§ Lords amendment: No. 20, in page 12, line 1, leave out subsection (7).
§ The Secretary of State for Health (Mr. Kenneth Clarke)
I beg to move, That this House doth disagree with the Lords in the said amendment.
The House will know that the amendment deals with the vexed question of charges for dental examinations. I shall seek to persuade the House this evening that their Lordships made an error when they sought to remove the power from the Bill, and that the Health Service can make extremely good use of the revenue that can be raised by the introduction of charges.
It is relevant first to consider the matter against the background of the Autumn Statement and the increased spending announced today. I know from discussions with some of my hon. Friends that that announcement may be used against me by some. The argument runs that, with so much money going into the National Health Service, we do not need to seek increased revenue from those of the population whom we judge can well afford to pay a modest sum for their dental examinations. It is certainly true that this debate is taking place against the background of a fairly dramatic increase in the spending available to the National Health Service next year.
Given the difficulty of absorbing the Autumn Statement, it is possible that not all hon. Members have yet assimulated the news that we have heard. The hon. Member for Livingston (Mr. Cook) described the announcement as a standstill budget. I do not understand that. It would appear from some of the hon. Gentleman's comments that he may be labouring under the misapprehension that the increased spending that we provided to fund in full the nurses' regrading exercise and pay increase is part of the £1.8 billion for England. I see that he is shaking his head, so he has appreciated that fact. What we are talking about by way of provision by the taxpayer is an increase in spending next year over and above the outturn this year, which includes all the money that we have provided for the nurses' regrading exercise and that will continue. Over and above what we have provided this year for the Health Service, and over and above the provision that we have made for the funding of the nurses' pay award, an additional £1.6 billion—£1,600 859 million—will be provided for the Health Service next year in England alone. On top of that, we expect continued efforts by way of cost improvement programmes and revenue generation—made easier by the Bill—to make available to the English National Health Service £1.8 billion.
The hon. Member for Livingston would not forgive me if I excluded Scotland, Wales and Northern Ireland from my remarks about the Health Service. If those figures are included, the increased spending available to the Health Service next year amounts to well over £2 billion—4½ per cent. over and above the raised forecast for inflation announced by the Chancellor today. That figure includes increases in expenditure on primary health care, with which we are principally concerned this evening. At the moment, we are spending more than £5,000 million on primary health care. During this Government's period of office, the figure has risen substantially—by 43 per cent. over and above the level of inflation since 1979. Our public spending proposals include plans to increase spending on primary care services by a further £600 million over the next few years.
The National Health Service is faced with a splendid opportunity to expand its patient services—while maintaining the high quality of medical and nursing services that we know we can expect from it—to meet the increasing demands that today's population puts upon it. The relevance of that is that there may be a temptation among hon. Members on both sides of the House to say that because this money has been made available, thanks to the Government's choice of priorities in this year's public spending round, we can take it easy and relax a little.
Why do we need to look for the provision of further revenue for the Service by introducing charges for dental examinations? I hope that that reaction to the large increase in provision for the Health Service will not affect the House, and will not affect people in the National Health Service either. We will waste the opportunity that the present economic success of the country has given to us if we allow increased spending by the Health Service to be combined with easing off all that we have done to try to give priority to patient care and developing the Service from the resources that we have.
The same mood could affect National Health Service managers. There will be a temptation in some authorities to defer a difficult closure decision, even if the hospital is redundant to Health Service needs and the money could be used elsewhere. There may be the temptation, which I fear will be encouraged by some members of the trade union and Labour movement, to ease off in our efforts to raise efficiency and to make better use of our manpower. That would be a mistake and would dissipate our opportunity. I believe that it would be a mistake for the House to reverse the decision that we took before the summer recess to give these powers to raise further revenue for the Health Service by charging for dental examinations. There is a choice in all things, and there is a clear choice when hon. Members decide which way to vote on this amendment.
We are talking about dental charges that will raise nearly £50 million in a full year. The best estimate that we can make for what those charges could raise is £49 million. The choice that faces us is whether we raise that £49 million and put it into improving the service to patients 860 provided by the National Health Service or whether we allow it to stay in the pockets of that section of the population who would not qualify for exemption, those who are, by definitions better off. The sum of £49 million is not insignificant. The choice that their Lordships made in another place was to let the people who would otherwise pay keep the money and not to put that money into the National Health Service.
When one looks at what £49 million would buy, it is equivalent to at least one new district hospital each year. If one takes the average cost, it would pay for 21,000 hip replacement operations each year. It would pay for more than 65,000 cataract operations at the average cost, if that £49 million was put to what I regard as better use. To find out what can be achieved on the margin of the Health Service, one only has to look at the Government's recent waiting list initiative. By spending £30 million on the margin, we have been able to provide treatment for 110,000 more in-patients in hospitals. The £30 million for the waiting list initiative is dwarfed by the money that we expect to raise from dental examination charges.
§ Sir Michael McNair-Wilson (Newbury)
Will my right hon. and learned Friend say whether the £49 million represents the number of people who are having dental examinations at this time, or is it an estimate of the number who may have them if the charges are imposed?
§ Mr. Clarke
I shall be coming to that crucial point in my speech. I do not believe that the dental charges will have any significant or noticeable effect on the number of people who have dental examinations. That is probably the issue that divides some of us most strongly this evening, but I believe that all experience is against that.
The £49 million is the sum at issue on this amendment for dental charges. It is no good saying that £49 million does not matter and that it is peanuts, and it is something that surely can be found from the Government's finances in their present state. It is not peanuts to the people who could have those extra operations or treatment in some other part of the Service if we allow this revenue to be raised and used properly. It is no good saying that, if the House reverses the decision that it took a few months ago and decides that, after all, it does not want to raise this revenue, we will somehow reopen the Autumn Statement and find the money to replace it. That is simply not on. I understand that an hon. Member put that to my right hon. Friend the Chancellor of the Exchequer earlier. One cannot run a whelk stall that way, let alone a Government.
On this year's spending, the settlement that we have made in United Kingdom terms is more than £2 billion extra spending over and above this year's spending, over and above the nurses' pay settlement and over and above the £50 million that we are planning to spend, and which I certainly do not wish to forgo. I hope that that explains to my hon. Friends—it may come as a surprise to some of them, but it should not—why the discussions on this year's public spending round were not easy. I have the greatest respect for my right hon. Friend the Chief Secretary, who is also a personal friend. We discussed this matter for a long time. One meeting that we had lasted for five and a half hours. At the end of it, we had not settled very much, so we had to start again. Throughout those discussions I never reopened this question, because the Chief Secretary himself wanted to give higher priority to the Health Service and its patient care. They were friendly 861 discussions, and neither of us wanted to go backwards and take out of the Service £50 million for dental charges, of which we believe the Health Service can make adequate use.
§ Mr. Peter Griffiths
In the list of improvements that my right hon. and learned Friend has suggested could be made in the National Health Service from this £50 million, he has made no mention of any improvements in dentistry. Our right hon. Friend, the then Minister of Health, said in Committee—at column 262—that at least part of it would go into improved primary dental care.
§ Mr. Clarke
I know. I am trying not to repeat the arguments that my right hon. and hon. Friends have used extensively on Second Reading, in Committee and on Report, though I am bound to repeat some of them. Some money will be put into dental services, and that is something for which the Bill is paving the way. Measures are included to promote dental health and the prevention of dental disease, and to improve the quality and distribution of dental services. Those extend from more fluoridation to more training for the dental profession.
I must say to my hon. Friend the Member for Portsmouth, North (Mr. Griffiths) that it is no good anyone thinking that they can vote against the new dental charges and not put any of those at risk. I am sure that we shall not be able to charge ahead improving dental services as the profession expects, quite rightly, that we shall do if the House decides to deny us £50 million that we believe we can legitimately raise from dental charges. We shall have to find the £50 million out of our previous intentions. The dental service need not think that it will be exempt, if the dentists have persuaded the House not to introduce these charges. However, I trust that we shall not come to that.
§ Mr. Maxwell-Hyslop
Is my right hon. and learned Friend telling the House, as a new Secretary of State in the Department, that his right hon. and learned Friend, the Parliamentary Secretary to the Treasury so failed in his duty to him that he did not warn him that, when he met the Chief Secretary to the Treasury, he should do so on the supposition that there was a great probability that the original decision of the House would be reversed and that, the Lords having passed this amendment, it would very possibly be sustained by this House? Is he telling us that he had no advice whatever from the Parliamentary Secretary to the Treasury on this matter? He has told us that he went into his meeting with the Chief Secretary to the Treasury not taking this into consideration. Did he or did he not have advice from the Parliamentary Secretary to the Treasury on this point? If he did not, the Parliamentary Secretary to the Treasury let him down severely.
§ Mr. Clarke
I have had a number of conversations on this subject with my right hon. and learned Friend the Parliamentary Secretary to the Treasury since I took up my post. He, together with my right hon. Friend the Secretary of State for Social Security, took the measure through the House only a few months ago and received an adequate majority of, I believe, 81 for it. We know that since then people have reflected further, but the fact is that, although some of those hon. Members who now say that 862 they are leading a rebellion against us voted in favour of these charges only a few months ago, they now claim to see great problems of principle. However, my right hon. Friend the Chief Secretary to the Treasury and myself have great faith in the logical approach—especially of our party—to these matters. We trust that when confronted with the use to which £49 million could be put—and, I hope, having considered whether there is any serious risk of people being deterred from treatment—we shall achieve that majority, or something like it, again.
§ Mr. Clarke
I shall give way to my hon. Friend in a moment. The danger in these debates is that I shall be giving way all the time. I shall come to any deterrents later.
I would point out to my hon. Friends—this is also appropriate to the Labour party when it was in government—that in primary health care it has always been the policy of successive Governments that those who are comparatively better off when compared with the very poorest in society should contribute to the cost of optical, dental and pharmaceutical services. That point has not been raised as an issue of principle on all but the briefest of occasions since Nye Bevan found it objectionable in 1951, when the then Labour Government introduced charges. What has happened—not only during this Government's period of office—has been that those charges have been raised substantially. In our opinion, those charges are a proper contribution to the revenue that is required to support and improve primary health care services. I have already said that we have increased real terms expenditure on those services by 43 per cent. since we came into office.
At times I have taken part in the debates that have been held each year on health charges. I am afraid that at times I have regarded them as a bit of ritual and I believe that I have said so on occasions because when in opposition the Labour party makes ritual objections. On every occasion when we raise charges, people always say that that will have a deterrent effect on those people coming forward to seek treatment. I have no doubt that some hon. Members raised that point as long ago as 1976 when the Labour Government raised charges by 35.3 per cent. in one year and then raised them in the next year by 27 per cent. Our biggest increase was 32 per cent. in 1980 and in subsequent years we have always raised charges. The real terms level of those charges has always increased because the real terms cost of primary health care has always increased.
We have frequently had votes on those issues and some hon. Members have asserted that the old and the poor would be deterred from using the services if we carried on increasing the charges for non-exempt groups. However, it has never been the case that there has been any decline in the service. In fact, although Governments have increased the level of the charges every year, there has been a steady increase in the numbers of courses of treatment. Occasionally, there has been a small drop in the first part of the year, but by the end of the year—I have with me the figures for every year from 1975 to 1986–87—the numbers of courses of treatment have increased.
§ Mr. Cook
I am obliged to the Secretary of State for giving way to me. For the guidance of the House, will the Secretary of State clarify whether the chief medical officer agrees with him that he would not expect people to be deterred by a charge for dental examination or has the chief medical officer offered the Secretary of State the medical advice that that would greatly damage an important preventive service?
§ Mr. Clarke
I regard the advice of the chief medical officer—as I regard the advice of all my officials—as confidential—[Interruption.] I also regard this issue as tedious. The hon. Gentleman raised it repeatedly with my predecessor. He should be careful because, although his reputation is justifiably high, he blew his attack on the Government and child benefit last week by becoming obsessed with a silly letter that someone had got for him, thus throwing away any opportunity to satisfy even his hon. Friends. If the hon. Gentleman wants to take us back through his exchanges of correspondence with my predecessor about the advice of the chief medical officer, he can occupy the time of the House in that way if he wants, but I am certainly not going to move away from the long-standing convention that such advice is confidential.
The key point is that there have been steady increases in the numbers of courses of treatment every time that we have raised charges. Some of those charges are now quite high—the present maximum being £150 for a treatment. We did not start raising charges—our predecessors did that—but we have never apologised for raising charges to pay for treatment. The cumulative effect is that during our period of office, from 1979 to 1987, courses of dental treatment have risen from 31 million per year to nearly 37 million per year. That is an increse of 19 per cent. and means that there are almost one fifth more instances of people using primary health care than when we started hiking up the charges. There has been an annual increase of about 2.7 per cent.
Looking at the figures for the use of the dental service, what strikes me is that the group of the population which has raised its use of dental services more than any other is pensioners and retired people. Each year we have increased charges and each year the Labour party has gone through the ritual of opposing that, yet pensioners' use of dental services has risen faster than that of any other group. During the lifetime of this Government, pensioners' use of dental services has nearly doubled. There has been a 92 per cent. increase in the period from 1979 to 1987.
§ Mr. Clarke
I shall give way to my hon. Friend the Member for Davyhulme (Mr. Churchill) because I think that he was first.
§ Mr. Churchill
I am grateful to my right hon. and learned Friend for giving way. He seems to be under the firm impression that by introducing or raising such charges he stimulates the uptake—[Interruption.]—or at least there is no decline. Is he going to tell us that he is about to introduce charges for breast cancer screening and for 864 cervical smear testing and that that would not have a deleterious effect on the uptake? If he does, quite frankly not many people will believe him.
§ Mr. Clarke
With great respect to my hon. Friend, who is a colleague of long standing, he does not do me a service by slightly parodying my argument. Of course, I was not saying that levying charges would in itself encourage a greater uptake—[Interruption.]—well, some people might be tempted to. It is not usually the experience that people have less regard for something that they pay for than for something that they get free. However, I have not used that argument. I am saying that against the history of some pretty steep increases in the costs that people expect to face when they cross the threshold of a dentist's surgery, the public are making ever more use of the dental service—pensioners most spectacularly.
§ Mr. Clarke
No. Of course, we are not introducing charges for those other things. I am putting the current position firmly in the context of the long-standing charges for optical, pharmaceutical and dental services. We have absolutely no proposition to put forward charges for those other screening tests.
§ Dr. Moonie
The Secretary of State has correctly described the long-term trend in the use of the service. Will he confirm that on every occasion in the past 10 years on which charges have been raised the level of usage immediately thereafter has fallen?
§ Mr. Clarke
I think that I have said that. What usually happens is that its use falls off for a short time, but uptake then catches up. I will not labour that point any further because the figures are plainly on my side.
The increase in the use of the dental service coincides with a period during which the dental health of the nation has been improving. The number of people who have rushed to the dentist for toothache, for extractions and for fillings is certainly not increasing—if anything, it is decreasing. However, people are making ever more use of the dental service for the most expensive treatment such as bridges and crowns.
§ Mr. Clarke
I should like to continue my case for a little longer and then I shall give way again. The case that I am making—and I am not putting it in the manner that my hon. Friend the Member for Davyhulme suggested—is that all our experience shows that quite sharp increases in charges under both Labour and Conservative Governments have not deterred people from going to the dentist. Therefore, there is no reason to believe that the impact of charges on this test will be any different from the impact made by those other charges.
I shall go further, because if there is any deterrent effect—I recognise that the hon. Member for Kirkaldy (Dr. Moonie) clearly does not believe that there has been no impact—on those seeking treatment, the impact of the charge that we are proposing for this test is likely to be much less—indeed, non-existent. [Interruption.] We shall have two debates and I shall deal with each test in turn because the arguments are slightly different.
865 The charge that we are proposing for the dental test is tiny compared with most dentistry costs and is not a significant figure for the group of people whom we are discussing who are, by definition, not the very poor and are not exempt. We intend to apply to the test the same principle that we apply to other dental services. The charge represents three quarters of the cost of treatment or, in this case, the examination, so, under the present agreement with the profession regarding the level of reimbursement for the service, the charge will be £3.15 for those people who are not exempt.
That leads me to the key point, which explains why the charges for treatment have not deterred people from going to the dentist. There are more than 20 million people to whom none of this applies because they are exempt from any form of charge. About 38 per cent. of the population is exempt. I have been a little generous to my critics when I have occasionally talked about the one in three who are exempt and the two in three—the better off—who have to pay. That is under-selling our case a little. In fact, four out of 10 are exempt, and the better-off six out of 10 will have to face this enormous sum of £3.15 about every six months if they want to go to the dentist. The exempt groups are children under 16, students under 19, other young people under the age of 18, pregnant women and nursing mothers and people on low incomes, which means primarily people receiving income support or family credit.
§ Mr. Dykes
I am loth to interrupt my right hon. and learned Friend's beguiling advocacy, but, on reflection, does he not consider that he was a little unfair to our hon. Friend the Member for Davyhulme (Mr. Churchill) who voiced Conservative Members' anxieties? Does he further agree—assuming that he wins vital votes for the Government tonight—that Conservative Members are anxious that, when the charges are imposed, they may be rapidly increased? I have the greatest respect for him and believe that, if the National Health Service were to be safe in anyone's hands, it would be safe in his, but is he not the victim of a long-term Adam Smith design to impose charges on all sorts of screening services in hospitals, clinics and other institutions? Why does he not acknowledge that anxiety and assure us that, if the use of screening facilities falls drastically—assuming that the Government win the vote and impose the charges—he will reconsider the matter in, say, a year's time? Will he also solemnly reassure the House that he does not intend to impose additional charges on other screening services?
