THE NATIONAL HEALTH SERVICE

HL Deb 14 November 1979 vol 402 cc1254-66

3.6 p.m.

Lord WINSTANLEY rose to call attention to the increasing inability of the National Health Service to meet the needs of patients, and to the necessity for the more efficient use of existing resources and the improvement of industrial relations within the service, and to move for Papers. The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper. As noble Lords are aware, this is one of those rare occasions—some, though by no means all, might say too rare occasions—on which the privilege of selecting the topic for debate in your Lordships' House is bestowed upon noble Lords sitting on the Liberal Benches. I hope that in focusing attention on the National Health Service and its present problems and inadequacies, we are not merely pursuing a long-standing interest and preoccupation of our own, which dates back to the National Insurance Act 1911—a Liberal measure. This gave birth to the beginnings of the National Health Service, with the old panel doctor and so on for insured persons, though, unhappily, not for the dependants of insured persons; a measure taken further by a notable document, the Beveridge Report, whose author was a distinguished Liberal Member of your Lordships' House. I hope that we are also serving the interests of this House as a whole.

We have among us noble Lords and Baronesses with immense knowledge and experience of this subject, whose collective wisdom, at a time when Government must be devoting their thoughts to the National Health Service, should surely not be allowed to go to waste. And, after all, whether we are experts or not, we are all patients or potential patients. In discussing these matters before the Government make up their mind about the report of the Royal Commission and other pressing matters, it is surely appropriate that your Lordships' House should have an opportunity to make the kind of constructive contribution to the formulative stage of policy-making of which we all know it is so very capable.

I must begin by saying at once that I, as a doctor with more than 30 years of experience working in the National Health Service, and as spokesman for my Party on this subject, have brought with me no magic instantaneous cure, no revolutionary therapeutic measure which, at a stroke, could shorten waiting lists for in-patient or for out-patient hospital treatment; empty GPs' waiting rooms or reduce their visiting lists: conjure up skilled and necessary workers, not just doctors and nurses, but speech therapists, chiropodists and many others of the same kind who, in some areas, are conspicuous at the moment by their absence; halt the closure of pharmacies, which is now proceeding at a rate of something like nine per week and causing immense inconvenience to many patients in many areas; bring back to our shores some of those anaesthetists, radiologists and other consultants whose disciplines do not require linguistic ability, but who have left our shores to work for higher remunerations in the EEC; provide a dental service in districts where none now exists; make kidney transplants readily available to all who need them; restore the situation when GPs had time not only to talk to their patients but to listen to them as well; or, indeed, restore a sense of harmony, commitment and partnership between all those different groups who work within the National Health Service, and a commitment to the needs of patients rather than, perhaps, to their own needs as individual groups working in the service. No, my Lords; neither I nor anyone else has a magic wand with which to do any of those things. Things are not like that. All we can do is to accept that all problems do not necessarily have solutions, but we must look for those solutions none the less.

Having looked at the long list of distinguished speakers in today's debate, I am sure that suggestions will be made from all parts of your Lordships' House from which a Government that is willing to listen and able to learn could derive much benefit and assistance. In that connection, I must say that fate appears to have exercised a nice discrimination in timing by striking down with ill-health certain noble Lords on these Benches who were to have supported me. Furthermore, the noble Baroness, Lady Robson of Kiddington, who is so experienced in hospital matters and administration, has been summoned to grass roots to deal with a crisis and will not be able to be here to support me.

Let us consider some basic facts. First, we must all get rid of the notion that we in this country spend an unusually large percentage of our resources on health. We do not. If we examine the facts critically, as I am sure many noble Lords have done, we find that in fact we spend on health less per head of our population than many other of our European partners and, indeed, many nations beyond the Iron Curtain and in other parts of the world. I should like this country to spend a great deal more on health but I must reluctantly accept that at the moment it is unlikely that we shall. Also I have to accept that there are other functions which are desperately in need of money—matters like housing, education, food—which are relevant to the health of our community. So we have to accept that at the moment the amount which can be spent on health is necessarily limited.

We must also accept that we shall never be able to spend enough money to do everything for everybody. The cost of modern methods of treatment, diagnosis and investigation in one way or another is now so large that if every single thing which could conceivably be of benefit to the patient was at once to be made readily available to every man, woman and child, the Health Service—and, indeed, almost everything else—would come grinding to a halt. Let me give your Lordships a tiny example; namely, the immense progress which has been made in recent years in the transplantation of human organs and human tissue. Immense strides have properly been made in heart transplants, liver transplants and so on and they must be commended, but if we were to accept that any man, woman or child who could conceivably benefit from a human organ transplant must immediately have a right to that human organ transplant, then we should realise that we just could not cope.

