long-term hope that prevention will reduce the incidence of illness. But we have no chance of doing it quickly. Therefore, the extra activity that we hope will come into primary care as a result of the White Paper will require further resources. We know that resources are already under strain, and the hon. Member for Livingston drew our attention—if we needed it—to the statement from the presidents of the royal colleges.

What are the Government doing to provide extra resources? In his statement of 25 November, my hon. Friend the Minister for Health outlined the Government's commitment to putting more resources into primary health care. He reminded us that existing plans already provided for an additional £570 million in real terms by 1990–91. Today, he talked about £600 million. I do not know whether he was rounding up or whether we have got another £30 million out of him.

Mr. Newton

I started rounding down and said that we were committed to spending at least another £500 million. The programme of additional expenditure contained in the White Paper will take it from under £600 million to well over £600 million.

Sir David Price

My hon. Friend went on to say in his statement that the £570 million will be further increased by the substantial extra resources that the Government will make available to finance the improvements that I have described today." —[Official Report, 25 November 1987; Vol. 123, c. 260.] Paragraph 2.6 of the White Paper examines the Government's intentions and suggests that additional resources will be available. That puts a different light on the Government's proposals from what was said by the hon. Member for Livingston and by some of my hon. Friends. Will my hon. Friend the Under-Secretary of State who will reply to the debate spell out more precisely the Government's commitment to provide these extra resources? It is important for us all to know what that commitment is. I will carry the whole House with me when I say that to move forward in health promotion, the prevention of illness and immunisation—all the matters that were set out in the Select Committee report— we shall need extra resources. I believe that the Government are committed to making available those extra resources, but that message is not getting through to the public or to the House. Much of the debate so far has centred on the false idea that the Government are reducing resources.

Mr. Peter Thurnham (Bolton, North-East)

It seems a pity that that point has not got through to the professionals. When the discussion document was put out for consultation, no suggestions were made about how the developments could be financed. The professionals were slow to come forward, but they were not slow to be entrepreneurial. My right hon. Friend the Secretary of State has said that the Health Service could consider other opportunities, but the professionals have not been slow to find other opportunities to boost their income. The Sunday Times said that consultants in the Bristol hospital were earning £60,000. Perhaps members of the profession will come forward with suggestions.

Sir David Price

My hon. Friend makes a useful intervention which goes rather wider than the scope of the Bill, but he takes me on to my next point. If, as a nation, we are to develop our health services as everybody wants, we must consider new methods of financing them. That takes up my hon. Friend's point.

We must not reject ideologically the use of charges, but we must ask what sort of charges should be made and whether they are acceptable medically. The hon. Member for Livingston made a very telling point. I could put the same point in the language of the Royal College of Nursing which said that we encourage free medical checks of all parts of our body by clinicians except our teeth and our eyes for which we will have to pay. This distinction requires a more detailed justification than we have had so far. I am not opposed to the concept of charges. It is an important matter and we must discuss which charges are relevant. No charge must be imposed which might reduce a citizen's access to services because he cannot afford them.

Mr. Galbraith

I do not agree with charges, but there are different types of services for which we can charge, for example, treatment, including prescription of spectacles, and screening. That is an important distinction. People would continue to take up preventive treatment, but they would not take up a screening test.

Sir David Price

I sympathise with the hon. Gentleman's point. Let me move from charging to my old hobby horse, which I do not apologise for raising again. We must aim at smaller lists for general practice. I have already quoted the Select Committee's recommendation on this matter and, with the indulgence of the House, I shall repeat it because it goes to the heart of improving the scope of primary health care. We said: With an ageing population, earlier patient discharge from hospital—particularly of children, increasing opportunities for diagnosis in general practice to reduce referrals to hospital, as well as greater responsibility for the management of chronic disease in general practice and a greater emphasis on a range of preventive services, the case for further reduction in the GP list size seems unanswerable. I believe that it is unanswerable. The measures necessary to implement the House's intention for better primary health care — the House supports the White Paper's intentions—must centre upon the reduction of list sizes.

If we wish to improve our primary health care, we must recognise that nurses should play a greater role than they have hitherto and that they are professionally competent to do so. I hope, therefore, that the House will agree with what we said in paragraph 60 of our report, which is clearly relevant to the Bill. We state: There must also be better training for nurses and a proper career structure, if they are to perform an extended role in the community. Steps need to be taken to recognise and raise the status of nurses working in primary care. Practice nurses need training specifically directed towards work in the community. If the Government accept that view, why does clause 12 provide extra remuneration for training by doctors, but does not extend it to nurses? It would be an important improvement to the Bill if a clause to that effect were added.

In the same vein, why are the Government not taking advantage of the Bill to permit nurses with appropriate training limited powers to prescribe and in defined circumstances to modify dosage"? That was our recommendation 30 with which the Government agreed in principle. In their reply they said that they accepted the proposal, but that they would have to consult the professional standing advisory committees. It is nine months since we made that proposal and a good deal longer since Julia Cumberlege also proposed it. We must take advantage of the Bill because we do not have a Bill like this every year. Therefore, I hope that the Government will add a new clause to that effect.

There are many other matters with which I should like to deal. We issued a long report with 62 recommendations. I wish to put a few of our points in headline form because they are relevant to our debate. We must consider the role of other professionals in primary health care, particularly physiotherapists and occupational therapists. It is important to include social workers in the primary health care team. We must develop pathological and radiological services and bring them closer to the community, giving a quicker back-up to primary health care. The community hospital must support the general practice and act as a satellite to the district general hospital, thus linking the hospital service through to general practice. We must also consider how voluntary bodies fit into the scheme of health care. I wish to impress on the House the need for closer ties between hospitals and general practice. Those ties should be so close that there would be a seamless robe of care from the patients' bedside right through to intensive care, if needed. We do not make this any easier when we separate the family practitioner service from the hospital service. As my right hon. Friend knows, this is one of my hobby horses. Scotland shows a very much better example in these matters.

Occupational medicine has a contribution to make in improving