§ Mr. Clarke
No, I have no intention of introducing charges on any other things. As my hon. Friend the Member for Birmingham, Edgbaston (Dame J. Knight) may recollect from our previous exchanges about eye tests, I never say never in politics, so I will say now, as I said on those occasions, "for the time being". I am certainly not party to any desire to extend charges. [Interruption.] It would be a totally different argument if we did so.
I see what we are doing this evening as being consistent with a long-standing policy, which goes back 30 years, of imposing charges for optical, dental and pharmaceutical services. It would be a significant change of policy if we introduced charges for medical procedures such as those that have been cited. Certainly, the Government and I have no such present intention. The Autumn Statement 866 contained no provision for any new charges, but that does not alter the case in respect of the dental examination charge for the 60 per cent. of people who are not exempt. That charge of £3.15 is incurred about once every six months by that section of the population who go to the dentist. My right hon. Friend the Secretary of State for Social Security made an announcement last Thursday about the uprating of benefit and, as a result of that, a further 90,000 people will be exempted from dental charges. It was a side effect of my right hon. Friend's welcome statement that that widened the category of people in receipt of benefit and who are, therefore, protected against this sum of £3.15.
It is not just the history of charges, but common sense that tells us that people will not be deterred by that sum. Common sense sometimes needs to be reinforced by research. Plenty of research cited in debate has been carried out among that section of the population which probably comprises quite a large number of hon. Members and who do not usually go to the dentist for a dental examination. When those people were asked why they do not go to the dentist, the cost of treatment, which can be up to £150, was ranked fourth among the reasons given, the principal reason being that many people do not see the need to do so. They also cite the pain, and the difficulty of finding a good dentist. Then comes the possibility that it might cost them money.
§ Mr. Clarke
Among better-off people, attending the dentist for a regular examination is largely a matter of attitude and habit. Those attitudes and habits are changing. In the past 10 years, the proportion of the adult population attending a dentist regularly has risen from 44 per cent. to about 50 per cent., despite the increases in charges.
§ Mr. Anthony Steen (South Hams)
Will my right hon. and learned Friend confirm that pensioners with no source of income other than their state pension, although they might have their own home or flat, will not have to pay dental or eyesight charges?
§ Mr. Clarke
I can certainly confirm that point and it is important that we do so. Concern is often expressed about pensioners in such debates, for reasons that we all understand, but the social pattern of the country has changed in recent years and it is no longer the case that everyone of pensionable age can be assumed to be in the poorest category. Some pensioners are pretty hard-up, but others have quite large disposable incomes.
We give the same protection to pensioners as we give to the rest of the population. That is based on the best possible foundation, that of their income and means. The people in the category described by my hon. Friend do not have to pay for dental tests and the poorest pensioners, certainly those relying solely on their retirement income, would qualify for income relief.
§ Mr. Nicholas Bennett (Pembroke)
In order to put the £3.15 charge every six months into perspective, in comparison with other costs for families, will my right hon. and learned Friend confirm that the family expenditure survey shows that the average family in this country spends £8 a week on alcohol and £3 a week on toiletries?
§ Mr. Clarke
The average family also spends £4.50 a week on tobacco. [Interruption.] My hon. Friend's point is perfectly valid. Given the expenditure pattern of any household in this country, an expenditure of £3.15 every six months is an infinitesimal part of the household budgets of all those people who do not fall into the exemption categories. We shall waste the resources available to the Health Service if we continue to provide this examination free to a large section of the population who would pay it without thinking seriously about it and thereby contribute a sum of £50 million each year to the resources of the Health Service.
That is my case. We are discussing a misplaced sense of priorities which suddenly seized their Lordships when they first considered the matter. Just as they exercised their undoubted right to send the measure back to us to reconsider it. I strongly believe that we should exercise our undoubted right to send it back to their Lordships for them to reconsider it when they see the consequences for National Health Service spending and treatment.
The vast majority of the £50 million that we forgo—in my opinion all of it—is wasted. It will be a case of resources needlessly turned aside if the House votes against the Government. Those who occupy the Chamber do not constitute a typical cross-section of the population, but by definition all of us are not exempt from Health Service charges. If the House decides to agree with the amendment, everyone sitting in the Chamber will be able to continue having dental examinations scot free. I am sure that no hon. Member would argue that he would be put off by having to pay a charge of £3.15. I am sure that the majority of those whom we are talking about would similarly not be put off. The £50 million that we are forgoing is dead money that is not serving any useful purpose. It is a source of revenue of which the Health Service could make good use.
§ Mr. Clarke
No, I shall not give way. [HON. MEMBERS: "Give way."] My hon. Friend and I are familiar with our mutual views. I am sure that I shall continue to exchange views with him on radio and television. He will have plenty of opportunities to express his views. As he feels so strongly about them, I am surprised that he has come in so late in the day. My hon. Friend is protecting those members of the population to whom I have referred against expenditure of £3.15 every now and again.
Labour Members have surprised me. I thought that they would he wedded to the principle that the better-off section of the population—we are talking about the comparatively better-off by definition—should contribute towards health services for the population as a whole. It seems astonishing that the Labour party should seek to protect higher-rate taxpayers from having to incur a penny piece of expenditure for their dental examinations. The Labour party is saying that the £50 million that might be spent each year on patient services should remain in the pockets of the non-exempt population. I trust that my right hon. and hon. Friends do not agree with that.
I am not prepared to agree with the argument that the National Health Service should cut its planned expansion to the extent of £50 million, or to any other extent, for the non-exempt categories. I believe that all those who are 868 committed to the NHS and to the expansion of patient care, and who wish to see us continue to make further advances in increasing the quality and quantity of health care, will vote in support of the Government this evening, and in so doing disagree with the Lords in this ill-thought-out amendment.
§ Mr. Robin Cook
This is the first of two debates on a principle that has greatly exercised many hon. Members on both sides of the House. As it is the first of the two, it may be appropriate to begin by rehearsing the recent history of the Government's disturbing proposals. They have their roots in the Green Paper on primary care which the Government produced in April 1986. I am bound to observe that one needs to be the most keen and enthusiastic gardener to spot the roots in the Green Paper. There was not the slightest hint that the Government intended to introduce charges for dental examinations or eye tests. There was no suggestion of the most controversial proposal that the Government have brought forward on primary care.
The first question that I must ask the Secretary of State, especially after listening to his address to the House, is why, if the Government had it in mind to introduce the charges when they produced the Green Paper, they did not share the idea with the world at a time when the public and expert opinion could have commented on the proposal and perhaps saved the Secretary of State from the embarrassing and difficult position in which he now finds himself in defending what is a friendless proposal. No one put that in the Government's mind during the consultation period that followed the introduction of the Green Paper. In answer to a question by my hon. Friend the Member for Holborn and St. Pancras (Mr. Dobson), the Government candidly stated that no one during the consultation period had suggested charging for dental examinations or eye tests.
The proposal surfaced, newly born but fully fledged, last year in a White Paper. Having produced proposals without consultation, the Government have refused to listen to what anyone has to say about them. I congratulate the Secretary of State and his predecessor on the unusual achievement of securing positive harmony, not merely a degree of unity, among the diverse Health Service lobby groups and professional organisations. They are united in condemning the proposals. Charges for dental examinations and eye tests have been condemned by the British Dental Association, the British Medical Association, the Royal College of Nursing, the Faculty of Community Medicine, the Royal Society of Health, the King's Fund Institute, the Society of Family Practitioner Committees—despite the fact that the Secretary of State has called for all future appointments to be submitted to him for political vetting—the Imperial Cancer Research Fund, the Patients Association, the National Consumer Association and the Association of Community Health Councils.
The Secretary of State told me that he regarded it as tedious to be asked to acquaint the House with the views of the chief medical officer. We all understood what he meant when he said that. I am prepared to give him the chief medical officer. I shall no longer press him to tell us what advice he gave. I merely invite him to name one reputable medical body that is supportive of the proposal to introduce charges for dental examinations and eye tests. By "reputable medical body", I do not mean those 869 factories for ideological axe-grinding such as the Adam Smith Institute and the Institute for Economic Affairs, which are the only friends of the proposal left.
All medical opinion outside the Department and, as far as we can see, inside it has advised against the charges. We are told that the charge for a dental examination is to be only £3.15. Those who say "only £315" show a remarkable lack of understanding of what that sum means to somebody on £100 a week. There are those who talk about the price of a pint of bitter, and if any hon. Member pays £3:15 for one I shall be glad to invite him to my constituency, where he can be entertained much more cheaply.
We all know what happens to charges under the Government. As the hon. Member for Harrow, East (Mr. Dykes) has said, charges are increased or, as the Government would describe it, reviewed. Some of us remember when prescription charges were only 20p. Since then the cost of such a charge has multiplied 13 times. With that rate of inflation, we shall have a £40 dental examination charge within nine years. Such an increase would be rather faster than the rate of wage increases. It is ironic that the new charge is being imposed in the one area of health policy where the deterrent effect has been repeatedly proven.
The Secretary of State has denied that charges for dental treatment would result in any form of deterrence. I take issue with the right hon. and learned Gentleman. I shall give two examples that have arisen since the House debated the issue on Report in May. The first example is the result of the change in the age of exemption which was made in 1981. Until 1981, any youth under 21 years of age was exempt from charges for dental treatment. In 1981, the Government reduced the exemption level to 18. Until 1981, the number of courses of dental treatment for 17 and 18-year-olds was almost identical. There was only a marginal diference between the two age groups. In 1982, there were 710,000 courses of dental treatment for 17-year-olds and only 554,000 for 18-year-olds. It was not, as the Secretary of State would have us believe, a merely temporary effect to be wiped out by long-term trends. In 1986, the last year for which we have figures, there were 632,000 courses of treatment for 17-year-olds and only 495,000 for 18-year-olds. The figures are eloquent testimony to the fact that among this age group there was a marked deterrent effect following the introduction of dental charges.
§ Mr. Robert Key (Salisbury)
I have also seen the figures, but I place a completely different interpretation on them. They show the remarkable success of preventive dentistry and the fact that children's teeth over the years have become very much better.
§ Mr. Cook
I cannot express just how glad I am that I gave way to the hon. Gentleman. If he seriously believes that the success of the treatment of 17-year-olds explains the 30 per cent. drop in treatment among 18-year-olds, I have no doubt about which Lobby we will find him in when the Division bell rings.
I want to adduce another piece of evidence for our case which comes from the other end of the age spectrum where the effect of dental charges has been clearly established to have had a deterrent effect. My point relates to a study of 870 dental treatment among pensioners published by Health Care UK in August. It showed that among pensioners liable to pay for their dental treatment, only half as many as were exempt were likely to opt for expensive treatment. There was a very clear and statistically clear difference. It is more worrying to note that the study showed that those pensioners liable to pay were four times as likely to require emergency treatment when they went for treatment. That shows that that group, because they knew that they had to pay, put off going to the dentist until the crisis occurred. How much more likely is that to occur if those pensioners now have to pay not simply for treatment, but for the check-up?
There is only one conclusion. As a result of the measure, we will see a serious reverse in the long, slow advance in preservation work by dentists. It is inevitable that there will be a tendency to an increase in extractions and loss of teeth as a result of people coming too late for successful intervention.
The Secretary of State made much of the fact that he was saving the Health Service money. He said that he would save £49 million which could be spent to improve primary care. There can be no better way of spending £49 million on primary care than to ensure that people are encouraged to go regularly for a dental check-up and have no disincentive to do that.
I do not want to embarrass the hon. Member for Davyhulme (Mr. Churchill), but I strongly endorse his observation. Every argument of principle used by the Secretary of State to defend the charge could be applied to every other case of preventive medicine. As I listened to the Secretary of State's arguments, I thought that the same arguments would sound equally valid and nonsensical were the Secretary of State to come to the Dispatch Box and say that he was proposing to introduce a charge of £3.15 for a cervical cancer smear. We can see all the arguments that could be adduced: it is not much, it is the price of three or four gin and tonics; there is no evidence that it would stop people coming forward; women surely value their lives more than £3.15 and, indeed, encouraging them to pay £3.15 might make them value the smear all the more. Were the Secretary of State to do that, he would be drowned in a gale of derision because the whole point—[Interruption.] If my hon. Friends will allow me, the Secretary of State would be drowned in a gale of derision from the Opposition Benches.
I want to refer to Conservative Back Benchers. When the hon. Member for Pembroke (Mr. Bennett) intervened in the Secretary of State's speech, I was fascinated to hear the right hon. and learned Gentleman say that the hon. Gentleman's arguments were "perfectly valid." The hon. Member for Pembroke played a distinguished part on Report when we debated this issue. Sixteen Conservative Members took part in the debate and the hon. Gentleman was one of only two who supported the proposals. I warn the Secretary of State that the hon. Member for Pembroke was engagingly frank about why he supported charges. He made it clear that he was in favour of charging for everything provided by primary care—visits to GPs and the rest. That is the argument which the Secretary of State found "perfectly valid."
§ Mr. Nicholas Bennett
I did not actually say that. I said that I was in favour of a charge for going to the doctor for those who could afford it. That is different from saying that every piece of primary health care should be charged 871 for. That is a perfectly reasonable case to put. It is not a case which so far has the acceptance of the Government, but that does not mean that Conservative Members cannot engage in a debate on where the Health Service is going.
§ Mr. Cook
I do not want the hon. Gentleman to misunderstand me. I welcome his presence and candour. However, I rather doubt whether the Secretary of State does the same. The Secretary of State should note where this "perfectly valid" argument is taking him. It is taking him, as the hon. Member for Pembroke honestly and fairly made clear, towards charges for visits to doctors by those who can afford them.
The arguments are well understood and well known. They are well understood because we have been over this ground—
§ Mr. Cook
No. If the hon. Gentleman will allow me, I will continue, because many Conservative Members want to intervene in the debate and I am anxious to leave adequate time for them.
The arguments are well understood because we have been over this ground before. It is worth recording that on every occasion that we have done that, the Government have lost the argument. They lost it on Report and in another place and that is why we have returned to it today. Latterly in ministerial briefings, a new and rather unpleasant theme has surfaced. Journalists have told us that the Government are determined to get their business through. They will not back down. The Secretary of State may he wet, but he will prove that he is tough. I am referring to the same Ministers who have discovered that they are such sticklers for constitutional convention that they regard it as improper to tell us what the chief medical officer advised them.
A much greater constitutional convention is the function of Government to listen to Parliament. The will of Parliament on this matter is perfectly plain. It was shown on Report and in the vote in another place and it was shown in an early-day motion. The Secretary of State knows perfectly well that if there were a secret ballot on the proposal, he would go down. His only hope of surviving is if his right hon. and learned Friend the Member for Ribble Valley (Mr. Waddington) and his hon. Friends stand at the right doors and the wrong doors and smile menacingly at hon. Members who go through the wrong one.
The Secretary of State does not demonstrate strength by refusing to admit that he is wrong and cannot convince anyone. He shows weakness. There can be no greater display of strength than for the Secretary of State to tell us that he has gathered the views of those working in dentistry and listened to his colleagues and he has changed his mind and will not proceed. There is still time for him to show that strength of mind at the end of this debate. However, if he persists in ignoring the views expressed in the Chamber, he must be defeated in the Division.
§ Sir George Young (Ealing, Acton)
It is common ground between both sides of the House that the National Health Service needs the extra resources announced today, which I am sure we all welcome. It is also common ground that it is perfectly legitimate for the users of the NHS to 872 make a contribution towards its costs. Under both Labour and Conservative Governments there have been charges for prescriptions and dental treatment.
The Conservative party has always made it clear that it is part of our philosophy to try to reduce direct taxation partly by cutting public expenditure and by increasing indirect taxes and introducing more realistic prices for parts of the public sector. As my right hon. and learned Friend the Secretary of State has already said, since we have been in office we have increased substantially prescription charges and charges for treatment without a lot of heart-searching and weekend activity by the Whips.
Those who subscribe to the deterrent argument against charging for dental treatment have to bear in mind the substantial increases that we have already introduced, which we have all defended, partly by saying that the money goes to improve the quality of service provided by the NHS, but also by arguing that those who benefit directly from parts of the NHS should make a modest contribution if their means permit it.
The debate this evening is about whether dental charges are simply an acceptable extension of a principle that has already been conceded or whether they raise a new issue that makes them unacceptable. Of course I am influenced by the fact that a large number of my hon. Friends with whom I usually instinctively align myself find themselves deeply unhappy about the charges.
However, anyone who visits his dentist for a check-up has already accepted that he may end up paying. There are about 37 million treatments a year and 8 million check-ups, so it follows that most people who go to the dentist know that at the end of the day they will have to pay something. Indeed, part of the point of going to the dentist for a check-up is to find out whether one needs treatment before a problem becomes painful. What the proposals are doing in practice is to substitute the inevitability of a charge with the probability of a charge. I do not find that unacceptable. I do not find any matter of high principle at stake, particularly if the charge is only £3.15.