Next we must accept that the workload, already large, is growing and that it will grow further. On 5th July 1948 when our National Health Service originally began, I think many people were under certain delusions; namely, that if we removed the financial barrier which existed at that time between the patient and his doctor, somehow or other ill health would be banished from the face of the earth and the need for doctors and resources in health would diminish steadily and remorselessly as we made the service available. Regrettably and unhappily, the reverse is the case.

We have to accept that our very success has added and still is adding to the total workload. Every time we learn to treat a disease which formerly was not treatable, so we increase the total workload. Every time we prolong the life of a person who formerly would no longer be with us but who continues to live and who now requires regular treatment, regular care and maintenance therapy of one kind and another, we increase the workload. In our country there are today thousands, indeed millions of people alive who in past years would have been no burden to anybody at all. They are alive and they are consuming resources; and they are requiring increasing resources. That is a fact with which we must all grapple. The workload is growing and it will continue to grow.

There seems also to be some kind of melancholy law of medical science that as we get rid of old diseases like diphtheria and the old nutritional diseases—and we have got rid of a great many, to our very great credit: to the credit of the professions and also to the credit of those who have been responsible for hygiene, sanitation, better housing and things of that kind—so it appears that new diseases arise to take their place. Let us think, if we can call them diseases, of the immense burden caused by accidents on the road, in the home, and at work and also of the growth of cancer and cardiovascular disease which in part may be related to the way in which we now live—to our modern life style. We have to accept that the workload will grow and that it is continuing to grow and that the more successful we are in medicine the more that load will grow. So the problem facing us is how to cope with an increasing volume of work when resources are finite and limited and when those resources are going to grow only at a minimal rate in the immediately foreseeable future.

First, we must look at legitimate ways to reduce the workload—not by stopping doing necessary things but by seeking ways by which we could possibly reduce the total burden of ill health and the total burden at the moment bearing down upon our resources. Next, surely, we must look very carefully at ways of using those resources which we have very much more efficiently and very much more effectively than we now do.

In trying to answer those two immense questions, what can I do? In a short debate I can merely try to drop one or two pebbles in the pond, if I may so describe this august House, in the hope of producing a few ripples. There are minor aspects of this subject. One could talk about the whole problem of coping with, dealing with and caring for the psychiatric-geriatric patient. That would be a day's debate, yet it is a tiny part of the whole subject; so I hope noble Lords will forgive me if I generalise and merely make a few pointers which I hope will promote and provoke observations from other speakers.

Let me deal with the question of reducing the workload. First, surely we must direct more and more of our attention to the environment in which we live—the environment at work, at home, on the roads, the air we breathe and so on. I do not think I need to elaborate on that. I am quite sure that many noble Lords are aware of small things which can be done with our environment that would very rapidly indeed reduce the total volume of ill health and of illness in the community in which we live. Let me take as a tiny example something to do with our environment. Surely in the long run it is going to be very much more profitable to dissuade people from smoking rather than to set up more and more complex and expensive thoracic units in different parts of the country. That would be a simple and short way to cut down the workload and reduce the overall burden.

Next we must look more closely at the question of health education. As a doctor speaking about health education, I do not mean cultivating somehow or another a new generation of amateur doctors—the kind of people who used to walk into my surgery every day to blind me with science out of the Readers' Digest. I do not mean that for a moment. I mean cultivating a greater understanding among our people of what health really is and how to achieve and maintain it. I mean, also, cultivating a greater understanding of those conditions and symptoms which require attention and the work provided by highly trained people, by resources which are in very short supply, and those which in point of fact can be left to get better on their own.

I used to get a little tired of the sort of patient who came to me at the end of a long surgery and said: Isn't it awful, all these people here wasting your time?". He was never the one who was wasting my time; it was all the other people. What I am endeavouring to say is that the vast number of people who come to doctors' surgeries come for reassurance; they come merely because they wish to know about this symptom, that symptom or the other symptom—does it matter? Provided you can convince them that it does not matter, they can go away happily. They do not necessarily need treatment or further investigation, but it is a little unfortunate that the general practitioner finds it easier to give a patient a prescription rather than to explain to that patient that he does not really need a , prescription. I am sorry to labour that point, but it is a fact that if colleagues who are general practitioners could see their way to spend a little more time in explaining to patients that something will get better on its own and they should not worry about it, I think in the long term we should reap considerable rewards. Whereas in a minute and a half one can dish out a bottle of inert medicine or harmless pills, it might take half an hour to explain that the patient does not really need the medicine or the pills.

Health education has to be started in the schools. There are many old dogs who can no longer learn new tricks—I am not addressing my remarks to anybody in particular, but I think that if we were to start with the younger generation there is surely hope that in the future we may have people who, first, understand the way in which to recognise danger signals which indicate an immediate need for advice and perhaps further investigation and who can also understand that certain things may be safely left to get better on their own.

