The National Health Service

HL Deb 09 November 1983 vol 444 cc802-917

3.5 p.m.

Lord Molloy rose to call attention to the future of the National Health Service: and to move for Papers.

The noble Lord said: My Lords, over the centuries the British people have submitted many theories, principles and practical inventions which have been to the advantage of mankind. The principle of Parliamentary government was to lead to the principle of democracy and free speech. In the field of invention the British led the way by introducing very remarkable things which were all, as I have said, to the advantage of mankind. Then, at the end of the last war—probably the most horrendous war in the world's history—it was the British people who told the Government of the day, via manifestos and free democratic elections, to introduce a service which can be called one of the greatest examples of humane behaviour that this unfortunate world has ever witnessed.

In consequence thereof, if there is one piece of legislation and one social service creation that has quietly become "beloved and most valued" to the British people, it is the British National Health Service. It has excelled in the fields of both curative and preventive medicine; the prosthesis experts; the wide range of consultants, surgeons, dentists, dental surgeons, opticians, general practitioners and the whole array of doctors and nursing and midwifery skills and talents; ambulance staff and ancillary staff; dieticians, remedial gymnasts, orthoptists, chiropodists, speech therapists and radiographers; scientists, chemists, metallurgists and engineers—a vast plexus of crafts and skills, a truly mighty gathering of our nation's abilities and disciplines, all engaged in the most civilised and humane endeavour of preventing and/or curing disease and the ravages of sickness, and of easing suffering, and all united in their endeavours to make folk well again. I do not forget, either, those in the National Health Service who devote their lives and their skills and abilities to the tender area of psychiatry and mentalillness.

My first question to the Front Bench opposite is: Who, from this grand gathering of Britain's National Health Service talents and workforce, comprise the Secretary of State's tail of the service for the cuts programme? Who, of all that list, represent the tail which has to suffer cuts? I suggest that the real tail could well be the ministerial suite in Alexander Fleming House. I feel that it behoves us all to acknowledge that we are all involved in adhering to the command of Parliament, which, when the National Health Service was created, charged administrators, Ministers and, indeed, the nation to observe at all times certain fundamental principles; for example, To promote the establishment in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness and for that purpose to provide or secure effective provisions of services in accordance with the provisions of this Act. That applied to Scotland, too. The service was to be available at all times at the point of need to all our people, and was not to be denied to any British man, woman or child who was sick or ill on the basis of their inability to pay.

One realises the situation in the United States of America where, as I read only this week, there was a case of a man who spent 500,000 dollars on behalf of his wife who then died of cancer. I thought we had put that kind of thing behind us but, as I shall show, there are indications that some people want to bring that kind of thing back; want to make money out of suffering, disease, pain and anguish. It would be better to acknowledge this and decide in what direction we are going rather than blind ourselves to the facts and pretend that such is not happening.

We have to bear in mind that just a few years ago Parliament decided to look at the National Health Service because there had been all kinds of rumours to the effect that the NHS was not running properly, that there were abuses of the system, and so forth. Parliament in her wisdom set up a Royal Commission, and those who served on that Royal Commission included people who were chosen because they were not particularly enamoured of the National Health Service. When that Royal Commission reported, its members unanimously declared—including those who thought that the National Health Service needed some changes—that in the interests of our nation the NHS should return to the principles laid down by Aneurin Bevan when it was introduced just after the second world war. That is why I believe we must return to the original conception—for economic, industrial and humane reasons.

If the Government, by legislation, do not abolish the NHS, then they must fully maintain it, for it could be argued that surreptitiously to whittle away the NHS, or parts of it, would be in breach of the existing statute and would constitute an act of treachery designed to undermine our country's social services and damage the health of our nation; for to attack our National Health Service is to attack the British people.

Of course, there is a real danger to the NHS. We all appreciate and acknowledge that we cannot have such a wonderful institution, a great educational system, and practise all those things we wish to practise unless the economy of our nation is strong and we can afford to do so. It behoves employers and trade unions to realise that fact from time to time. Their actions should be judged as to whether they might damage institutions such as the NHS. If a strong economy is required in order to maintain a first-class NHS, then we must have a guarantee of growing economic development. That is vital to the future of the nation and certainly vital to the future of the NHS.