My right hon. and learned Friend referred to the survey. I hope that he will use that survey not just to reinforce his case in the debate but to look at the three most important reasons why people do not go to the dentist and launch a campaign with the dental profession to bring down those barriers. Many of us would be reassured if, when he replies, there was some sign that that survey was being taken seriously and that there would be a campaign to promote more visits to the dentist.
However, there is another reason for querying the reservations of my hon. Friends. I do not accept the distinction between diagnosis, for which one must not charge, and treatment, for which one can charge. With the development of preventive medicine and health education, that distinction is being blurred. We should not encourage people to believe that they have been treated if they are given a prescription or have a tooth removed, but have not been treated if they are given some helpful advice or friendly warning about their lifestyle, diet or smoking. The diagnosis often embraces such health education and promotional activity which may be far more valuable and cost-effective than treatment. I do not understand the argument that it is legitimate to charge for curative medicine, but illegitimate to charge for preventive medicine.
873 My hon. Friends underestimate the willingness of many people who visit the dentist, whose incomes have risen over the past nine years and whose taxes have been reduced, to make some contribution towards that service, especially if that contribution in turn goes back to funding its expansion. I do not feel in the least apologetic or defensive about this. I am happy to defend the measure in my constituency, and I shall vote against the Lords amendment tonight.
§ Mr. Fearn
I wish to speak against the Government's amendment and in favour of Lords amendment No. 20.
Each day that I appear in Parliament, each day that goes by, I find it more and more incredible that the Government get away with introducing legislation that flies in the face of all expert advice and public opinion. With the exception of a few members of the Government, I do not know anyone or anybody connected with the dental or medical profession who supports the introduction of charges for dental checks. Yet the Secretary of State seems hell bent on getting the clause on to the statute book, even though the measure contradicts the Government's professed objectives.
The thrust of the White Paper "Promoting Better Health", so the Government would have us believe, was, as the title suggests, the promotion of preventive medicine to improve the health of individuals. Indeed, one of the paper's stated aims was to achieve the wider availability of dental treatment. But when the Bill was presented to the House, we found that the Government had, by one fell stroke, reduced the availability of dental treatment to many of the population by introducing a charge for dental checks.
When the deterrent argument was put forward previously, the Government responded by saying that as the charge would be only £3.15 it would not act as a deterrent. My answer to such callousness is that whoever makes such statements has obviously never had to count the pennies on a Monday morning to see whether there is enough to cover the cost of sending the children to school on the bus or enough even to buy them a lunch when they get there. He has obviously never had to count his pension pittance to decide whether he should have meat for the day's meal or put an extra 50p in the meter.
§ Mr. John Marshall (Hendon, South)
The hon. Gentleman refers to £3.15 as a deterrent. Is he aware that gross average earnings are £224 a week and £3.15 is less than 2 per cent. of that?
§ Mr. Fearn
I am aware of most incomes, but I do know about the incomes of the poorer people, which the hon. Gentleman may not know about.
It is no good someone saying to me that there is a safety net to cover such cases, because it is quite clear that many people do not take up state benefits. That is not surprising when one sees the length of the forms that have to be filled in and the number of questions to be answered. I think that 17 pages is the latest figure. Most important of all is the stigma attached to such benefits. Therefore, it is not surprising that people do not apply for them.
Another factor in the cost of dental charges is that if and when the measure is introduced the cost may be only small at first, but if we look at prescription charges over the past 10 years, we all know that if the Government have 874 anything to do with it, it will not be long before the charges are increased to a rate way above inflation. Charges for dental checks, whatever they cost, are contrary to good preventive medicine.
The Government admit that there has been a great improvement in the dental health of the British people, including those in Scotland, who in the past had a poor dental health record. Much of that success is due to preventive measures. Regular check-ups play an important part in that process. Any action that reduces them can only be a step backwards.
It is well documented that dental checks play an important role in the early detection of life-threatening diseases such as oral cancer. Not so well known is the role that they play in the detection of other diseases, as the experience of one of my constituents highlights. A few years ago, after going from one specialist to another and undergoing tests for cancer, tuberculosis and many other conditions, and weighing only six stones, she visited her dentist for a check-up. He promptly sent her back to her doctor with a suggestion that she was suffering from an over-active thyroid. His diagnosis proved to be correct. We should look to the diagnoses of dentists to give patients the chance to live.
Are we really to run the risk of allowing the detection of many diseases to fall by the wayside and in doing so add to the costs of the NHS? It is clear that if the House does not support Lords amendment No. 20 today a significant number of people, not just the very poor, will be deterred from visiting their dentist until it is too late.
In the short term, it is possible that this clause will save the NHS a little money, but in the long term it will prove to be far more expensive, as dentists and doctors are required to treat conditions that, if detected earlier, would have been easier to treat and cure. The repercussions from the introduction of dental charges on the health of individuals and on the Health Service cannot and must not be underestimated.
§ 7 pm
§ Mr. Michael Colvin (Romsey and Waterside)
I shall be brief because I appreciate that it is in the Government's interest that this debate should go on as long as possible. I congratulate my right hon. and learned Friend the Secretary of State on proposing his amendment in what I may describe as his characteristically robust style. When he hitches up his trousers, we all know that he is going to sock it to us. However, I think that he has got it wrong. I believe that right hon. and hon. Members would find great support for their Lordships outside this Chamber. There is a danger that if we were to resist the Lords amendment and returned the clause to their Lordships, they might amend it once more, and we would embark upon the kind of parliamentary ping pong that could eventually lead to a constitutional crisis.
I wholeheartedly support the Bill, which follows the White Paper on primary health care, "Promoting Better Heath". Among the White Paper's four objectives that are to be enshrined in the Bill are the promotion of health, the prevention of illness, and the importance of getting value for money. I feel sure that Members on both sides of the House wholeheartedly agree with those objectives.
Those parts of the Government's strategy have my wholehearted support. The Government have already demonstrated their commitment to primary health care by 875 spending £5 billion per annum for that purpose, in preventing disease. The hon. Member for Livingston (Mr. Cook) commented that the White Paper makes no mention of charges, but I draw the attention of the House to the Conservative manifesto for the last general election, which was not all that long ago, which also made no mention of them.
I believe that the House is puzzled by two Government inconsistencies. First, the Government are inconsistent in introducing eye and dental inspection charges when so many other examinations remain free of charge. Two of my hon. Friends mentioned breast screening and cervical smear tests, which are free. Why is that so? If one is to be consistent, charges should he imposed for all tests. Secondly, the Government are inconsistent in demonstrating their belief in preventive medicine while at the same time proposing measures that will harm prevention and increase the number of people needing to be cured.
The Government have tried this before, in 1980, when my hon. Friend the Member for Reading, East (Sir G. Vaughan) was the Minister of Health, and when the Government attempted to introduce eye inspection charges. On that occasion, my hon. Friend accepted that my hon. Friends the Members for Birmingham, Edgbaston (Dame J. Knight) and for Woodspring (Sir P. Dean) were strongly opposed to the Government's proposals. My hon. Friend the Member for Reading, East acknowledged that it was a very important matter. He said:In no way do we wish to create a deterrent for people seeking eye testing who need treatment.He went on to say:It is characteristic of this Government"—and he was speaking then of a Conservative Government also—
and of our democratic process, that when strong representations are made to us we are only too willing to consider them carefully … It is not our intention to proceed with charges for sight testing."—[Official Report, 15 May 1980; Vol. 984, c. 1781–82.]If that was good enough then, it is good enough now. What has changed? There have been a few changes. One of the opponents then is now a Dame, and another has become Deputy Speaker. The Minister at the time is now a so-called rebel. Another fundamental change is that today's economy is much stronger than it was in 1980. However, if one accepts my right hon. and learned Friend's proposition that the Government are trying to save money for the National Health Service, which I do not, surely the argument for maintaining free tests is far stronger today than it was in 1980. Why did the Government accept the proposition that tests should be free in 1980 but are trying to impose charges now?
In this debate on dental charges—and the same is true in respect of eye testing—both sides base their arguments on presumption. The Government presume that charges will not deter, and that, in the case of dental inspections, about £50 million a year will be saved, whereas the so-called rebels presume that charges will act as a deterrent that will in the long run cost the Health Service much more in patient treatment than will be saved in the short term.
The Government have got it wrong. There is reasonable doubt on both sides. We are not debating something inanimate but are considering our constituents' health and the prevention of what can be serious diseases. It is a matter of life and death, and we do not dice with death. My right hon. and learned Friend should not do so either. 876 In the face of any reasonable doubt, tests must remain free of charge. That proposition is supported not only by the specialist organisations concerned with both dental and eyesight but also by the BMA and the British Dental Association.
The BDA maintains that, if there is any doubt, tests should remain free of charge. It points to two vulnerable groups—the young and the elderly. Until 1981, no charges were made for NHS dental treatment to those aged under 21, with the exception of denture charges, which were rarely relevant but were imposed from the age of 16. After April 1981, charges applied from the age of 18, except for patients in full-time education, when they began at 19 years of age. That brought about a short, sharp drop in treatment provision in the age group concerned. So paying does deter.
As to the elderly, I may point out that about half of all oral cancers are found among those aged 65 and over. Additionally, the risk of death from oral cancer is even greater than it is from cervical cancer, for which tests are still free.
I cannot be described by any of my right hon. or hon. Friends as a Tory wet, and nor can many of my hon. Friends who signed early-day motion 1405 and who I hope will be joining me in the Lobby tonight to vote against this proposition. We oppose the imposition of charges because we want to save money for the Health Service.
Once I was unwise enough to suggest in this Chamber that a politician's mind is determined by the state of his seat. I was told to withdraw such an offensive generalisation, but it seemed to make sense to me that before going into the Lobby to vote against the Government I should find out what my constituents had to say.
About 10 days ago, there was a meeting of my constituency Conservative Association executive, which had a heated debate on this matter. There were about 50 people present, and at the end two of them decided that there should be charges for everything, and that there should be means testing. Everyone else who was present supported me. That was not done out of loyalty to me but because they felt it was sensible to maintain free dental and eye tests. Last Friday, I attended a social event at one of my branches, in a place called Braishfield, when about 150 people were present. I would describe them as fairly well heeled and the kind of people who would probably anyway pay for their dental and eye tests. They too were solidly with me.
If that were not enough, on leaving Conservative Central Office the other day, I was hailed by a senior lady official who shouted "Charges!" at me. Memories of the military assault course immediately flooded back. When I turned to her, she added, "Dental and eye tests." I asked her what she meant and she replied, "The Tory women are behind you." I can think of better places to put the Tory women—[HON. MEMBERS: "Oh!"] If they believe that dental and eye tests should remain free, we should thank them for their support. I only regret that they cannot be with us in the No Lobby tonight. I call on my hon. Friends and on Opposition Members who feel that getting better value for the National Health Service is important, and who agree with the contention that prevention is better than cure, to support me in the Lobby tonight and oppose the Government.
§ Dr. Moonie
I listened with some puzzlement to the Secretary of State, who is after all one of the more intelligent Ministers and is renowned for his oratorical skill and his intellect. If we think about his intellect for a moment, we can admire the skill with which he left the Department of Trade and Industry ahead of the Barlow Clowes affair.
§ Dr. Moonie
And the Royal Ordnance factories, as my hon. Friend reminds me. But we might find it a little puzzling that the right hon. and learned Gentleman has managed to walk into this can of worms—if the House will forgive the mixed metaphor.
I feel that we should cut through some of the more flatulent rhetoric that we have heard and try to get to the nub of the problem. There must be few hon. Members in the Chamber who seriously believe that the future of the Health Service over the next year depends on whether we introduce charges for tooth and eye examinations. That is nonsense.
§ Dr. Moonie
The hon. Gentleman may say that, but it is the argument that the Secretary of State used in a direct threat to his Back Benchers.
§ Dr. Moonie
No, I shall not give way. I do not intend to waste my time or that of the House. The hon. Gentleman can make his own speech if he wants to. That ought to clear the Chamber.
We saw the same spectacle last year. The right hon. and learned Gentleman's predecessor appeared before the House in October and told us that there was nothing wrong with the NHS and that no money would be forthcoming. What happened six weeks later? Back he came, tail beween his legs, and, lo and behold, the Treasury had found the extra money needed to keep the Health Service afloat for that year. It is absolute nonsense for the right hon. and learned Gentleman to suggest that, were the £49 million that will supposedly be saved by this measure to be lost to the NHS, it would not be replaced if it was needed. Of course it would be, and the right hon. and learned Gentleman knows that fine as well.
I shall confine my remarks to the role of prevention in our society's health. It is a subject on which I have touched before and, sadly, will have to touch frequently in the coming years. Last week in the Palace of Westminster we held an inaugural meeting for the Public Health Alliance. More than 100 people from all professions turned up, as well as lay people interested in public health—people who fear that we have lost our way in preventive medicine over the past few years, and who intend to try to do something about it. It might well be appropriate to mention the Secretary of State when we talk about people who have lost their way.
§ Dr. Moonie
I think that remarks about smoking and drinking should be aimed at the Secretary of State rather than me. No doubt they frequently are.
We were worried about the development of public health in this country. What have the Government contributed? Last week we heard of the disgraceful 878 freezing of child benefit yet again, and now these proposals are before us. While other people are trying to reawaken our concern for public health, the Government appear to be doing their best to destroy it.
It is easy for us to forget how much we owe to public health measures, as opposed to those that members of my profession tend to claim as their own. Most are outwith our knowledge and are gradual factors that appear over the years. For example, the development of adequate sewerage and water supplies in the 19th century laid the foundation for health in our cities, and abolished cholera in this country many decades before it was abolished in other similar western countries.
In the 20th century, we have seen the advances made in the provision of school meals, school medical services, immunisation for children and many other measures that have contributed to improvements in public health over the past 100 years. Better wages and conditions over 20 or 30 years reduced deaths from tuberculosis from over 100,000 a year to almost nil.
Sad to say, the Government remain to be convinced of the value of those methods. I shall not talk about cancer screening, as other hon. Members have referred to it. But if we are introducing an adequate screening service which we hope will reduce mortality from cervical cancer in particular, there is—as others have said—no logic in failing to charge for that as well, as the Government seem to think that charging has no effect.
§ Dr. Moonie
No, I will not. I am mindful that hon. Members have been asked to limit the length of their contributions, and I do not wish to waste the House's time. [Interruption.] I look forward with great interest to the deeply intellectual contribution of the hon. Member for Tatton (Mr. Hamilton). I cannot think of anything worthwhile that he has said in the past, but perhaps tonight he will break the trend of a lifetime. [Interruption.] That is something foreign to the hon. Gentleman, but the longer that Tory Members are in the House the more they live and learn.
Child benefit has been cut in real terms by the failure to uprate. As the Black report said in 1980, by increasing child benefit the Government could immediately make the most important contribution that any Government could make to improving the health of mothers and children. Unfortunately, it was ignored by the Minister of the time, and it has been ignored by Ministers today. Let us remember the effect of that failure. The child of an unskilled labourer is still more than eight times as likely to die before reaching adulthood as is the child of a professional person such as myself. That is what we mean when we talk about preventive medicine, and that is what the Government cannot escape.
No member of my profession, the dental profession or any other profession would say that the charges will not have a deterrent effect—none, at least, whose views are worth listening to. I have heard both from their associations and from them in person, and I have had scores of letters from my constituents and others. Not even the Department's chief medical officer supports the 879 Secretary of State's contention, and I am certain that in his heart of hearts the right hon. and learned Gentleman does not support it either.
This is not just a matter of dental hygiene or of retaining our teeth. There is no doubt that the development of serious conditions, particularly oral cancer, can be prevented through early diagnosis. Oral cancer, for those who have not seen anyone suffering from it, is one of the most hideous ways of dying imaginable. It was described to me as such by a consultant over 20 years ago when I had my first lecture in ear, nose and throat medicine. I saw the patients in his ward, and I have seen the effects of the disease, which still kills the vast majority of those who get it—largely through the lack of adequate measures to arrest it before too late. This measure will enhance the risks.
The Secretary of State says that 38 per cent. of people will he exempt from charges. Many of those are people who will not take up family credit—the 70 per cent. who are missing out on benefit and who will likewise miss out on their exemption from charges, either because they are ignorant of it or, as in the vast majority of cases, because they are too proud to pay for the health that they ought to have as of right.
I, for one, have no objection to paying more in taxes to ensure that these services remain free for everyone regardless of their means, and I trust that enough Conservative Members will support us in the Division to defeat the Government.
§ Mr. Michael Morris (Northampton, South)
The logic of the argument of the hon. Member for Kirkcaldy (Dr. Moonie) is that we should have no prescription charges—[Interruption.]—but of course a Labour Government introduced prescription charges in 1949. We all know that we need prescription charges to provide some revenue for the Health Service and to ensure that medicines are valued as medicines and not treated in a frivolous manner.
We owe thanks to my right hon. and learned Friend the Secretary of State for Health and his team today. They have brought before the House the largest ever increase for the National Health Service. With that £2,000 million we can begin to make progress. My right hon. and learned Friend is right to ask whether an extra £49 million matters in a sum as large as £2,000 million. I suggest that it does matter. By any yardstick £49 million is a lot of money. There are about 200 district health authorities in the country, and that £49 million represents about £250,000 for my district.