Of course, if we had a more sensible approach to the whole question of certification, not only from Government but perhaps from many firms who insist on a doctor's note being produced when a person has been off for two days with a bad cold, that might cut down some of the unnecessary work. I am merely saying that health education is extremely important, and I say most earnestly to the Government that they will not save money in the long run by saving money in the short run. It is possible that health education could be better done; greater use could be made of the media, not to teach people to be amateur doctors or to teach them about elaborate scientific techniques which are nothing to do with them, but to teach them to recognise that many things can be left to get better on their own so that skilled manpower can be devoted to things that really matter, and to recognise in fact that many things do not require the use either of the doctors or of the hospitals.

I will now move on to the whole question of preventive medicine. Immediately one mentions that people tend to give three loud cheers and to say, "That is the way to proceed". Certainly it is, but even in that field we must have some kind of study of cost effectiveness. We have to start thinking about the elaborate schemes into which we enter, such as cervical cytology schemes, cervical smears—a campaign which I supported for many years—and from time to time we have to examine the way in which we are using the resources which are in extremely short supply, and assess whether or not we are getting a return for our investment in terms of real relief from human illness and suffering. So we have to look at them very carefully. Some things are obvious and have brought immediate benefits, like the immunisation programme for diphtheria. Before that was introduced we had some 80,000 cases a year of that very serious disease; within a matter of years the total number was down to single figures, and it remains down. That is the kind of preventive medicine which really brings immediate results.

Perhaps I might not be straying from our rules of order (if we have any rules) if I say something to anticipate a debate which is to take place tomorrow, to be introduced by the noble Lord, Lord Campbell of Croy. Let us take the matter of fluoridation of water supplies. I do not want to start that debate here and now: I merely say that in my honest opinion—and I say this now so that your Lordships will not have to listen to me tomorrow on the same subject—no public health measure has ever been so exhaustively studied and found so free of undesirable side effects or consequences, and demonstrated to be so capable of making a substantial contribution to the public health. If something of that kind can be done and can bring an immediate return in terms of an improvement in the public health, surely that is the way to bridge the present gap between work load and resources.

We must even look at things which perhaps sound a little exotic, like genetic counselling. In many ways modern medicine has taken evolution by the scruff of the neck. No longer does the principle of the survival of the fittest endure. I am not saying that it should. We now make absolutely certain that the least fit not only survive—as indeed they should—but survive and reproduce and multiply; and again so they should. But we will disregard what we have learned about the transmission of genetically transmitted diseases at our peril. If we expand the kind of genetic counselling services which have come into being, then again we can do something to reduce the growing number of genetically transmitted diseases from which people in our country are suffering.

Many minor matters contribute to this in a wholly innocent fashion. If we take societies like the British Diabetic Association—a remarkable society doing wonderful work for diabetics—the kind of disadvantage is that this kind of society, which works for people who suffer from a particular ailment, tends also to become a social gathering, so that the diabetic meets only people who are diabetics and it then happens (not surprisingly) that an increasing number of people suffering from diabetes marry diabetics, with the result that we slowly increase the total amount of diabetes within the community. That does not greatly matter, my Lords, because here we have a disease which can now be controlled, but controlled at a price. It would surely be better to give some thought to those procedures. I merely say that in passing. I repeat, we ignore what we have learned about genetically transmitted diseases at our peril. We are not doing enough to explain what we have learned to people and to advise them about it.

I wish now to say something briefly about making better use of our limited resources. The efficiency of the National Health Service depends on four factors: the number and quality of the people doing the work; the adequacy or otherwise of the premises within which they work—such as the hospitals, the clinics, the doctors' surgeries, and so on; the tools with which they work—the X-ray appliances, the kidney machines, surgical instruments, the drugs and medicines and, finally, the administration by which those other three are welded together and given to the patient. In each of those four areas there are deficiencies, but there is also waste and duplication. So far as the number and quality of the people doing the work are concerned, over and over again we come across examples of people duplicating other people's work. For example, we get duplication as between the school medical service and the family doctor; as between the occupational medical service and family doctors, and indeed hospital doctors.

In short, so far as people are concerned we are not really spending time on the things which bring the maximum return and we are often duplicating the work of others. Many of my colleagues in your Lordships' House who are doctors and who practice medicine, either in hospitals or outside, if they pause and think I am sure they will tell us that they often spend time doing work which really could be done by somebody with much less expensive training and could be done in a very different way. We make nothing like enough use of ancillaries of one kind or another; nor do we make enough use of volunteers and of voluntary organisations, which are only too willing, ready and able, as they have demonstrated over and over again, to save the National Health Service enormous amounts of money by providing services themselves.

On premises, it is a waste of resources to persist with old and dilapidated buildings which consume resources and waste them. It is a waste of resources, as other noble Lords will explain, I am sure, to have in hospital at a very high daily cost people who frankly ought to be looked after outside hospital, at home or in ways which are very much less consumptive of resources which are in very short supply.