At the moment, the picture is not very encouraging. It cannot be very encouraging when nearly 4 million of our fellow Britons are on the dole—and among them are doctors and nurses. We have seen this week the incredible unison between the CBI and the TUC in expressing their apprehension about where the Government are going. It is very important for the future of the NHS to be examined without bias, and despite present-day concern all exaggeration must be avoided. The Government must also avoid bland dismissal of worrying facts or papering them over with ministerial banalities.

People are concerned and their fears are not allayed by the Prime Minister's assertion that the NHS is only safe in Tory hands—particularly when medical staff are among the ranks of monetarist-created unemployed. When the Secretary of State, Mr. Norman Fowler—the implementer of the cuts —declares his love and concern for the NHS, some of us could be forgiven for thinking that he sounds like Caliban making overtures to Juliet. The Secretary of State submitted to a Sunday newspaper, as Mr. Kinnock pointed out in another place, that spending on the NHS was up by nearly 17 per cent. more than prices. Economists of all persuasions have pointed out that this is a dangerously selective practice. It is true only in relation to the retail price index and not in respect of medical costs. As for the improvements claimed, any doctor's surgery or any hospital, noting the frustration caused by the increase in its waiting lists, demonstrates that there has been no improvement.

Indeed, the Secretary of State announced last month that NHS staff will be further reduced by 5,000—but that the reductions were not cuts. The Government's own statistics show the loss of hundreds of wards and jobs in hospitals planned for demolition. We have this information from one Government source while another Government source says the very opposite. According to Mr. Fowler, we are spending much more on the NHS. We all know that wards are being closed and that doctors and nurses are out of work, that waiting lists are getting longer, and that there is a fall in morale in the NHS—yet we are spending more. With the exception of the Prime Minister, Mr. Fowler is the first Secretary of State to be entitled to the accolade of achieving the apotheosis of mismanagement; spending more and getting less.

What is really distasteful is that the system devised in 1976 by the Resource Allocation Working Party— RAWP—included, inter alia, redistribution of resources within the National Health Service. Now this is foundering because of the Government's gradual reduction of the National Health Service's real share of the national income. It is this sort of thing that is causing concern throughout the land.

Let us examine some examples of the evidence of concern. The regional health authority covering Liverpool is now threatening savage cuts in a fairly new hospital which was opened just five years ago at a cost of £65 million. Savage cuts are proposed by the city health authority and many of them have been introduced. The cuts are condemned by the consultants in this hospital. Many of the consultants scout around the wards trying to find beds for new patients. Some in-patients have to occupy chairs while their beds are being used for day surgery. The health authority is now engaged in making cuts of nearly another £7 million in this particularly hard-pressed area of Liverpool.

The imposition of the manpower cuts are really deadly. They have been condemned by the BMA's junior doctors' section; by nurses; and by the ancillary staff. The Government argue that the cuts are efficiency cuts and do not affect patient care. That is the argument put forward by the Minister. What reply is made by general practitioners, consultants, specialists, junior doctors, nurses and all the others involved? These people, who form the back-up staff necessary for patient care, say that the idea that fewer staff makes for greater efficiency is given the lie in the wards of the elderly chronically sick, where nurses cannot meet work loads.

I am going to refer later on to the views of Care for the Aged.

When we turn to look at other evidence—I have not time to give it all—in the North West Thames Region there is an absolute tragedy facing Hammersmith and Fulham. The regional health authority has agreed to a reduction of 1,000 jobs, and that is 500 fewer than originally planned, as was pointed out by The Times newspaper. In the Brent area in the Central Middlesex Hospital cuts have meant that an electrocardiograph machine, a resuscitation machine and airflow fans—vital for patients—have all had to be cut out.

Then there is another pretty deadly element in the story of the North West Thames region. Some members of that authority demurred and found they could not go all the way with the Moscow type Government instruction. When they rebelled they received a letter—I am bound to say they included the noble and, if I may use the word, gallant Baroness Cox—saying that if they do not toe the line then out they go. It is not signed by Brezhnev, Stalin or anyone of that ilk, but it seems to me that there is not much difference in principle. That is something I believe all of us in this Chamber ought to look at very closely. Certainly I hope the Minister will give some assurance to the House when the reply is made tonight.