If we consider dentistry in Northampton, that £250,000 which, roughly speaking, represents the revenue from the charges paid by the 50 per cent. of people who go to the dentist, would more than fund the orthodontic unit for which we have been waiting. If there were a poll in Northampton on whether people should spend £3.15 on a dental check-up and that money should be used to set up an orthodontic surgery unit in the Northampton general hospital, I am prepared to wager that the majority of people in my constituency would want the money to be invested in oral surgery.
It is helpful of the British Dental Association to arm us all with figures. Those figures clearly show that since the charges for courses of treatment have risen dramatically, there has been an increase in uptake among the elderly. In 1968, 27 per cent. of people were having courses of 880 treatment. The latest figures from the British Dental Association show that the uptake has risen to 45 per cent. Despite increased costs, the elderly use the service.
My hon. Friend the Member for Ealing, Acton (Sir G. Young) was quite right. Those who turn up at the dentist expect to pay for a course of treatment. They know that a course of treatment will cost more than £2 or £3. It will be a significant sum. The real challenge is not the £3 charge, but how to get the other 50 per cent. of the nation to have any sort of check-up. I hope that my right hon. and learned Friend will pick up the point raised by my hon. Friend.
I am quite sure that my right hon. and learned Friend is absolutely right to apply the charge. I want the money to be reinvested in an orthodontic unit in Northampton general hospital.
§ Mrs. Rosie Barnes (Greenwich)
According to the Chancellor, the economy is thriving. Today, he has announced increased funding in a number of key areas.
The health and well-being of our citizens must be a priority for any Government. It makes sense economically, politically and morally. If the Government are committed to primary health care and preventive medicine, why are they taking the illogical and counter-productive step of introducing charges for basic examinations which have always been free in the past? The poorer members of society—those just above the level of eligibility For exemption—will not come forward and they will certainly suffer. Charges will be a disincentive and will reduce take-up.
A real commitment to preventive medicine and primary care would mean more rather than less free screening. We are eroding the principle of the National Health Service free at the point of use. We should be prepared to pay for the National Health Service, but we should pay for it through taxation. Those of us who are better off are prepared to pay more at that stage to maintain the principle of the National Health Service being free at the point of use.
Why have the Government singled out specific tests on eyes and teeth? Are opticians and dentists considered to be the fat cats of the medical profession? Is it thought that they can absorb such costs? It will not happen. The Royal National Institute for the Blind has carried out a survey which shows that it will cost £10 for eye tests and £3.15 for dental tests. Are we to assume that eyes and teeth are optional extras—a cosmetic area that does not involve life and death as much as other areas do? What about hearing tests, cervical smears, breast screening, routine tests in pregnancy, and blood tests? Will those all suffer the same fate? What is the principle that sets those two tests apart from the rest? I do not understand it.
It seems to be a miserly act. We are talking about 40 per cent. exemption, but we are contemplating a huge bureaucracy and administrative cost to ascertain who should pay charges and who should not. It seems very silly that, if the money is available to invest further in the Health Service, we should start charging for vital tests. Where will it end?
The principle of the National Health Service being free at the point of use is vital arid must be defended tonight. Yes, we must pay, but we should pay through taxation and not when we need medical care.
§ Sir Gerard Vaughan (Reading, East)
I very much regret having to disagree with my right hon. and learned Friend's 881 arguments in this matter, especially on a day when he has raised such very large sums for the National Health Service, which we all know are much needed. We know that from our waiting lists and ward closures. I congratulate him on that. He put forward a very persuasive argument. That is not surprising when one considers that he is a distinguished barrister. His argument was entirely about money. He did not really refer to the other important issues.
If eye and dental tests were simply tests for spectacles or for holes in teeth, I would agree with him. I see no reason why people who can afford to pay should not contribute to the cost of the National Health Service through a charge. But, as we all know, there is another side to the argument which was touched on by the hon. Member for Greenwich (Mrs. Barnes)—the case for preventive medicine.
I have to tell my right hon. and learned Friend that times have changed, and people are looking for more and more health screening and preventive care. They have got the message that the Government have been putting forward that people should have their health checked regularly. My right hon. and learned Friend is promoting that message and I wish him success. The more people go for health checks the sooner disease can be detected. So we come to the curious situation in which breast screening, cervical screening, blood pressure checks, blood cholesterol tests, diabetes tests and a whole range of other things are all free. When it comes to having one's eyes examined, which is not the same as being measured for spectacles, and having one's mouth examined, which is not necessarily the same as looking for holes in teeth, people will be charged. Such examinations are valuable for the early detection of disease. My right hon. and learned Friend never referred to that—that is why I disagree with him so strongly.
If we are to maintain a National Health Service which is free at the point of need, we should include screening for health care. Others have spoken about oral cancer, but there are more than 200 illnesses or conditions which can be diagnosed by examining the mouth. Even more important conditions can be detected by examining somebody's eyes. We use our eyes to look out on the world, but they also provide a means of looking into the body. Although often referred to in another way, I am basically a neurologist and I have detected early brain tumours where there is papilloedema or pressure on the back of the eye, and early diabetes. A colleague in the House told me recently that his wife had been diagnosed as having a high cholesterol level when she went to have her spectacles checked.
We are opening up preventive medicine, so even if my right hon. and learned Friend wins the Division tonight, can he not come up to date and provide a comprehensive health screening service which can detect disease early on? It would save money in the long run, not cost extra. My right hon. and learned Friend looks as though he disagrees, but he is a barrister. I am a doctor. I resent being told that eye examinations and mouth examinations—I am not calling them dental checks—are not important in health care for our community. I hope that my right hon. 882 and learned Friend will have the courage to say, "I have made a mistake and I shall let the Lords amendment stand."
§ Dame Jill Knight (Birmingham, Edgbaston)
Can I ask my hon. Friend about some information that I received recently? I was told that dentists frequently discover oral cancer and are able to deal with it and that they know that it is more common than cervical cancer. If there is to be a charge for checking whether there is a cancer in the mouth, is there to be no charge for checking the presence of a cancer in another part of the body?
§ Sir Gerard Vaughan
My hon. Friend has drawn attention to one of the anomalies and inconsistencies in the Government's stance. It is absolutely ludicrous to charge for inspections at one end of the body but not at the other. It is ludicrous, for example, to have free urine tests for diabetes but to charge for eye examinations which may discover diabetes.
I am aware that many others wish to speak and I think that I have made my point. This is an illogical and out-of-date proposal and I hope that the Government will think again.
§ Mr. David Hinchliffe (Wakefield)
I have followed the Bill throughout and served on the Standing Committee, but I am amazed that the Government have offered no defence for what they are pushing through. I am all the more amazed in view of the Chancellor's statement today, as he more or less claimed that the Exchequer has never had it so good. Nevertheless, he desperately needs what the Secretary of State called peanuts, which would be made available as a result of the proposed charges. The Prime Minister's statement today also astonished me. She said that people will be put out if they are not allowed to pay for check-ups.
The hon. Member for Northampton, South (Mr. Morris) said that people are upset because they cannot pay for their bypass operations, tonsilectomies, or hip replacements. I have not had sacks full of mail on that issue, but I have had a vast quantity of mail from people who deeply resent the Government's policies on this issue. The Prime Minister scraped the very bottom of her barrel when she spoke of people being offended by not being able to pay. That comment was greeted with derision, even on her own Back Benches.
I commend Conservative Members who are standing out against the Government on this issue. Their sincerity is not in doubt. It is important to highlight the fact that there is a significant difference between the stance of Tory rebels and that of the Labour Opposition. The Tory rebels see the Government's stance in terms of the damage that will be done to preventive health care just to generate relatively small revenue for the NHS. I listened in Committee to the hon. Member for Harlow (Mr. Hayes), who spoke fluently and sincerely. I do not doubt the correctness of the stance that he took in Committee. The Tory rebels are right—the Government have failed to provide a scrap of evidence which has medical backing in support of what they are doing.
The Opposition agree with the Tory rebels, but we also see the change as part of a wider process of moving from state provision of a National Health Service to a system based on the purchase and sale of health care. That is crucial to an understanding of why the Government are refusing to bow to the reasonable arguments being 883 advanced by Conservative Members. The issue must be seen in the context of much wider developments in the NHS.
The Government have encouraged the belief that we cannot afford a National Health Service. We are frequently told that there are too many old people, that people are living longer, that the NHS is a bottomless pit and that expectations are too high. Health Ministers have also tried to create an expectation of paying for health care. How else are we to explain prescription charges shooting through the roof in spite of the Government's arguments as presented in the Tory manifestos of 1979 and since? I am deeply offended when I see people in my surgeries who take it for granted that they have to bribe consultants to gain access to the basic health care to which they are entitled and for which they have paid for many years.
These proposals can be understood only in terms of the Government's ideological hatred of the central principles that underpin the NHS. They regard the NHS as the last bastion of collective provision which must be dismantled by the thrust of Thatcherism. They regard it as a barrier to total freedom from the state, and as a barrier to American-style health care as a business and an enterprise.
I believe that charges for dental and eyesight checks are a calculated step towards the establishment of a health care market. The Bill is yet another nail in the NHS's coffin. That being so, I strongly urge those who believe in the NHS to support the Lords amendment.
§ Mr. John Greenway (Ryedale)
There has been perhaps more emotion in the debates on this issue than on any other issue so far in this Parliament. The Government's case is more credible than has been portrayed in the media and in previous debates. It has been strongly argued that examination charges will seriously deter people from regular attendance, to the detriment of patients, and that those who are deterred will suffer adverse consequences. I am not convinced that that will happen. Such evidence as exists is inclined to support the opposite point of view.
As the House will recall from earlier debates, for more than 15 years—
§ Mr. Dennis Canavan (Falkirk, West)
On a point of order, Madam Deputy Speaker. That man is reading every word of his speech, which has obviously been written by some party or Government hack.
§ Mr. Canavan
Further to the point of order, Madam Deputy Speaker. There is a rule of the House that one is not permitted to read a speech. That man is reading a speech.
§ Madam Deputy Speaker
I am sure that the hon. Member for Ryedale (Mr. Greenway) is referring to his notes copiously.
§ Mr. Greenway
Thank you, Madam Deputy Speaker. Had the hon. Member for Falkirk, West (Mr. Canavan) waited a moment longer, he would have heard me say that, for the past 15 or 16 years, I have run a business advising general dental practitioners on the management of their practices, so, without any question, all the words that 884 shall say will be words that I have written, including those in the many speeches that I have made to dental meetings throughout the country for the past 15 or 16 years.
I have observed many changes in the general dental service. There has been a dramatic improvement in dental health. Let us get one thing clear: the dedication and application of general dental practitioners have been major contributory factors in the improvement in the nation's dental health. Other factors are also evident. There has been a general increased awareness by the public of the need for self-care and oral hygiene. The use of fluoride, largely in toothpaste but also in water supplies, and more sensible diet, with a lower sugar intake, has reduced tooth decay. Despite that, 50 per cent. or more of the public do not regularly visit a dentist. In the latest issue of the British Dental Journal, one of the new regional advisers in general dental practice wrote:
Let's call It 'Dental Consultation."'He said:
dentists should be asking themselves why around 26 million people in the UK do not share the profession's perception of need for regular dental care.Can it be that people do not attend a dentist more frequently because of the low priority they give dental treatment and regular dental attendance? Cost is cited by opponents of the new charge as a major deterrent. "People cannot afford it," they say. I do not accept that. We have already heard an announcement by my right hon. and learned Friend the Secretary of State about exemptions, so those who are poor and at the bottom end of the income scale will get help and will not have to pay. As my right hon. and learned Friend said, that number was increased only last week.
Those who argue costs as a deterrent really mean that there are many who would rather spend their money on something else. That is true, especially of the young. My right hon. and learned Friend will recall that I wrote to him about four weeks ago and suggested that, if there is to be any change in the Government's thinking, perhaps we should reconsider the position of young adults. It is clear already from this debate that some hon. Members are persuaded by that view. Whatever we decide tonight, that is a matter to which we may have to return.
Anyone who travels regularly on trains will see 19, 20, 21 and 22-year-olds consume at least £3.15 worth of beer apiece between King's Cross and York and, I dare say, other destinations as well.
§ Mr. Greenway
It is mostly in second class.
The opponents of these modest charges seem to have concluded that the priorities of some, if not all, patients are so irresponsible that they will present themselves for dental examination only if it is free. Are we really saying that the public's appreciation of the need and value of a regular dental consultation is so pathetically low that we must not require a modest charge from those who can afford it? What an inverted sense of proportion among people—mostly on the Opposition Benches, but also, sad to say, some Conservative Members—who say one minute that a regular dental check is a potentially life-saving necessity, yet in the next breath say that it can be done only if we provide it free of charge. Nothing is more certain to undermine the real value of a service or benefit than free universal provision.
885 7.45 pm
It is an incontrovertible fact that, over the past 15 years, dental charges, which were started by the Labour party, have improved the efficiency and standard of the general dental service. Patients have more consumer awareness. The same is true of optical care. Extending charges to include dental examinations will present a major challenge to the profession and the Government to ensure that the public give dentistry the priority that it deserves.
Priority is what the debate should be about—increasing priority and awareness of the need for regular dental attendance, especially among the 26 million people who do not now attend. The majority would get free treatment as well as a free dental examination. It will be a shocking indictment of every one of us who is concerned with this matter—not just the patients but the profession, family practitioner committees, the Department, the Government Front Bench and us politicians—if these modest charges prove a barrier to dental attendance.
The White Paper promised that the Government would support a campaign for the promotion of general dental health. Let us get on with it soon. Although I do not accept the argument that charges should be a deterrent, that is not to say that helping patients to avoid high charges and to meet their obligations does not have merit. The first way to avoid high charges is to attend a dentist regularly. The examination charge, which we are debating, is part of an overall strategy of proportional charges under which regular attenders will pay no more than under the old system. That is a fact.
Dental insurance has a role to play. I am talking not about private dental insurance but about the member companies of the British Health Care Association, which provides schemes so that their members can insure, at a modest amount, to receive cash benefits when they have to pay a charge for dentistry or for optical work or if they are in hospital. Last year, British Health Care Association members paid about £7.5 million in cash benefits to members for dental treatment. That is only 2.5 per cent. of the amount raised from patient charges. Clearly, there is plenty of scope. Most members of these schemes are encouraged to join them by their employers. Employers can play a role in ensuring that they take a lead and that their employees have the benefit of such schemes.
The issue goes much further than the examination charge. I should like to refer to three other matters. First, there is the overwhelming need for a restructuring of the general dental service and the way in which dental practitioners are remunerated. As with so many other facets of our NHS, the present system was established 40 years ago. Then the profession had little time to do more than repair the effects of neglect. Indeed, GDPs did so well financially that fees were cut. Even 10 years ago, dentists were keen to absorb every new technique to improve output and meet demand. All that has largely changed. Now practitioners increasingly find that their regular patients require little, if any, dental treatment. One of my hon. Friends said some 8 million of the 37 million courses of treatment are examine and report only.
Since the debate about charges began a year ago, the fee paid to a dentist for an examination has increased from £3.90 to £4.20, the £3.15 that patients will be asked to pay being 75 per cent. of that. If the practitioner is required to 886 screen for so many different illnesses, why is he so appallingly badly remunerated for doing so? It is because the present structure assumes that he will find that a great deal of treatment is required, but increasingly that is not the case. We must embark on urgent negotiations about that matter. I am disappointed that a year has passed since I made that request in the House and we seem to have got no further because we have been distracted by the argument about free examinations. We must have a continuing fair contract to reward the proper relationship between general dental practitioners and their patients and to reward good conservative treatment which lasts. Let us get on with that.
Secondly, there is the question of resources. If the charges were not accompanied by a major commitment of extra resources such as that my right hon. Friend the Chancellor announced today, there might be grounds for opposing the charges. Some dentists have suggested that the Government are abandoning the general dental service, but that is not true. Some hon. Members may be surprised to learn that in the past three years the net pay of general dental practitioners has been increased by almost a quarter and the fees paid on their item of service scale by one third—three times the rate of general inflation.
The Government's commitment does not end there. This year's fee scale already incorporates some of the measures outlined in the White Paper. My hon. Friend the Member for Portsmouth, North (Mr. Griffiths) asked about this earlier. I can tell him that there are already pilot schemes to redistribute dentists more evenly throughout the country. There is one scheme in Walsall and three in the north-east. There are also changes in the prior approval rules to give practitioners more control over their clinical judgments and the treatment that they give. That, too, is incorporated in this year's fee scale. There is also more funding for postgraduate vocational training. The findings of the Windermere relativities inquiry have been incorporated straightaway. Some Opposition Members may not know what that means. Members of the profession decided how money should be redistributed across the fee scale to reflect the type of work being done in the National Health Service today, not that of 40 years ago.
I am sure that everyone in the House and throughout the country wants the Government to put more money into the Health Service to fund nurses' pay. That has been given proper priority. We now need to consider where the extra resources are going. Some district health authorities have achieved great efficiency in their operations, but they need more money. I want more money for Scarborough and for York. If voting for examination charges will help to achieve that, so much the better.