I move on to the tools with which we work. How many patients are referred regularly for unnecessary X-rays merely because it has been the habit to send the patient for X-rays, or merely because it is a wise precaution in case there should be some medico-legal inquiry crop up at a later stage and some learned counsel asks, "Did you not send the patient for an X-ray?"? People are sent daily to casualty departments for X-rays which nobody wants to look at, merely for the sake of some kind of medico-legal necessity which might possibly arise in the future.

What about drugs? I have no wish to see a nationalised drug industry. The nationalised pharmaceutical industry of the Soviet Union has produced no new therapeutic substance of any significance at all, whereas our own industry has produced an enormous number of new products which have revolutionised people's lives. But while we keep on producing new products, I do not see much enthusiasm for getting rid of old ones. Because doctors are conservative people and some doctors greatly object to anybody telling them what to prescribe or not to prescribe, it is now necessary for the average pharmacist to have on his shelves perhaps 80 or 90 different kinds of antihistamines, 40 or 50 different kinds of iron preparations, just in case some obstinate and conservative old general practitioner insists on going on prescribing them. All of us who work in this field in any way must be prepared to start doing something about variety reduction so far as the use of instruments are concerned and so far as drugs are concerned, and we must also be prepared to start doing something in the way of cost-effective studies with regard to what we are actually doing.

On administration I do not wish to say very much. A lot will be said in the course of this debate. I agree that we should phase out one tier. I am not sure that I would like to discuss which tier, but whichever tier is phased out I hope it will be recognised that there is a real need to establish and preserve some kind of health service unit which has substantial local involvement, local commitment, and is capable of generating local pride in the health services within a locality. Let us not move away from that, whatever else we do.

On industrial relations I will say little. My noble friend Lord Rochester will deal with that aspect of the subject from our point of view. It is a very important aspect and one to which some answer will have to be found. I have no magic wand and I greatly doubt whether my noble friend Lord Rochester has.

Finally, may I say a word about finance and charges. I should like to refer noble Lords in particular to Recommendation 112 of the Royal Commission report, which substantially turns the Commission's back on the idea of charges at the time of need and recommends the gradual phasing out of charges. I am under no delusion that the National Health Service is free. It has to be paid for. I take the view, and my noble friends take the view, that it is better that it should be paid for throughout life on a taxation or insurance basis rather than at the time of need by the patient.

Here I must say a final word about the rumours with regard to a massive increase in prescription charges. With regard to prescription charges I merely say this, that a whole system of elaborate exceptions and exemptions, with season tickets or certificates of pre-payment, exceptions for this category of diseases or that, cannot make right in the end something which is wrong and a muddle to start with. If the present Government decide that they wish to make a charge, so be it. I would not agree with them. I believe payment should be spread throughout life and not levied at the time of need when the patient is least able to pay.

But surely that charge should be related to the actual demand made on the service. A prescription charge does not do that. The patient who spends three-quarters of an hour of a general practitioner's time for matrimonial advice, often very necessary advice, needs no prescription, pays nothing. The patient with diabetes who may want some insulin, cotton wool, surgical spirit, needles or whatever, might pay £2 or £3 and take only half a minute of the doctor's time. There is no relation to the cost of the drug. An individual drug might cost £50 a tablet and the patient will pay 70p. A prescription for iron and vitamins might cost a few pence a bucketful, but the patient may pay £2 or £3. Let us remember that the patient who costs the State money by having his pneumonia in hospital not only gets his drugs free but he gets his laundry and food and everything else free. The patient who has his pneumonia at home and saves us money has to pay a prescription charge on his drugs which could add up to £4 or £5 or even more.

Let us remember the consequences of prescription charges and what happened before. They lead first of all to poly-pharmacy; that is, an enthusiastic effort by the drug firms to save patients money by including in one tablet nine or ten ingredients which would formerly have been prescribed separately. It is not very good pharmacy, not very good therapeutics; but it is very attractive to the GP who wishes to save his patient money, so he prescribes that which in the end may cost the service a good deal more. This tendency to prescribe blunderbuss preparations, everything in one tablet rather than in several, could cost money in the long run. One other consequence of prescription charges is bulk prescribing. General practitioners will, as prices go up, prescribe in larger and larger amounts, particularly for elderly patients, in the hope that it will save them money. It will not save the Government money; it will in the long run cost money.

My Lords, I have gone on speaking for longer than I meant to. To conclude I would merely say this. I hope, and I feel sure, that in the course of our discussions on this Motion we will realise that what matters in the National Health Service is the patient. I would say that when those who work in the National Health Service and those who legislate about it in this House or in another place come to consider the Health Service entirely from the point of view of the patient, rather than from the point of view of their own wellbeing in their own work, whatever it is, then I think we shall make progress at long last.

My Lords, I beg to move for Papers.