The job losses in the North West Thames region are estimated at 1,700; that is according to official figures from the BMA and the Guardian newspaper. But then to be fair—and I want to be very fair—take, for example, in the Trent area which covers South Yorkshire, Lincoln, Leicestershire and Nottinghamshire, there are gains there of 520 staff. The regional authority asked for 1,100. They were not dismissed out of hand; at least they got 520 more. The North East Thames Regional Health Authority is shedding 1,000 jobs. Ward closures are expected in Islington, Bloomsbury, Hampstead, Redbridge, Bethnal Green, Tower Hamlets, Enfield, Southend and Thurrock.

May I give another example from the Northern Region Health Authority. It is pretty well known that there was a tremendously stormy meeting at Newcastle-on-Tyne. People giving of their voluntary time having stormy meetings with doctors and stormy meetings with the chairman of the regional health authority, is something which is not nice to have to relate. I would have thought that in any civilised way of behaviour these cuts would not have been so savage and dictatorial once people realised the bitterness which would be created within regional health authorities. That health authority needs an extra 735 staff to develop hospitals in Northumberland, Tyne and Wear, Durham, Cleveland and Cumbria.

All this is somewhat confusing when one has to give credit to the Secretary of State and to the Government—and I readily give them credit—for the £2 million grant which has been given to health authorities to place severely mentally handicapped children in better surroundings. I think that is a wonderful thing to do. So what are we faced with? There is schizophrenia in the upper echelons of the National Health Service at the DHSS headquarters because we are getting Dr. Jekyll for a couple of days and Mr. Hyde for the rest of the month.

In Newcastle-onTyne—this is further evidence of the cuts—the district health authority was not allowed to join with Darlington for a more efficient laundry service which they had carefully worked out and which would save the authority no less than £100,000. The Ministry said "No way; Privatise". There is adherence to ridiculous dogma if you like! I can only conclude that the decision was made by another sick person.

There are areas in other parts of the country which are threatened and they have had clashes with their RHAs and with the Government. It is a very worrying list. When we are told that those concerned have no worry about the NHS, why is it that these massive quarrels are taking place in South Glamorgan, West Yorkshire, East Anglia, other parts of Wales and Scotland, Wessex, the West Midlands, the Oxford region and Devon? These serious skirmishes could lead to a serious national disruption which would benefit nobody and must be avoided. The Government seem intent on creating unemployed from the NHS, getting rid of doctors and nurses; they seem determined to have their cuts and if that great Government operation is successful they do not mind even if the patient dies. That seems to me an absurd way to work.

I mentioned the fact that in one aspect at least the Government—and I complimented them—had done something to help with regard to the older folk. But now Age Concern is one of the protesters. I want this House to know who these protesters are. We should try and get out of our minds that they are all agents of Moscow, adherents of Trotskyism, or anything of that sort. If you say that, then you are going to condemn a great many honourable people who have given their lives to the NHS. Age Concern say that authorities are discussing closing wards and discharging patients quickly to reduce staff. They say that this cutting down on in-patient stays is leading to an increasing number of elderly people being sent home or into nursing homes without adequate preparation for community care. Further cuts will be inevitable if the NHS suffers the cuts now being discussed by the Cabinet. These are not my words, they are the words of Age Concern.

What is Age Concern? Let us have a look at these people who have said these things. The governing body comprises representatives from all over our island, plus 70 major national organisations. They include representatives, from the Abbeyfield Society to the Women's Royal Voluntary Service. So the WRVS are associated with the words that I have just read to the House. In the view of Age Concern the cuts in this year's budget will force many health authorities to cut services to patients. From their experience this is a very serious matter.

Whom have we among the other protesters? There is the Association of Nursing Management, as constituted by the Royal College of Nursing. Also among the protesters is the Royal College of Nursing itself. There is the Hospital Junior Staffs' Committee, who have made a savage attack on the cuts and the dismissal of so many nurses, ancillaries and doctors. There is the Confederation of Health Service Employees, the National Association of Health Authorities, the Management Advisory Service, the National Association of Local Government Officers, the BMA General Practitioners Committee and NUPE. Then there is the statement made by the BMA itself in condemnation of these cuts. Last of all, there is the Labour Party.