Thirdly, we should extend consumer choice to other parts of the NHS, perhaps to other areas of general practice as well as to the hospital service. Contrasting levels of efficiency between one district and another can no longer be tolerated in a society in which, despite record funding, resources must continually struggle to keep pace with technological change. If we want more resources, we must be willing to take unpopular decisions to achieve them without damaging the economy. It is understandable that Labour Members have the audacity to bite the hand that feeds them, but I urge Conservative colleagues in this House and in the other place not to interpret an unpopular decision as a wrong decision. With demands on the Health 887 Service often seemingly infinite, it is essential that resources are put to the best use and reasonable opportunities for raising revenue are maximised. That is the moral case in favour of charges. It is not a popular message, but it is a right and responsible one.
§ Rev. Martin Smyth (Belfast, South)
The Secretary of State made the point that this was a national health debate, and I was happy that he referred to Northern Ireland as well as to England, Scotland and Wales, because this national debate affects us all.
Much has been made of today's cash injection of £1.8 billion into the Health Service. The Select Committee said that £2 billion would be needed and was accused by the Department of plucking figures out of the air, so I welcome the fact that our assessment has been accepted. That assessment, however, was made earlier in the Session and did not cover further increases in wage settlements.
Coming to the nub of the debate, it was fascinating to hear the Minister suggest today that some of his Back-Bench colleagues had changed their minds since the House first voted on this. My profession is always happy when people change their minds, when they repent, come to their senses and go along the right road. I regret, however, that it seems that the Minister has backslidden as in an earlier incarnation he supported a free Health Service at the point of delivery and made much of that principle. I hope that those who realised that they were wrong a few months back will stick to their guns today and see us through this time. The comments of the hon. Member for Northampton, South (Mr. Morris) in relation to the point made by the hon. Member for Kirkcaldy (Dr. Moonie) were not in support of charges for consultation but defended the concept that there might be a ground for paying for services. In my judgment, that would cover prescriptions rather than charges for seeing the doctor before being told what one requires. We must stick together on that and ensure that the National Health Service is maintained on that basis.
To refer specifically to Northern Ireland, it has been argued that the charges will not deter anyone from consulting a dentist, optician, optometrist or ophthalmic surgeon, but I query that. If the Government are already spending money on PR campaigns to encourage people to take up social service benefits, I suspect that it will take a great deal more PR work to encourage people to go to the dentist or the optician with the argument that the charge is only a minimum amount.
A short time ago a colleague asked me why the charge was to be £3.15. He said, "Isn't that three guineas?" The secret has slipped out. Guineas are still used regularly for legal fees. Those who suggest that three guineas is not much should bear in mind that, although it may not be much for those in the legal profession, it means a lot to the people about whom we are concerned. It may be that the Government have discovered this as a way of cutting down waiting lists. With the rationalisation of health care delivery in Northern Ireland, ophthalmic work has been centralised, particularly in the Royal Victoria hospital, Belfast, with a unit at Altnagelvin to cover the north-west. That was an attempt to provide modern health care in a rational and financially disciplined way. In fact, the waiting lists are increasing because, instead of finances being directed to help that service, they are being curbed time and again.
888 8 pm
When considering this issue tonight we must deal with the question of the care of patients and the deliverance of that care. I share the experience of other hon. Members—and I cannot imagine that the Government have missed it—that modern care of patients can be enhanced by eye tests and dental checks. Therefore, although others may have changed their minds, my hon. Friends and I are even more confirmed in our opposition to the Government's proposals, which we shall oppose in the Lobby tonight.
§ Mr. John Maples (Lewisham, West)
It must be especially galling for the Labour party to have this much-trailed debate on the very day on which my right hon. Friend the Chancellor of the Exchequer has announced additional funding for the NHS of £2 billion. At the time of the Budget, Opposition Members were saying that the 2p tax cut would have been far better spent on the Health Service. They now find that my right hon. Friend has succeeded in doing both, contrary to all their predictions. That must stick somewhat. I cannot help but think that, even if a Labour Secretary of State had had the option of another £40 million to spend, he would choose to spend it on removing the proposed charges. That £40 million, together with the £100 million for eye tests, can be used for so many other things. I cannot believe that even the hon. Member for Livingston (Mr. Cook) would choose to spend that money on removing charges for tests.
The argument against charges for the tests is the argument against all charges in the NHS, which after the implementation of the new charges will raise about £800 million or £900 million a year. If the Opposition were to follow the purity of their argument, the first additional £1 billion that they chose to spend on the Health Service would not buy one additional operation. I simply cannot believe that that is what they want.
The only really important consideration is whether the charges will act as a material deterrent to people having eye or dental checks. Whenever charges are introduced or increased, the Opposition claim that people's attendance will go down. That was said when dental charges were raised and, again, very vociferously when charges were introduced for glasses. The Opposition said that people would not have glasses and would crash into each other on motorways or walk into lamp posts. That has not happened. Instead, the number of eye tests and the number of prescriptions for lenses has risen but. as the Government predicted, the charges for glasses have gone down.
Figures for dentistry have been bandied about tonight. Charges have been increased every year since 1976, yet the number of courses of dental treatment has also risen every year since 1976. It is unlikely that the charges will prove a deterrent. After all, the low income groups and all children are exempt, so we are really discussing only the 60 per cent. of the population who form the wealthier groups. For them, £3 for a dental check and £10 for an eye test once a year is not a material sum that will deter them. I cannot believe that the reason why some people will not have checks is that they will have to pay. Although the tests are currently free, they know that if anything is wrong they will have to pay for treatment. That does not put them off. People sometimes do not go to the dentist until there is obviously something wrong or they do not go to an optician until they think that they need glasses. A £3 or a £10 charge will not act as a deterrent.
889 The weakness of the deterrent argument is given away in a lobbying circular that we have all received from the Federation of Ophthalmic and Dispensing Opticians. It states thatpeople will find the need to pay for a sight test a psychological, even if not a serious financial deterrent.It demonstrates the weakness of the financial argument when the federation is thrown back on arguing a psychological deterrent.
The Opposition are, in effect, saying that the 60 per cent. in the wealthier groups are not sufficiently responsible to decide whether to go to the dentist or to have an eye test because they will have to pay £3 or £10. If that is the Opposition's opinion of the level of people's responsibility for their own affairs, it is amazing that they allow them to do anything on their own.
I believe that many sight tests will, in fact, still be free. When I drive to my constituency I go along the Walworth road and past the headquarters of the Labour party. Right on the border of the constituency of the hon. Member for Peckham (Ms. Harman) is a large shop, which was not there a few years ago. Perhaps when the hon. Member for Livingston is bored at an NEC meeting the hon. Lady could take him there as it is only 200 or 300 yards from the Labour party headquarters. The shop takes up two huge shop fronts and is called Betterspecs. It has a big sign in the window saying, "Free eye tests". I suspect that that will happen throughout much of the country.
If I am wrong about the deterrent argument, what will be the consequences? On the whole, they will not be that serious. If people are walking around wearing the wrong glasses, or if they do not have a tooth filled until it begins to ache, those are not really serious consequences. They are certainly not life threatening. One or two examples of possible serious consequences have been mentioned, such as glaucoma and oral cancer. We must remember that, when people have free eye or dental checks, it is not because they want to find out whether they have glaucoma or oral cancer. Those are accidental, random discoveries in the process of doing something else. A dental check is not a screening process for oral cancer; it is simply one of the by-products. I understand that the average dentist comes across only two cases of oral cancer during the whole of his career. If we want a screening process for oral cancer, that must be the most expensive and inefficient way of providing it.
§ Mr. Michael Carttiss (Great Yarmouth)
Does not my hon. Friend think that if two people discover that they have oral cancer that can be cured and that will save them a lifetime of disfigurement that is well worth the free checks? How can my hon. Friend calculate that in money terms?
§ Mr. Maples
Of course I understand that that is an awful disease, as is glaucoma. However, it is about time that my hon. Friend began to cost various elements of the NHS budget, because a cost can be put on all these matters. I repeat that if the only reason for a free dental check is to detect so few cases of oral cancer, it must be the most inefficient and expensive way of doing it that we could ever devise. I do not believe that charges would be a deterrent or that there would be dire consequencies. If, in the event, I am wrong and there is a huge increase in undetected glaucoma cases, that would be an argument for 890 heavily promoting the need for people to have their eyes tested occasionally to ensure that they are not contracting that disease.
Ever since tax-cutting Budgets were introduced, the Opposition have said that the public would prefer the money to be spent on the NHS. They say that the public are willing to spend enormous amounts on the NHS rather than have tax cuts. For a man on average earnings, the 2p tax cut in the last Budget is worth about £170 a year—£3.40 a week. Are we to believe that that same person is not prepared to spend £3 and £10 on dental and eye tests? Is a person willing to forgo all his income tax cuts so that the money can be spent on the NHS not to be trusted voluntarily, of his own free will, to spend £3 or £10 on dental and eye checks? That is an extremely patronising attitude. The inescapable conclusion that we must reach is that the Opposition think that the only good provision in society is that provided by the state and that no one can be trusted to do anything on his own.
The arguments of opponents of the proposal go to the root of the whole idea of charging in the National Health Service. If it is wrong to charge for dental checks and eye tests, it must be wrong to charge for other things. Charges, which come only from the wealthier 60 per cent. of the population, raise about £800 million a year. It cannot be sensible to spend an additional £800 million to absorb those charges back into the public purse when that money could be spent on buying so many other things for the Health Service.
When one considers that 60 per cent. of the population, it is worth remembering what has happened to their finances over the past 10 years. We know that the take-home pay of men on average earnings has risen by 29 per cent. a year over the past 10 years. The pay of those on half average earnings has risen by 22 per cent. and the pay of those on three quarters of average earnings has risen by 26 per cent. Those are substantial sums. Over the past 10 years, the take-home pay of a man on average earnings has increased by £2,400. For someone on three quarters of average earnings—about the level at which family credit runs out and at which the person becomes liable for charges—income has increased by £1,800 a year. The income of a person on half average earnings—about £120 a week—has increased by £1,100 a year.
The idea that people with those increased personal resources and increased individual wealth are not prepared to take some responsibility for paying minor charges towards health care is incredible in every sense of the word. If the increases continue, over the next 10 years, a person on average earnings will have an income of £5,000 or £6,000 more. It is surely a sensible proposition that out of that amount some marginal contribution should be made towards the cost of individual health care.
That is also the case for pensioners. Pensioners' incomes did not rise very much under the previous Labour Government. Since the Conservative Government came to power, pensions have risen quite a lot. The average pension has risen from about £100 a week in 1980 to about £135 a week in 1990—an increase of about 35 per cent. In view of that increase, it is reasonable to suggest that pensioners should make some contribution to their own health care and that they are able and willing to do so.
§ Mr. Frank Haynes (Ashfield)
I wonder why the hon. Member, like many of his hon. Friends, referred to average earnings. I come from the mining industry and the phrase 891 "average earnings" there told a false story, which the hon. Gentleman is doing tonight—with respect. Half the men at the pit were in the top income bracket, but the other half —the lower-paid workers—received 50 per cent. less than that. What about the lower-paid workers? They are the people for whom we are fighting, and the hon. Gentleman should be fighting for them as well.
§ Mr. Maples
People on family credit, which is about three quarters of average earnings, will not have to pay for tests. No children will have to pay for tests. A person on three quarters of average earnings is £1,800 a year better off in terms of take-home pay than 10 years ago. People on lower incomes than that will probably be on family credit and will receive the benefit of free tests, as my right hon. Friend the Secretary of State has proposed. It is simply not true to say that I take no account of the lower paid. I did not need to bring them into the argument because they will be exempted from paying for dental or eye tests. It is only those who earn more than three quarters of average earnings who will be affected.
Most people are far richer than they were 10 years ago and are able and willing to pay modest charges towards items of health care. Charges will not be a deterrent to people seeking services. There must be better ways of spending £140 million than this one.
§ Mr. Keith Vaz (Leicester, East)
Yesterday afternoon, I led a delegation of pensioners from my constituency to meet the Prime Minister at No. 10 Downing street. We took her a giant pair of spectacles which measured 2ft 6in across, and a giant tooth. The more uncharitable among us might suggest that they were the right size for the Prime Minister in view of the size of her head and mouth. Of course, I am not that uncharitable. The reason why we took the spectacles and the tooth there was to show the Prime Minister the great concern felt by people in Leicester and, particularly, by pensioners about the proposed charges.
I was accompanied on the visit by Les George, aged 66, from Maplin road, Nethershall in Leicester. He remembers that when he was a young boy, the Labour Government introduced the National Health Service and that the National Health Service was free at the point of need. Irene Howell, aged 65, also accompanied us and, as we walked up to No. 10, she reminded us that had she not had a test, she might have lost the sight of one eye. Also with us was Mary Draycott, a young mother with two children, who has been campaigning hard for the decentralisation of health and dental services in the outer estates of Leicester. The delegation represented many pensioners in places such as Nethershall, Northfields, Evington, Thurnby Lodge and Belgrave, who are deeply concerned about the proposed charges.
Before I came into the Chamber this evening, I spoke to a constituent who came down from Leicester in a coach to present me with a letter, which I should like to read to the House. She writes:I urge you to oppose and do all you can to oppose the proposals for the introduction of sight and dental charges. They will not improve the nation's eyesight or hearing. You may be able to eat with false teeth, walk with false legs but you cannot see with a false eye. Mrs. Thatcher is a wolf in sheep's clothing crying crocodile tears.892 That letter came from a constituent who had never written to a Member of Parliament before, but who felt so outraged that she came all the way down from Leicester.
The charges are mean and vindictive. They are imposed by those who can afford to pay them.
§ Mr. Vaz
That is quite right. I have had three pay rises in the year and a half in which I have been a Member of Parliament, for which I did not have to bargain.
Many of my constituents and the constituents of my hon. and learned Friend the Member for Leicester, West (Mr. Janner) are unable to afford the charges. The experts in Leicester are united. The secretary of the family practitioner committee said:
During my career, three people have been operated on the day after I examined them and detected a blood clot or tumour.General health will deteriorate because the chance to operate early will vanish and it could be too late by the time the patient notices the signs, then the treatment could be more complicated, dangerous and expensive.More people will go blind as a result of less early detection which will cost more in the long run to care for them.If the Minister tells me this evening that voting for health charges will mean that money can be invested in the health service in Leicester, let him come up with a number of assurances. The first assurance I seek is that the eight hospitals in Leicestershire that are about to be closed will not close. They include Ashby and district hospital, Catmose Vale hospital, Fielding Johnson hospital, Higham Grange, Roundhill maternity home, Regent hospital, Loughborough and Blaby hospital in the constituency of the Chancellor of the Exchequer. If the Minister assures me and my hon. Friends that people in Leicestershire, like Mrs. Broughton who is 87 years old, will not have to wait two years to have hearing aids made for them, that the current hospital waiting list of 8,500 will be cleared, that 200 people who are waiting for operations on the orthopaedic waiting list will be cleared off the list and that the Towers hospital which is under threat of closure will not close, we shall be tempted to listen to his arguments. It will take 60 days of full surgery lists to clear the cases that I have mentioned.
The Government say that they want a first-class service. We want a first-class Health Service. We do not want the jumble sale Health Service that we have at the moment, which means that hon. Members are invited to hospital fetes and charitable events to raise money for worthy causes such as the purchase of a kidney unit at Leicester general hospital.
Three weeks ago a number of my colleagues and I visited America. We visited an emergency room in a hospital. There, I witnessed a patient who had come in in great pain being asked, as the very first question, by the administrator: "Do you have insurance?" When he said that he did not, the patient, who was in great agony, was referred to the nearest public hospital, at which he no doubt had to wait because the public health service in America has been undermined to such a great extent. That is the kind of Health Service that the Government want, and the next Bill that comes before the House will provide for people to be charged when they visit their general practitioner. It already costs people in America £25 to see their GP.
893 I commend the hon. Member for Rutland and Melton (Mr. Latham)—another Leicestershire Member, and one with whom I do not agree on any other issue—on the stand that he has taken. This morning he declared on Radio Leicester that he would be voting against the charges. I urge all other Conservative Members to join the hon. Gentleman in taking that principled stand and to vote against the charges.
§ Mr. Churchill
I wholeheartedly repudiate the offensive remarks made by the hon. Member for Leicester, East (Mr. Vaz) about my right hon. Friend the Prime Minister. Such remarks do nothing to further the cause that he claims to support.
I warmly welcome the Chancellor's announcement that the Treasury coffers are awash with money and especially the news that an extra £2,000 million is to be made available for the Health Service in the coming year and a further £2,500 million in the year 1990–91. It is excellent news, and I applaud it.
I therefore find all the more regrettable and unnecessary the Government's determination to reverse the Lords amendment and for the first time to impose charges for eye and dental checks. I speak as one who is not known as a notorious wet.
The Government proclaim that they are in favour of preventive medicine. I welcome that commitment. Preventive medicine is not only right but it is the most cost-effective form of health care. Much more expensive treatments and hospitalisation further down the line may be required if preventive medicine does not exist or is inadequate.
There can be no doubt that over the years free eye and dental checks have made a significant contribution to preventive medicine. I firmly believe that to impose charges is as retrograde as it is unnecessary.
§ Mr. Churchill
I am obliged to the hon. Gentleman.
My right hon. and learned Friend the Secretary of State makes the perfectly fair point that I—and others as fortunate as I am—should not have free eye and dental checks. There is no earthly reason why I should. However, as I have told my right hon. and learned Friend the Secretary of State, neither I nor, I suspect, many others in my fortunate position have ever availed themselves of free eye and dental checks. It is a wholly bogus argument to say that, because the likes of Lord Hanson and Sir Ralph Halpern must be disbarred from going for free eye or dental checks, other people on earnings way below the average should be deprived of free tests.
I regret to have to say to my right hon. and learned Friend the Secretary of State—I am sorry that he cannot be in his place—that his belief that charges will not act as a deterrent is wholly unconvincing. If he is so sure that that is so, why in logic are not the Government moving to impose charges for breast cancer checks and cervical smears? There is no difference in logic between the two forms of screening.
I shall tell my right hon. and learned Friend why he is not moving in that direction. In his heart of hearts he knows that such charges would have a profoundly deterrent effect on those who need to be encouraged to go for regular checks. Regrettably, the present measure has 894 nothing to do with encouraging preventive medicine and everything to do with pressure from the Treasury. I acknowledge that the list of exemptions is sizeable; 38 per cent.—no fewer than 20 million of our fellow citizens—will be exempted. The key argument advanced by the Secretary of State in favour of imposing charges is that everybody who does not qualify for an exemption can well afford £3.15 for a dental check or £10 for an eye test in this increasingly prosperous Britain.
Is that really so? Let me cite the case of a constituent of mine who came to my advice bureau in Manchester only last weekend. He is in his late 50s. He lives alone. He is self-employed and his business has not been prospering. Last year he earned only £2,880. That works out at £57 a week net of tax, or one quarter of average earnings. After he has paid £23 a week in rent for his council house, now that his housing benefit has been reduced to only £1.23, he has no more than £25 a week of disposable income on which to live. Because he is in full-time employment, because he works more than 20 hours a week and because he is not a single parent, he does not qualify for income support. Therefore, he would be required to pay eye and dental charges under the proposal. Is it reasonable or right to expect an individual at the bottom end of the economic scale to pay such charges? He has only £3.50 a day on which to live—less than the Secretary of State is paying for his evening meal in the House. Is it reasonable to charge such a man £10 for an eye test? Of course it is not, and my right hon. and learned Friend knows that it is not.
Let me make a proposition to my hon. and learned Friend who is to wind up the debate. If he can tell me that my constituent, with less than £25 a week on which to live, will be exempt from the charges, I shall abandon my intention to vote against the Government and I shall join my hon. and learned Friend in the Lobby in support of the measure. However, I must tell him that the advice that I have received from the Secretary of State's private office, as well as from my local DHSS office, is that my constituent would not qualify, because he does not qualify for income support. On that basis, I have no hesitation whatever in saying that I shall oppose these objectionable and damaging measures not only on behalf of my constituent, but on behalf of thousands like him in constituencies throughout the country. It is no use brandishing averages, because we know how many are so high above the average, and it behoves us to pay attention also to those who are so far below the average and who are not caught by any safety net.
It gives me no pleasure whatever to vote against the Government, but I must say to my right hon. Friends that the Government are wrong in this matter, and they have lost the argument. They deserve to be defeated.
§ Mr. Roger King (Birmingham, Northfield)
After nearly three hours of debate, many arguments have been ranged for and against the amendment and many points have been made many times. Very little new can be said either for or against the amendment. However, I believe that the Lords amendment should be rejected, because the Government's proposals are constructive and will eventually filter through to an improvement in the National Health Service generally.
The crux of the issue is whether it is morally right or wrong to pay for a check-up of any kind. The distinction 895 between breast and cervical cancer tests and dental and optical check-ups is that the former are generally done at a hospital or by a general practitioner, but the optical and dental check-ups are done in semi-autonomous establishments on the fringe of the National Health Service. As we know, the optical testing side of the Health Service has been freed into a more competitive environment and that has filtered through to a more competitive product being provided. If the Lords amendment is rejected and the charges are allowed, we will see some competitiveness introduced into the market and eventually we will find that optical tests will cost very little and, perhaps, a good deal less than the £10 proposed.
Over the years the National Health Service has changed and people's perception of it has changed. When it was created in 1948, no one had any disposable income, and the National Health Service did not do a great deal more that repair broken bones and remove tonsils—[HON. MEMBERS: "Rubbish."]—in the early 1950s. Of course, it did a great deal more than that, but it was nowhere near as sophisticated as it is today, and the demands for treatment become ever higher as new expertise and techniques are developed which are ever more costly. Because of that, we must consider new ways of providing funding for the Health Service.
Our people have more disposable income and they are entitled to choose how they spend it. I do not believe that, because the majority of the population will be charged £3.15 for a dental check-up, they will not take the time or trouble to have that check-up. On the contrary, we have had well-documented evidence that as a result of some of the dental costs that have been passed on to the consumer more people are having dental treatment. Whether the connection is that, because one is paying for something, a value can be placed upon it, is open to conjecture. I believe that if a value is put on something, people are more likely to value the service that they receive.
It is encouraging that 40 per cent. of the population will not have to pay anything for their dental check-ups and 37 per cent. will not pay for optical tests. However, there are people who will be on the borderline. There will be areas that we will need to look at closely so that people are not disadvantaged in the way that my hon. Friend the Member for Davyhulme (Mr. Churchill) mentioned.
Some people feel that the NHS should be free at the point of use. Of course, NHS treatment is not free at the point of use to the extent that we might like, as some charges were introduced in 1976, and prescription charges have been with us on and off for some time. The emotive issue of treatment being free at the point of delivery is misplaced. I suppose that it could be said indirectly that if one is a BUPA subscriber, one's service is free in that one pays insurance and BUPA pays for one's treatment after it has been received. However, we do not describe BUPA as free at the point of service. The National Health Service treatment is not free, because we pay into a national insurance scheme, and we have paid heavily for it over the years.
I do not believe that it is correct for the Labour party to lecture us on treatment charges when, of course, in 1976 it was involved in implementing many charges. The hon. Member for Livingston (Mr. Cook) had the temerity to suggest that if we had a secret ballot everything would be greatly different. The Labour Government never had a secret ballot when they were in office in 1979 and decided to put up prescription rates. They never had a secret ballot 896 when they decided to cut the hospital building programme. They certainly did not have a secret ballot when they decided whether to cut pensions and so forth.
§ Mr. Robin Cook
The reason why the 1974 to 1979 Government did not hold secret ballots was that those of us who disagreed with them did not require a secret ballot in order to express our view. We had the courage to do so and did so regularly.
§ Mr. King
The evidence tonight shows that neither do we. We do not need a secret ballot to express our view. To suggest that we should have a secret ballot on this one issue when the evidence is that when Labour was last in office it was making unpalatable decisions and did not have a secret ballot is unfair.
Our Health Service will obviously become more complex as years go by. I believe that it is right to establish as a principle—as we have already done—that some contribution by the user where he can afford it is the way that it should develop. Wage rates have gone up by 9 per cent. in the last 12 months. If we add to that the tax cuts that were passed on to the population, we see that real disposable income is a great deal more because of the Government's economic policies.
I believe that what we are asking for is not unreasonable or unrealistic. The financial resources that will be released because of the extra income that will come into the Service will be of benefit to the Service generally. Because of the new money that will go a long way to improving the Service, together with what was announced in the Autumn Statement, the Government's proposal has my support.
§ Mr. Eddie Loyden (Liverpool, Garston)
First, we should establish that the National Health Service brought in by the first post-war Labour Government made a dramatic change in the health care of the nation. I believe that every intrusion that is made by the Government in introducing charges for this, that and the other erodes day by day the National Health Service that was created in the early post-war years. I know that there will be hot denials from those on the Government Front Bench if I suggest that behind those charges and the Government's geneal attitude towards the Health Service there is a blatant ideological attitude that intends in time to dismantle what we know as the Health Service of this country.
People outside will not allow the Government to take away the great benefits that have flowed from the National Health Service. Shortly after the war people were given the opportunity to have access to free health care for the first time. Many were elderly people without teeth and who needed spectacles which they did not have. The National Health Service changed the whole nature of health care in this country. The first generation of post-war babies proved the value of the Health Service beyond any doubt.
Many of the comments made tonight by Conservative Members make it absolutely clear that this is not simply a question of charging for dental or optical testing. It is part of the continuing attack on the Health Service by those Conservative Members who want to see the end of the Health Service and who want to see it in the hands of the market because of the profits that can be made. They want only those who can afford health care to have health care. That was exactly the position before the founding of the Health Service.
897 Having grown up in a working-class area of Liverpool, I can tell the House of the many children who died in those cobbled streets because there was no Health Service. The child mortality rate in Liverpool was one of the highest in the country. Many of the afflictions suffered by working-class families were due to inadequate medical care, and, in some cases, to inadequate housing. Those afflictions led to the creation of the National Health Service.
It is a scandal that, having seen the benefits of the National Health Service, the Government make continuing attacks on it both in the House and outside. That is especially true of some of the Government's Back-Bench Members. Indeed, when listening to one Conservative Member, I wondered whether he was talking about Sainsburys or about the Health Service because he referred to "a better product". Where are we going when the Government's Back Benchers seek to bring the Health Service into the market? It is an absolute disgrace that hon. Members should talk about the Health Service in that way.
I happen to be one of those 250,000 people who have benefited from an eye test—
§ Mr. Deputy Speaker (Mr. Harold Walker)
Order. Does the hon. Gentleman see the difficulty of the Chair? The debate has tended to go wider and wider in scope until it is now in danger of becoming a general debate on the Health Service. This debate is about dental charges. A later amendment deals specifically with optical charges. I understand that the hon. Gentleman wishes to speak to that. Therefore, I hope that he will not encroach too much on the subject of that amendment.
§ Mr. Loyden
With all due respect, Mr. Deputy Speaker, all aspects of testing have been spoken about tonight, including cervical cancer and oral testing.
§ Mr. Loyden
I hope to illustrate the importance of those tests which at least some Conservative Members recognise.
I happen to be one of the 250,000 people who, through an eye test, have been detected as having glaucoma. As most people know, glaucoma can—
§ Mr. Deputy Speaker
Order. I do not want to prevent the hon. Gentleman from making his speech, but I question whether this is the appropriate time.
§ Mr. Deputy Speaker
Order. Perhaps the hon. Gentleman will save his remarks about optical problems and optical tests until we reach that specific amendment.
§ Mr. Loyden
I remind you, Mr. Deputy Speaker, that every test has been mentioned tonight but no objections have been raised from either the Chair or anywhere else. It is important to illustrate the benefits of testing because that is what we are really talking about. Charges are a deterrent to testing and one of the great elements in 898 preventive medicine is under threat. That, together with the threat to the Health Service, is the most important issue facing us tonight.
All hon. Members, whether speaking in favour of or against the Government's proposals, have pointed out that the Health Service has been moving far too slowly towards preventive medicine although it is moving in that direction. The screenings that take place are a sign of a healthier nation. Therefore, one of the greatest threats to the Health Service is the further erosion of testing that charges will cause. That applies not only to eyesight testing but to dental testing. There is an abundance of evidence to prove conclusively that oral testing can disclose illnesses that could result in either chronic illness or death that would otherwise not be detected.
It is a scandal that we should be debating such proposals in the House 40 years after the Health Service was created by a Labour Government. It is a scandal that we are debating further inroads into and erosions of a service that was once the envy of the world.
All those people who have the interests of the Health Service at heart, who want to see it move towards preventive rather than curative medicine and who want to move away from a drug-oriented Health Service that props up the companies that make billions of pounds of profits from supplying the drugs, believe that tonight's attacks on the Health Service eat into the Health Service and mean that we now have a Health Service inferior to that which we had in the past.
§ Mr. Key
The amendment is not just about specific health charges; it is not just about money or about the preservation of a particular legitimate vested interest; it is about something much wider and much more fundamental. It is about the best way of improving and maintaining the dental health of the nation.
Economists would tell us that we are into the hoary old chestnut of externalities—in other words, if I as an individual start using lead-free petrol, it does not make much difference to the state of the environment, but if everyone could be persuaded to use it, it would make a great deal of difference. That sort of argument can be applied to the problem facing us tonight.
The argument is about how we can persuade people to react to certain circumstances. Whichever way each of us votes tonight on this issue, I believe that we all want improved dental care for the whole nation. The question is, how do we achieve that? Do we best achieve it by mass state provision which is free at the point of consumption or by unbridled market forces? I shall seek to demonstrate that neither is the complete answer.
The little evidence that there is, as opposed to opinion or judgment—it is striking that, however strongly one feels on either side of the argument, there are only opinions and judgments and one cannot say that the argument is either black or white—shows clearly that the present system of free check-ups has been a failure. About 50 per cent. of people fail to take up the current free service. We are told that there are a number of reasons for that: for example, people may think that they do not need to go to a dentist until they are in trouble; some people have a blind fear of the dentist and some people have difficulty in finding a dentist who is conveniently close to their work. However, the cost of the treatment was ranked bottom among people's reasons for not going to the dentist.
899 The answer to all those failures must be better education. What have the Government done about that? Well, in 1981 the Government introduced a policy document entitled "Care in Action" in which they recognised the role of education and stated:Too many endanger their health through ignorance or social pressures. Public action can give people the information they need to make sensible decisions about personal health, and encourage in the community a reasonable attitude towards the main area for prevention".When the Health Education Authority was set up, the then Secretary of State, my right hon. Friend the Member for Sutton Coldfield (Mr. Fowler), stated:
As a special health authority, the new authority will be an integral part of the National Health Service in England. As a result, it should be more responsive than an outside body can be to the needs of the Service, and in turn will have more influence in setting priorities for the Service and ensuring that the needs of health education and promotion are properly recognised.That was a most important statement of intent. It is evident that, whatever the deterrent effects of charges, there is only unexpected evidence, as opposed to opinion. In 1976, the Labour Government raised dental charges by 36 per cent. and the number of procedures carried out by dentists rose. Even the evidence presented to hon. Members by the British Dental Association appeared to contradict that case.
The hon. Member for Livingston (Mr. Cook) had some fun at my expense about this, but it is important to consider the document that we have all been sent by the BDA. I have read it carefully and looked at the tables of statistics. It is a profoundly unconvincing case. If ever there were a case of lies, damn lies and statistics, it must be in this document. It is the most selective use of statistics that I can imagine. That is fair enough because the BDA is a legitimate vested interest. I do not therefore decry the case that it seeks to make, but nothing in life is free and the goods and service which are free at the point of consumption are, in general, valued least in society, whether junk mail or tap water. If dental care is free at the point of consumption, people seem prepared to put up with broken appointments, long waits in dingy waiting rooms, out-of-date magazines and rude receptionists. In short, we are very British and do not complain about the poor service.
On the other hand, if we are allocating our own cash, we expect service and standards. That is also in the national interest. We all benefit from the better use of resources. The evidence that we want better standards is there and we are already paying for better standards. Let us consider first the increase in the number of dental hygienists in most of our dental practices. Of course, there are the usual exemptions, but we pay for the benefit of those paradentists, who are a very good thing.
Secondly, may I draw the attention of the House to the problem of AIDS and dentists. That problem will grow significantly. My dental practice—I checked up this morning—is spending well over £1,000 on disposable gloves as a direct result of the AIDS problem, £500 a year on disposable bibs instead of the usual rubber bibs and £500 a year extra on surface anaesthetics instead of needles. At present, dentists have to wait over a year for reimbursement from the state because the state is bad at allocating resources. Standards in practices would rise if dentists had an acceptable cash flow. That would be one of the effects of introducing those charges. I would happily 900 pay up if I could see the standard of service go up. Both professional services and the quality of environment of dental surgeries would improve.
For five years, as a Member of this House, and for many years before that, I argued to the electorate that the purpose of cutting taxes and reducing Government involvement is not to give us an easy life, but to encourage us to take a more responsible attitude. That is a high moral argument and the care of ourselves, our families and our children should be a first charge on our income. If I can allocate those resources, rather than the inefficient state, it is not only in my interests, but in everyone else's interests too.
I cannot support the Lords amendment. I shall vote against it tonight. I have no intention of ratting on my Conservative principles which I have put to the electorate in election after election. I do not have a monopoly of virtue, nor do I believe that anybody else has in this important debate. However, we are harangued and preached at because of the success of the economy. We are told about record levels of personal debt, conspicuous consumption, imported electronic goods and about calls for deregulation of Sunday trading, the £8 a week per household spent on alchohol, the £4 per week per household spent on tobacco, booming sales of sweets and confectionery for children, but what price optical and dental health?
§ Mr. Jeff Rooker (Birmingham, Perry Barr)
I did not intend to speak in this debate and I do not intend to detain the House long because other hon. Members wish to speak. However, I want to illustrate the difference in the speeches of the hon. Members for Lewisham, West (Mr. Maples), for Davyhulme (Mr. Churchill) and for Birmingham, Northfield (Mr. King). The hon. Member for Davyhulme put the case against the Government, but his two hon. Friends spoke in favour of the Government. They and other hon. Members who support the Government are duty bound to put the case for supporting the Government on dental tests and eye tests, and for charging for other tests. They cannot simply say, "We think this is a good idea. People ought to pay for these tests. They should not be free" and then remain silent about all the other tests, for example, cervical smear tests and breast cancer screening. They cannot remain silent about those matters and put the case for the Government.