Only today in the Evening Standard there is this article which was published just a few hours ago: Nurses" new alert over health cuts. The Government was firmly told today that the present round of NHS cuts cannot be achieved without standards of care—and patients—suffering … The Royal College of Nursing believes that the Government is right to want to get maximum value for every pound spent in the health service. But it cannot agree with the blood-letting regime the Government is imposing to achieve this. The Government is demanding too much too quickly. These cuts cannot be imposed without standards of care—and patients—suffering". Those are not my words, and they are not the words of the Labour Party, but of the Royal College of Nursing. Is that body totally irresponsible? We must get this into proper perspective. Let us look at what the BMA has to say. I shall not take up time by reading all of its statement, which is available for everyone to read. Part of it states: Concern for the future of the National Health Service was voiced by representatives of all the major sections of the medical profession at a series of meetings of central BMA committees earlier this month". The statement later continues: It is already clear that if the cuts are carried forward into next year, there will be serious consequences to patients. Accordingly, the Council's Executive Committee has decided that an urgent meeting should be sought with the Secretary of State to impress upon him the paramount importance of the Health Service being adequately financed for 1984/85". I hope that all Benches in this House will support the BMA in its endeavours when it makes representations to the Secretary of State.

There is also another little piece that it is not nice for me to have to read out, It states: The Hospital Junior Staff Committee of the BMA have asked whether doctors should inform patients in cases where they believe health is at risk because of lack of funds. BMA Council has asked the Central Ethical Committee to re-examine existing guidelines to see if they should he updated". The BMA also says: Figures for unemployed doctors have always been difficult to obtain and they will be even more so in future as under new Department of Employment rules people registering as unemployed are no longer obliged to state the category of their employment". I believe that all those protesting voices should be heard and that full cognisance of their views should be taken in all our interests.

The victims of the cuts range from young children to the old and enfeebled. It is at the extreme ends that one sees the gross and almost vulgar effects of the cuts: among the young, the very aged and the enfeebled. They have no organisations. They have no trade union. They form the group that Aneurin Bevan referred to when he said that silent pain evokes no response. There is silent pain in our nation among the old. There is silent pain among the really poverty-stricken and their young. It would be wonderful if this should be the Chamber that takes up their cause, as I hope we shall. We cannot go on like this.

Several noble Lords

Oh!

Lord Molloy

My Lords, this is an extraordinarily serious situation. I cannot imagine anything more unbecoming, when one feels deeply about people in pain, people with cancer, people who are suffering, and people with relatives who are mental patients, than that it should be met with grimaces and chuckles from some Members of the Conservative party. I find that distasteful as well. Let that go on the record.

Let me now turn to the administrative costs. It has been claimed that the costs of the NHS are exorbitant. In fact, the administrative costs lie between 5 per cent. and 6 per cent. of the total. That is about the same as in Sweden: it is half as much as in France; a quarter as much as in the United States of America, and so on. There is a massive need for a cut, but that is on the drugs bill. I am not enough of an expert to know precisely what the specialists say, but I have not met any specialist in this field who does not say that it is disgraceful and disgusting that £300 million profit a year should be made by the drug suppliers. They point out the vast waste of doctors' samples. That is an outrage and an insult to a civilised society. All these millions are spent in propaganda within the NHS when cancer has not yet been designated as eligible for free prescription. I think that is very sad.

I must say a brief word on the Griffiths Report. The committee saw no trade unions in the NHS. I do not think it even saw anyone from the BMA. The proposals, from what I can gather, represent a more massive change in human terms than any of the reorganisations of the service by previous Govern ments. I ask the Minister who is to reply whether he is aware of the £1 million that has been spent since the Salmon Report on management training. All that is discarded in this infamous Griffiths Report which has been totally condemned, in particular by the general secretary of the Royal College of Nursing.

I do not see why we could not have involved such people as the noble Lord, Lord Hill of Luton, with his knowledge and ability. We would have had a short, sharp, but to the point and accurate, report drawn from his great ability and understanding of the health service and its management. That would have been far better than we have had from this so-called Griffiths Report.