It is all very well for the hon. Member for Northfield to say, "We freed up the market with regard to dental and eye tests, but we haven't freed up other tests yet." The implication is that, when they have freed up the means of checking for breast and cervical cancer, they will charge for those tests, although the hon. Gentleman could not quite bring himself to say that.
Every Conservative Member of Parliament who is prepared to support charging for preventive tests, leaving aside the charges for treatment and all the other red herrings that have been mentioned tonight, must follow the logic of their argument. We know what is happening. The House and the country are being softened up. When those charges have been introduced, it will be that much easier for other Ministers to say, "It's unfair for all those other tests to be taking place. Now people have to pay for dental tests and eye tests."
§ Mr. Key
The hon. Gentleman is a fair-minded debater. I could argue the case that we would not have been allowed 901 by the Chair to digress into the matters that he is raising. However, we should all be prepared to argue about the future funding of the National Health Service. One of the failures of the House and of this nation is that we have not been prepared to debate such difficult issues as the crisis facing the Health Service has become steadily worse.
§ Mr. Rooker
I am prepared to say, without stepping out of order, that I am not in favour of charging for preventive medicine. It does not matter whether it is eye tests, dental check-ups or any of the other tests associated with preventive medicine. If we go back a few years, I do not think that any hon. Member would have contemplated charging when the mass radiography units were going round the country. That is not so frequent today because there are other safer ways of checking on the problems of lung cancer.
Many millions of people are receiving preventive medicine free at the point of use, but against their will. That is because their water has fluoride in it. I have always supported fluoridation. I am prepared to accept that form of mass preventive medicine on its merits but not in principle. There are many, however, who do not want that mass medication, preventive though it might be.
The free marketeers on the Government Benches would argue that the public should pay for that treatment because it will prevent problems from occurring later. That is the logic of certain Conservative Members. I accept the honesty of the hon. Member for Salisbury (Mr. Key), because it is clear that he would support charges for cervical smears and other tests.
These issues must be faced fair and square. Most of the major diseases that caused generations to suffer were almost eliminated before the medical profession discovered what they were and what the treatment should be. I remember attending a lecture at the community medicine department of Guy's hospital many years ago. Slides were projected that showed graphs illustrating the numbers of people who were not dying as a result of contracting various diseases. We were then told when a cure had been found. It was clear that the fall in the line on the graphs did not depend on treatment. Instead, there was a direct relationship to public health policy that embraced community medicine and good hygiene. That is a factor that must be taken on board.
With advances in science it may be that other tests will be invented for some of the diseases that are prevalent now and for others that we may not even know about. A test for AIDS is an example that I use in passing, for five years ago we might not have known anything about the disease. There will be tests invented to prevent people of whatever age falling foul of certain illnesses or diseases, and we know that those tests will save money.
There are those who contract certain illnesses or diseases because we have not developed tests that will tell us when they are in the early stages of contracting them. If the relevant tests were invented, they would definitely save money. They would be cost effective. Is it being argued that although new tests will save money we should introduce charges for them? Surely that would be contrary to public health policy and our attitude to it for the past 100 years or more.
902 The Under-Secretary of State for Health, the hon. Member for Derbyshire, South (Mrs. Currie), is right to think that people are still ignorant about their own bodies. From time to time the hon. Lady tells the country the truth. Whenever she does so there is a reaction, but that is because of the way in which she puts her message across. The hon. Lady, in her own way, is attempting to educate. She is intent on educating the people en masse so that they can take better care of their bodies. She knows that most people are ignorant about their bodies in detail, especially when it comes to what they do to their bodies and the illness that will ensue 10 or 20 years later. The hon. Lady is engaging in a process of education.
An element of preventive medicine is to enable the public, without any barriers of mystique, to subject themselves to checks. If only small barriers are erected that does not matter. In effect, the money does not matter. Conservative Members talk about 60 per cent. exemptions, but if there were no problem about money we would not have arguments about two out of every three who are eligible for family credit not receiving it. There is ignorance of the system and ignorance of what is available. The same applies to charges for checks and to those who would be frightened of taking advantage of them. Unless Ministers are prepared to argue that they will consider later the cost effectiveness of other checks, their words are not worth the candle. I do not care what the costs are, because costs do not really matter. If the proposed costs are halved, some people will still be prevented from taking advantage of them.
We know that some people, either through illogicality or ignorance, will be prevented from going for checks. That is not good enough. That is contrary to everything that has happened in the development of public health policy over the past century. It would be a bad day for the Government and the House if we were to let that happen.
§ Mrs. Gillian Shephard (Norfolk, South-West)
I shall be very brief because most of the arguments that it is possible to deploy on this subject have been thoroughly rehearsed tonight, if not in earlier debates. However, I want to make two points, the first of which relates to the principle of charging for dental check-ups. No one can dispute the fact that the power to make appropriate charges for health services was built into the National Health Service Act 1946 from the very beginning. No one has tried to dispute the fact that Governments of all political persuasions have taken the chance to make charges when they wished during the 40-year history of the NHS.
My experience may be unique, but I have rarely had a free dental check-up. My dental check-ups always seem to be accompanied by an X-ray, cleaning or scaling for which I have to pay. I agree with my hon. Friend the Member for Ealing, Acton (Sir G. Young) who said that the boundaries between treatment and examination in that area of the Health Service are very blurred. Most people who attend a dental surgery expect to be charged either for something following from the check-up such as an X-ray or cleaning or for a course of prescribed treatment. I have no difficulty with the principle of charging for dental check-ups.
Not much has been made of my second point. Check-up charges are part of a total package for primary health care contained in the Bill. The package is designed to produce improvements worth £600 millon over the next three years for the primary health care network. As 903 represent a rural constituency in which primary health care is of the utmost importance, I welcome the improvements and I shall have no difficulty in supporting the Government in support of the charges as part of that package of overall improvements.
§ Mr. Carttiss
As has already been said, all the arguments have been advanced. When my right hon. Friend the Leader of the House was asked whether the Government would change their mind after the amendments were passed by the Lords, he said in April or June that he had heard no new arguments that would change the Government's view.
I have heard no new arguments to cause me to change my view that the Government have made a mistake. I recognise that my right hon. and hon. Friends on the Government Front Bench and my colleagues on the Back Benches have put forward some very persuasive arguments, and I understand what they have said. That is a matter of judgment. I would be very surprised if someone was deterred from having a dental check-up if the charge was £3. We are not talking about eye tests or a higher charge of £10 which would be a different deterrent.
Conservative Members have concentrated their attention on wealthy people whom it is alleged do not need free check-ups. No matter how wide ranging are the Government's exemptions, there will still be people, as we all know, who are just above that level and for whom a charge will make a difference. Of that there can be no doubt. If it does not make any difference, why do the Government continue to subsidise the wealthy middle class who want to attend opera and the Royal Shakespeare Company performances? My hon. Friend the Member for Hayes and Harlington (Mr. Dicks) is always on about that. Let us get the facts right.
Why is it such a dreadful thing to say to people who can afford to go somewhere else that they cannot have that one test free in the interests of preserving the principle of having an initial free check?
We have heard a lot about prescription charges. Every time anyone mentions the charges for the two tests we are told that we do not oppose charges for prescriptions. If I had been a Member when the Labour Government introduced prescription charges, I might have done so. What I do know is that once the principle—it may well have been right—was conceded, they were appropriate, indeed unavoidable, given the vast range of services that my hon. Friend the Member for Birmingham, Northfield (Mr. King) identified as showing that we have a much more comprehensive Health Service now than when it was formed. The arguments for that might be clear, but the fact remains that prescription charges keep going up and there is no doubt that these charges will go up. There is no way that in three years' time we will be talking about £10 for eye tests or £3 for dental check-ups.
I oppose the principle of charging for doctors' visits and all the rest, which has been debated thoroughly. Hon. Members have been nodding their heads. My hon. Friend the Member for Salisbury (Mr. Key) went like this when the hon. Member for Birmingham, Perry Barr (Mr. Rooker) asked whether he would approve of charging for cervical smears. Many Conservative Members will put their hands up if they are told to do so by my right hon. and learned Friend the Chief Whip, who has just walked in.
§ Mr. Deputy Speaker
Order. I hope that hon. Members will remember that Hansard cannot interpret hand signs.
§ Mr. Carttiss
The case is being advanced that there is no deterrent in these charges. Indeed, we have heard some interesting and persuasive points of view. It has been said that if we charge for something everybody will want to have it. That may well be true; I do not know. But this is a fundamental principle.
I am not sure whether the Government know the costs involved in introducing these charges. They say little. For example, we are told that charges are no deterrent. We are told that after a time patients will come back.
In Great Yarmouth dentists who are capable of operating on impacted wisdom teeth are referring their patients to the local hospital to have the operation there, not on medical or clinical grounds, but on social grounds because their patients are just above the exemption limit; they would have to pay the dentist but can be treated free in hospital.
There are many more such cases. If one talks to people who visit hospitals regularly, as I do, they tell of people being redirected. That is what will happen. People will go to their general practitioner complaining of a headache. Once he would have sent them to the optician, but now he will send them to the eye clinic in the local hospital. Make no mistake about it. Of course, that will not apply to everybody.
I seriously question how much of the £50 million that it is alleged will be redirected will be saved when the time comes. I congratulate my right hon. and learned Friend the Secretary of State and his colleagues in the Department of Health, and, indeed, my right hon. Friend the Chief Secretary to the Treasury, on having agreed the significant increase of £1.25 billion for the Health Service. I was asked to listen to the Autumn Statement. Having done so, I am reinforced in my view that we should not be introducing these charges.
When my right hon. and learned Friend opened the debate he observed that the Autumn Statement had certain elements in it and he asked whether we all understood it. I have examined it, and I find that when my right hon. Friend the Chancellor of the Exchequer stands at the Dispatch Box next March to present his Budget he will have a surplus of about £10 billion to £15 billion that he can use in various directions, including reduced taxation. He could also use it to continue providing what I happen to believe—although I recognise the alternative arguments—is a fundamental principle, a free service of dental and eye inspection.
Opposition Members made the point that one can go to a GP and say, "I have something wrong with my foot, doctor," and that he will examine it without charging £3. One might say to him, "I have something wrong with my arm—have a look at it." He might reply, "There is nothing wrong with it. It is all in your head." Why should those services be free while others are subject to a charge? Right hon. and hon. Members have asked that question several times today. It was asked in the debate on Report, but still no answer has been given. We shall not be given an answer because many of my right hon. and hon. Friends consider, for sound reasons, that there ought to be more Health 905 Service charges. I respect their view, but I still oppose it, and tell them that I hope very much that this is the last we shall hear of their proposal.
Conscious as I am of the passage of time, I shall conclude by quoting Bruce Anderson writing in The Sunday Telegraph:There is no justification for Tory Members whining and griping every time they have to explain an unpopular decision in their constituencies.That is not what it is all about. I had to explain to my constituents why it was that on Monday, and again on Thursday, I voted to pour more money down the EC drain on their behalf—much more money than is in question here. I also had to explain with enthusiasm to my constituents why the British Government allowed the American Air Force to use air bases in East Anglia from which to launch their bombing attack on Libya. I had to explain that to 70 constituents who were in Libya, working for the oil industry there. Worse still, I had to explain it to their wives, who were worried about them—but I had no difficulty doing so.
Great Yarmouth is not just my constituency. It is my home. It is my parents' home and the home of my grandparents and of their parents. I have to face my constituents not to explain unpopular decisions but to explain in terms that I can support and believe why I vote in the way that I do in Divisions. I can explain to my constituents why the Government are introducing this measure. I can understand the argument that has been advanced that the £50 million involved can be more effectively directed elsewhere.
My right hon. and learned Friend the Secretary of State commented on radio last night on whether those of his colleagues who oppose the Government wish to have on their consciences the loss of £50 million that could be spent in other areas. I do not want to have on my conscience the two people of whom my hon. Friend the Member for Lewisham, West (Mr. Maples) does not think too much because their dentist had discovered only two oral cancers. It is a case not of whingeing and whining but of being extremely proud of a Government who have done more for the Health Service than any other.
I strongly object to having to march into the Lobby with Opposition Members because on this occasion they happen to be right and the Government wrong. I trust that even at this late stage the Government will join me. I am not against the Government; I am voting for the Lords amendment and for the people who sent me here, and I hope that the Government will do so as well.
§ Mr. Peter Griffiths
The response by my right hon. and learned Friend the Secretary of State to my modest intervention during his opening speech was profoundly disappointing and disturbing. It was disappointing because it compounded what I thought at first was a modest error: when he listed the possible uses for the sum that could be saved by charging for dental checks, he did not mention any that had any relation to dentistry, and I now ask him to remedy that.
I found my right hon. and learned Friend's response offhand in the extreme. It was clearly intended to suggest that he agreed with my hon. Friend the Member for Birmingham, Northfield (Mr. King), who said earlier this evening that the optical and dental services were on the 906 fringe of the NHS. That is certainly not true of dental charges. For many people the regular visit to the dentist is their most common meeting with the NHS. I visit my dentist every six months; I do not visit my doctor that often. Throughout human history until the last century, inadequate dental health was one of the greatest causes of physical misery, and I consider the dental service one of the most important parts of the Health Service. My right hon. and learned Friend missed a great opportunity in brushing aside the suggestion that funds raised by imposing charges on dental inspections should be used at least in part to improve dental services.
I am particularly concerned about this because it contradicts comments made during the Bill's Committee stage by my right hon. Friend the Chancellor of the Duchy of Lancaster when he was Minister for Health. He said then that more than £50 million would be spent on improved primary health care, and that, while not all of it would be spent on dental services, they would be a priority. The impression given today was that they would not.
My hon. Friend the Member for Northampton, South (Mr. Morris) said that he could accept the imposition of charges for dental inspections if he then saw a new orthodontic hospital in Northampton. If we could see real developments in certain areas of dental provision, we might be able to argue that that was an improvement. Surely few people would argue that, if we were starting from scratch and had £50 million to spend on the dental part of the NHS, we should use it to provide free dental inspections for those who can afford to pay. But what worries me is that we have no indication that the Government intend to use the funds that they are raising —or at least a major part of them—to improve dental care.
My right hon. and learned Friend said that he felt that during the past few weeks the number of people expressing opposition to the measure had increased. I well understand why people may have begun to wonder when they find that the Government have apparently shifted their ground since the Committee stage. I am seeking a direct and specific assurance from the Minister that primary dental care will benefit from the change in the direction of funds brought about by the introduction of charges. I consider that that is the crux of the matter. That is what I wish to hear.
§ Mr. Keith Mans (Wyre)
Hon. Members have spoken about the many well-worn arguments that we have had tonight. Those arguments did not start tonight; they go back to last December when the Standing Committee of which I was a member first started discussing these clauses. Since last December, the Government have made available £3 billion of extra public money to the National Health Service. Therefore, I find it just a little extraordinary that Opposition Members should be so concerned about these matters, yet fail abysmally to applaud the huge extra sums of money that have been made available during the past year.
I find it extremely difficult to understand how they can suggest that many problems will arise from the charges. I do not consider that there is any fundamental difference between charging for treatment and charging for the tests that we are discussing tonight. In that respect I agree with my hon. Friend the Member for Ealing, Acton (Sir G. Young).
Opposition Members have produced statistics that suggest that a £3.15 charge for a check up will deter people 907 from going to the dentist. I do not believe that will be the case. It is not proven, and, judging from the arguments used tonight, it is most unlikely to occur.
It is much more likely that as a result of our debate tonight we shall well end up with a better dental service. It will not be the case that, simply because people have to pay £3.15 for a dental check-up, if they can afford it, that will affect whether they go to the dentist. However, the charge may affect the dental service that is provided. I am absolutely convinced that, although quite clearly not all the extra money will be spent on dental check-ups, some of it at least will help that cause. I strongly believe that we need to monitor exactly what occurs if the charges are introduced. We need to find out whether there is a decrease in the take-up rate of dental check-ups. I believe that the charges will make very little difference.
There is a more fundamental reason for rejecting the amendment. Ever since the foundation of the NHS, it has been short of funds for one reason or another—latterly much less so. The expanding need for health care in this country means that we have to make an increasing individual contribution to the Health Service. One of the main purposes of the charges is that they will allow people who can afford it to contribute to their own health. That must be a step in the right direction and must result in more resources being released for more important and more fundamental health care. Therefore, I shall support the Government tonight and I ask my hon. Friends to reject the amendment.
§ Mr. Edward Leigh (Gainsborough and Horncastle)
I hesitate to take part in the debate because the only time that one of my speeches in the House was reported around the world was when, in mid-flow, the crown expertly fitted to my front tooth by the National Health Service fell on to the Bench beside me. I hope that I shall be more successful this evening. [HON. MEMBERS: "Keep your mouth shut then."] I owe it to my constituents to say a few words. I do not doubt the Opposition's sincerity, but they have not examined needs and priorities accurately—the same needs and priorities that every Government have had to tackle. Perhaps I may quote the Chancellor of the Exchequer who said:It is clear that it is not possible in existing circumstances to permit any overall increase in the expenditure on the Health Services. Any expansion in one part of the service must in future be met by economies or, if necessary, by contraction in others. In exercising this essential control over total expenditure, regard will of course be had to priorities."—[Official Report, 18 April 1950; Vol. 474, c. 59.]That was what a Labour Chancellor, Sir Stafford Cripps, said. He was trying to grapple with the difficult problem of balancing needs and resources. A Minister of Health said:I am afraid it is necessary this afternoon—we need more money than my right hon. Friend the Chancellor of the Exchequer could see his way to provide. The measure we have taken to get that money has been described in some quarters as an attack on the Health Service or as the first step in dismantling the Service. I am tempted to voice the indignation I felt when I read those words, but I will refrain. Instead, I hope that my hon. Friends will reflect on what I have said this afternoon about the intentions and plans of myself and of my right hon. Friend to expand and develop the hospital and general practitioner service".—[Official Report, 24 April 1951; Vol. 486, c. 235.]That was said by Mr. Marquand, a Labour Minister of Health, when imposing charges on 24 April 1951. Already in the history of the National Health Service, Governments have had to make choices. We recognise that 908 if we are to protect people who can least afford to pay, we must ask those who can afford to pay a modest amount to make some contribution.
§ Mr. Leigh
No. I am trying to draw to a close.
The only alternative to asking people who can afford to pay to make a modest contribution is the philosophy of the queue. We all remember the words of the grandfather of my hon. Friend the Member for Davyhulme (Mr. Churchill), who reminded us that the Socialist way is he way of the queue. Ours is the way of the ladder. When people fall out of the queue, Socialists will employ officials to put them back in the queue. We give people a ladder, and if people fall off the ladder we provide the best ambulance service in the world.
Even Socialist Governments have recognised that the queue eventually becomes intolerable. I have another interesting quotation which runs:the ideal of a free service lasted in fact barely three years from its inception—charges of some kind have been in operation ever since 1951 … I have made my view known widely, over a long period, that ideally the National Health Service should be free to everyone at the time of need, and it is not at all difficult to find telling quotations from past speeches of mine over the years."—[Official Report, 30 May 1968; Vol. 765, c. 2255.]That was said by Mr. Kenneth Robinson when imposing prescription charges on behalf of the Labour Government in 1968.
Even Labour Governments have had to impose charges to avoid the philosophy of the queue. I do not doubt the sincerity of Opposition Members but, like most sincere people, their sincerity is small part self-deception and large part humbug and hypocrisy. One has only to examine the record of Labour Governments to realise that.
The argument that charges should not be imposed is false. Successive Governments have realised that they must be imposed. We must therefore ask whether it is necessary to impose these charges.
We know that some 20 million people—those who are least able to pay—will be exempted from the charges. We have dealt with the deterrent argument and heard that between 1976 and 1986 the number of people who received dental treatment increased by 7 million. We have heard also that people on the borderline of income support might be deterred from taking dental treatment. If that argument is true, is it not an argument against more charges? [HON. MEMBERS: "Yes."] There is the voice of the part of the Labour party which opposes all charges. If those hon. Members are honest, and lay aside self-deception, hypocrisy and humbug, they will realise that a Labour Government would have to impose such charges. I shall vote against Lords amendment No. 20.
My final point might give some comfort to Opposition Members. The points made by the hon. Member for Birmingham, Perry Barr (Mr. Rooker) were worth while. The time may come when the Government have to grasp the nettle of charges on other services. I do not say that such charges are desirable or necessary. My right hon. and learned Friend the Secretary of State gave the sincere and honest answer that in his view they were not yet necessary. The time may come when, if the NHS is not to absorb an increasing proportion of GNP and we are to continue to 909 provide services to those in need, we have to consider charges on other services. I do not for a moment think that that necessarily proves that these charges are wrong. They are a necessary fact of life which we must accept. I am sure that, for that reason, Ministers will get a majority for their motion.
§ Mr. David Atkinson (Bournemouth, East)
The House will welcome the extra £1.6 billion which my right hon. Friend the Chancellor has announced today for the National Health Service in England and Wales. I congratulate my right hon. and learned Friend the Secretary of State for Health on his considerable personal achievement in this respect, but we cannot continue indefinitely to find these extra massive resources for the NHS without a clear policy and direction for the future of health services. I hope that that will be the outcome of the review which my right hon. and learned Friend has inherited. It is therefore all the more regrettable that, on the same day that the Government have demonstrated, once again, that they are generating new resources for the NHS and much else, they find that they must also proceed to reinstate charges for dental treatments. As my right hon. and learned Friend the Secretary of State has reminded us, the Health and Medicines Bill is based on the 1986 Green Paper, "Primary Health Care", which contained a range of measures to promote good health and preventive care. Those measures will cost money to implement in the short term in order to save money in the long term through better health.
Two years ago, I consulted widely in my constituency with all the doctors, dentists and chemists about those proposals. The general reaction was positive—they welcomed them. Before us today is a new charge for dental examinations which was not proposed in the Green Paper, and therefore was not the subject of that consultation. It is obvious that, if it had been, the message would be what we are receiving now from the professions, that such a charge will serve to negate some aims that the Bill is designed to achieve and will be self-defeating, both financially and for the health of the patient.
I oppose the introduction of a dental examination charge for three reasons. First, it abandons the principle that the National Health Service should not charge patients for advice. Although I believe that we should be doing much more to encourage people to cover privately for their health needs, out of choice, the fundamental principle of a state-run service must be to enable people to seek medical advice regardless of means and without charge.
Secondly, once that principle has been broken, it becomes easier to introduce the charge elsewhere—for advice from the doctor, for screening and for smears. We have heard of a number of services where such a charge could be introduced. Once the principle has been broken, it also becomes easier to increase the charge. If the Bill is passed, this year we shall introduce a charge of £3.50 for a dental check. Next year, it will undoubtedly be at least £5, and it could escalate a the same rate as charges for dental treatment in recent years. That is not the right way to reform the financing of the NHS.
Thirdly, and contrary to what my right hon. and learned Friend the Secretary of State said earlier today, I accept that there is much in what the dental profession is 910 telling us, and has told my right hon. and learned Friend —that a dental examination charge, modest though that proposed is, will prove to be a disincentive to young adults, especially the 18 to 20-year-olds who will have to pay it. I accept that they are not as responsible as they should be and they will avoid going for a regular inspection. In the long run, that will prove more costly both to the National Health Service and to the patient. Treatment almost always follows the free examinations— treatment for which the patient pays. Examination charges for 18 to 20-year-olds will raise just £10 million and I do not believe that it is worth the candle.
I had expected my right hon. and learned Friend, by way of a concession, at least to exempt the elderly from the charges, but apart from those already specifically exempt he has not done so. In view of the early detection of oral cancers through routine dental examination, I believe that that is particularly harsh.
Had my right hon. and learned Friend the Minister said that the charges were a temporary measure to finance the preventive health care programme that he is about to launch—with, I hope, the wholesale introduction of fluoride in the drinking water—and that the charge would be lifted as soon as evidence showed that the programme was working and demand for treatment falling, I would have reconsidered my position. But my right hon. and learned Friend has not suggested that. The charge will be a permanent addition to the financing of the National Health Service and in my view will sabotage what this otherwise admirable Bill is designed to achieve. The abandonment of the principle of free examination under the National Health Service is not something that I can support today.
§ Mr. Mellor
The essential background to this wide-ranging and well-informed debate is that in the past 10 years provision for our dental services has been greatly increased, leading to better dental health among the population as a whole. There has been a marked increase in take-up of dental treatment throughout the country against a background of markedly increased charges for the treatment provided. That is the essential factual background against which all who are still considering how to cast their vote should begin their consideration.
Provision has been dramatically increased in the past 10 years. In 1978–79 the cost of dental services was £279 million. In 1987–88 it was £820 million—an increase of 43 per cent. in real terms. Even allowing for the impact of the contribution paid by the public in charges, that still represents an increase direct from the Government of 26 per cent. in real terms. That has led to better dental health. In 1973, 29 per cent. of five-year-olds in England and Wales were free of dental decay. By 1983 the figure had risen by more than half to 52 per cent. In 1968, the percentage of adults with no natural teeth was 37 per cent. In 1985 it was 22 per cent.
The percentage of adults attending the dentist regularly has risen from 40 per cent. in 1968 to 50 per cent. in 1985. As my hon. Friend the Member for Ryedale (Mr. Greenway) reminded us, however, even though 50 per cent. attendance is better than the 40 per cent. of 20 years ago, it still means that 50 per cent. do not go to the dentist regularly. That is an issue to which we should be devoting a great deal of attention.
There has also been increased take-up of the services that dentists have to offer. In 1979, the number of courses 911 of treatment in the United Kingdom was around 31 million. By 1986–87, only seven years later, there were 37 million courses of treatment. My right hon. and learned Friend has already reminded the House that especially noteworthy among that increase in treatment was the number of pensioners having their teeth checked—in most cases in the clear knowledge that it would lead to a course of treatment for which 80 per cent. of them would have to pay. Indeed, the increase in the number of pensioners having dental treatment during that period was 92 per cent.
§ Mr. Mellor
Yes, that is right. We estimate that of the 6.9 million people who will be exempted by virtue of receipt of income support, 2.5 million will be pensioners.
It is interesting that the take-up of treatment has risen sharply, notwithstanding the background of increased charges for treatment that have been significant during the past 10 years. It is also interesting to hear the Opposition's ritual denunciation of charges. However, we know that back in 1976 they put up charges for dental treatment by 35 per cent. and again in 1977 by 27 per cent.
In case the House is troubled by the Opposition's attitude, I must point out that they did not fuss about the odd three quid back in 1977 when they put up charges for plastic dentures from £12 to £20 and for metal dentures from £12 to £30. The minimum charge for treatment rose from £12 to £30 at a stroke, an increase of 150 per cent. We do not really need too many denunciations from the Opposition.
It is fair to say that in the increasingly prosperous society that has been created in Britain during the 1980s, the Government have also put up dental charges so that from a total of 20 per cent. of the cost of the dental service coming from patient contributions in 1980 the figure has risen steadily over the years to a current total of 32 per cent. That increase in patient contributions from 20 per cent. to 32 per cent. of the cost of an expanding service has happened while that service continued to expand and to treat increasing numbers of people—including an increasing number in the most vulnerable group, according to the definition applied by some of my hon. Friends. That is something that should be taken into account.
It is true that certain types of treatment have reduced in number, such as extractions and fillings, because they are not so necessary today. It is not because people are not taking up treatment, but because the general dental health of the population is improving. It is interesting to note that increased take-up has been more marked in some of the more expensive procedures for example, crowns in-creased by 83 per cent. and bridges by 535 per cent. during the lifetime of the Government, yet those are among the most expensive treatments available up to the £150 maximum that we have already specified.
The provision that we are debating is a charge of £3.15 for a dental examination—75 per cent. of the actual payment made to the dentist. It fits in with the procedures introduced in April under which, instead of there being up 912 to 100 per cent. charges—a point made by my hon. Friend the Member for Ryedale—we fixed on 75 per cent. for all procedures up to a maximum of £150. That is not without significance because it means that even with these additional charges if the House is minded to permit us to render them—more than 6 million of those who received 32 million courses of treatments last year would pay less than they did in April because of the adjustments. Thai is further evidence to convince anyone who needs persuading of the limited cost of the exercise to the patient.
§ Mr. Churchill
Can my hon. and learned Friend say whether the constituent whom I mentioned, who is single, self-employed and in his late 50s, without dependent children and in full-time employment, but earning only one quarter of average earnings, would qualify for free tests despite the fact that he is not on income support'?
§ Mr. Mellor
If my hon. Friend's constituent is not on income support, I am afraid that he will not qualify unless he falls within the category of the nearly poor set out by my predecessor in the debate in April. With the greatest respect, hon. Members cannot expect Ministers to be able categorically to answer such questions at the Dispatch Box, although it is something that would be well worth checking.
One of the key questions that has arisen in the debate concerns what we are really trying to achieve in the dental service. It is quite clear what we are trying to achieve. We are trying to build on our unparalleled success—certainly since the 1970s—to ensure that when people visit dentists, they visit well-trained dentists capable of dealing with all their problems. Above all, we want more people to visit the dentist. We know that 50 per cent. do not. The hon. Member for Livingston (Mr. Cook) drew entirely the wrong conclusions from the figures that he gave for teenagers who were not turning up for dental checks. It is interesting to note that people do not turn up for dental checks even though they are free. It shows that the problem is altogether more difficult than the question whether people will be deterred by the £3 charge. People put plenty of other reasons for not going to the dentist before cost. There are all the old fears about pain, and doubts about whether the dentist will be any good. One crunches one's way through all the unsuitable foods denounced so regularly by my hon. Friend the Parliamentary Under-Secretary of State and one thinks that one's teeth are standing up to the strain all right and says to oneself, "Why bother to go to the dentist?"
§ Mr. Mellor
Not for the moment.
That is why the focus of our attention is increasingly on prevention—on reaching out to people to find ways of persuading them to take better care of their teeth. That is why in this year alone we are spending £250,000 on an advertising campaign especially targeted on teenagers to try to persuade them to go for treatment.
Let me take up the point raised by my hon. Friend the Member for Portsmouth, North (Mr. Griffiths) and by my hon. Friend the Member for Ealing, Acton (Sir G. Young) about prevention campaigns. I wish I could have the attention of my hon. Friend the Member for Portsmouth, North, although I realise that it is difficult to hear against the background of the Opposition—[HoN. MEMBERS: "Get on with it".] All the money—the £50 million that will no 913 longer need to be paid out on dental examinations—will go back into the Health Service. I am not saying that every penny will go back into the dental service but there will be significantly expanded provision in dental services. My hon. Friend knows, from the figures that I have cited—an increase from under £300 million to over £800 million in eight years—I say that against the background of real achievement in the past— [Interruption.] One wonders where the Opposition get their facts when they ask about the expanded commitment. There are 22 per cent. more dentists in England and Wales than when the Labour Government left office 10 years ago. That is what we mean by expanded provision and a few jeers and caterwauls will not change that.
What do we seek to do to vindicate the commitment? We are looking to expand health education initiatives, to investigate means of improving the marketing of dental care and to increase the number of people who seek regular dental care. We shall be giving increased financial assistance towards the cost of establishing and equipping dental practices in those areas short of dentists. That should be of interest to Opposition Members who represent inner-city constituencies and who regularly say that they do not enjoy the level of provision available elsewhere in the country.
§ Mr. Mellor
I shall just finish a point, and then I shall give way to the hon. Gentleman. We shall give more money to expand the number of places in the vocational training schemes designed to improve the skills of family dentists, and more money for postgraduate training courses and for a training allowance for attendance at approved courses, because these days not every dentist has to come from Australia.
§ Mr. Battle
Will the hon. and learned Gentleman explain to the House why not one of the professional bodies that deal with this matter agrees with the Government on this issue?
§ Mr. Mellor
It is called vested interest, and I thought that Opposition Members— [Interruption.]
Another point was very properly raised during the debate, which was the question of additional charges. I know that a number of hon. Members are concerned about this matter, and I say categorically that the Government have no plans to introduce further charges —[Laughter.] I should like to reiterate and quote from the words of my right hon. Friend the Prime Minister, when she was interviewed on the BBC nine o'clock news on 21 December 1987. She said:
We have in fact introduced one or two extra charges which we think people can well afford, but at the moment we are not talking about extra charges beyond those which we have introduced, and the Government have no plans to introduce further charges.My hon. Friend the Member for Davyhulme (Mr. Churchill) and one or two other hon. Members asked what the difference was between charging for dental inspections and charging for people to have their breasts checked for cancer or to have a cervical check. Of course, I have said that there are no plans—nor would there be—to charge for such examinations. There is a difference in kind between those checks, which are a systematic search for disease, 914 and dental checks, which are basically a check to see whether dental treatment is required. [HON. MEMBERS: "Rubbish."] Oh yes, it has the fortuitous additional benefit that if a case of wider mouth disorder becomes apparent, a dentist can spot it. However, I say to hon. Members, who base their case on the detection of oral cancer, that it is idle to pretend that dental checks were ever intended or devised as a means of screening for oral cancer. They were not. That is categorically so.
I shall turn to the question of oral cancer which appears to me to be a significant point. Oral cancers are tragic and serious, and everybody wants to see them detected and, where possible, cured. Happily, it is a relatively rare condition in the United Kingdom, where there are some 1,500 cases of cancer of the mouth each year.
§ Mr. Mellor
My hon. Friend gives a false figure and I shall correct him later. There are 1,500 cases of cancer of the mouth each year. That means, spread as an average across all the dentists in the United Kingdom, that the average dentist would see two or three cases of oral cancer in his entire working life. The off-chance of picking out an oral cancer cannot be the basis for 100 per cent. free dental examinations.—[Horn. MEMBERS: "Withdraw."]
§ Mr. Mellor
In a recent survey the figures show that 40 per cent. of oral cancers are detected by dentists. That means that one dentist will see only one case of oral cancer every 20 years. I give way to my hon. Friend the Member for Harlow (Mr. Hayes).
§ 10 pm
§ Mr. Hayes
I am grateful to my hon. and learned Friend for giving way. According to all the professional bodies, which until this moment have been accepted by the Department of Health, last year alone, 2,604 oral cancers were discovered, approximately 41 per cent of which were presented to dentists. I am sure that my hon. and learned Friend will accept that one difficulty is that doctors are not properly trained to diagnose diseases of the oral cavity, whereas dentists are.
§ It being Ten o'clock, the debate stood adjourned.