I turn now to another aspect that is causing disturbance within the NHS staff. They want to know whether the Whitley machinery is to be destroyed; or worse, whether it is to be reduced to the degrading and ignoble status of being nothing more than a Government-controlled appendage. I hope the Minister will give an assurance that that will not be the case. People who work in the frontline of the NHS—all sections of the BMA, COHSE, the Royal College of Nursing, consultants and general practitioners—feel that at the moment admissions to hospitals are being fought over at the level of dogs fighting over a bone. It is "your liver case against my heart case", or hip replacements against eye operations. These great practitioners and people in the NHS believe that it is degrading to their professions and an insult to their patients.

Is this a deliberate policy to encourage the private sector? There have been appalling reports of cosmetic surgery in private hospitals putting cardiac surgery in NHS hospitals at risk. For example, there is the supply of blood to Ross Hall—Glasgow's £10 million private hospital—from NHS intended sources. Here again, I congratulate both the Secretary of State and the Minister of State on the firm line they have taken. One must be fair. On that account one would wish to congratulate the Minister for defending the NHS. But we must see to it that this creeping malaise goes no further. Even now in our country a kidney can be obtained from overseas and transplanted in a person in the United Kingdom at a cost of £14,300 a time. For the private sector really to flourish our NHS must be under-manned and undermined.

There are so many other things I should like to bring to the attention of your Lordships, but time does not allow for me to go through every mortal development that has taken place in this great service. However, in my remaining few minutes I just want to submit that there are certain things that we should be prepared to do at all times. There is a feeling, supported by fact, that our NHS is sickening for something serious. The very air within the NHS is redolent with crisis. Never since its inception has there been such staff consternation at all levels. This should be a feature of concern for any non-arrogant Government.

The patients, the public, and the professions within the NHS are worthy of our support. I seek the support of the high intelligence and unparalleled experience of this Chamber to join with me to defend Britain's National Health Service, which has served our nation so well. The time is now upon us for all men and women of goodwill to rally to the aid of this civilized service, combining as it does great knowledge and tremendous expertise with comfort and understanding and encompassing the benediction of compassion.

In conclusion, I seek to invoke this day the support of noble Lords from all Benches in a fervent appeal to Her Majesty's Government to arrest their dangerous policy, to consult the best minds within the NHS and the voluntary organisations, to remove this threat and worry to our nation, to dispel the anguish, and to evolve a policy not solely determined by cut and cash considerations and not based on the discipline of threat and fear but based rather on the sustained energy of high morale, partnership, mutual trust and confidence. My Lords, I beg to move for Papers.

3.40 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Lord Glenarthur)

My Lords, I am sure that we shall all be grateful to the noble Lord, Lord Molloy, for initiating today's debate; but I do not think he will be entirely surprised to hear that I disagree fundamentally with nearly everything that he has said. However, I am pleased to say that there is at least one point upon which I am in total agreement with him: that is—if I paraphrase his remarks correctly—that the future of the National Health Service is of vital interest to each and every one of us.

I say that not just because the National Health Service is the country's largest enterprise, using about one-twentieth of our economic product and our workforce—although those facts must be of particular concern to any Government. I say it because the health service is, and has been—as the noble Lord himself said—a source of pride to the nation for the past 30 years. It is an integral part of our national way of life. It is on those grounds that it is important for all of us to debate its future. But that debate must be based on fact and sound reasoning rather than on some of the wild allegations, misrepresentations and even, I have to say, unsubstantiated smears. I think that the noble Lord knows what I mean. He talked about making money out of pain and anguish.

During the election campaign, and since, we have heard a lot of wild talk about hidden manifestos and savage cuts to the National Health Service. The party opposite has tried to demonstrate by the power of rhetoric alone that the National Health Service is being brought to its knees. It has to rely on rhetoric because the facts do not substantiate its claims. But the issues within the National Health Service which confront us now and will do so in the future call for a national discussion. That discussion must start from the point of view of the patient. None of us must lose sight of the fact that what the health service is all about is the delivery of care to people. Everything else is secondary.

Despite what the noble Lord has said this afternoon, I hope that our debate today can be a useful contribution to that discussion. I am sure that it will be. The list of speakers in the debate is certainly long. Many noble Lords who are to speak have considerable first-hand experience of the way that the National Health Service works. Their contributions will be listened to with care and interest, as also will the maiden speech of the noble Lord, Lord Ennals, to which I know we all look forward, even if I am in some doubt as to how he will remain uncontroversial.

Let me set the record straight. Let me dispel some of the myths advocated so stridently by the noble Lord, Lord Molloy. What are the facts? This year we shall be spending at a record level on the National Health Service—over £15 billions in Great Britain. That is double what we spent in 1978–79. The economic cost of the National Health Service is up by about 17½ per cent. since then. The cash provided by the Government, together with the improvements in efficiency we have asked authorities to make, should allow for growth in services of some 7½ per cent. since 1978–79. In the depth of the worst recession for half a century this shows up well against the actual record of the party opposite when it was in office. Let us compare what it now promises with what it actually achieved. It promised 3 per cent. real growth a year. That is twice what it actually achieved. Its most notable legacy perhaps was a cut of about one-third, which is about £310 million in capital expenditure. Understandably the electorate have not been impressed by its promises!

In the debate in another place a fortnight ago my right honourable friend the Secretary of State for Social Services gave some facts to counter some of the wild allegations of the opposition. I shall repeat some of them to your Lordships today. According to the latest available figures, we were treating 640,000 more in-patient and day cases in 1981 than we were in 1978. We were treating 2 million more out-patients and emergency cases. We were treating 18 per cent. more geriatric in-patients and 14 per cent. more geriatric out-patients. We provided more than 2 million more courses of dental treatment. We gave 670,000 more sight tests. Almost 400,000 more people, most of them elderly, were visited at home. I could go on, but surely that is enough to show not only that we have demonstrated our commitment to the NHS with additional resources over the last four years but also that we have ensured that the National Health Service makes more effective and efficient use of those resources. We still face serious and difficult problems, but by any objective measure the health service has improved substantially during the life-time of the present Government. It is continuing to improve.

There is another area on which we have heard much ill founded comment in recent weeks. The noble Lord, Lord Molloy, drew attention to it. That is the question of manpower levels within the National Health Service and the steps that we took to control them. Again, let us look at the facts. The NHS pay bill accounts for some 75 per cent. of revenue expenditure in hospital and community health services. The NHS is the largest employer in Western Europe. In England we employ more than 1 million people. That is a whole time equivalent of about 820,000. Between September 1978 and September 1982 the numbers of staff working in the NHS increased by about 76,400. That is over 9 per cent. Most of the growth was in front line staff—that is to say doctors, nurses, professional and technical staff—in other words, those most directly concerned with patient care. Any discussion of the reductions in manpower required by 31st March 1984 must take account of the size of the National Health Service and the rate of growth which I have just described. We have asked for a reduction of 4,837 jobs. That is about half of 1 per cent. As we know, that request caused an uproar. The noble Lord referred to it. But I believe that such concern is seriously misplaced. It simply is not possible to suggest reasonably that a service employing 820,000 people cannot find manpower savings of 4,800.

The Economist on 1st October put all this into perspective. I am well aware that there is a difference between manufacturing industry and the National Health Service, but the article states: Much of manufacturing industry has found that it can take 10–20 per cent. job cuts while maintaining or increasing production; many offices have lost 5–10 per cent. Yet it is said hospitals cannot endure 1 per cent. Really? No one can seriously argue that a reduction of one half of 1 per cent. means the collapse of the National Health Service. The pay bill accounts for such a high proportion of expenditure that effective control of resources must mean control of manpower.

But this debate is about the future of the National Health Service. I have spent some time setting the record straight because it is important that we consider the future with a good appreciation of where we stand now, and what we have achieved so far. I hope that we should all agree that the health service should not only be effective but also as efficient as possible.

I hope I have made clear our firm commitment to the principle of the National Health Service and the present means of funding it, which is primarily through taxation; yet that commitment and the extent of the resources we are devoting to the health service make it even more important to ensure that we get proper value for the taxpayers' money. I have heard people being cynical about the scope for efficiency savings; yet the concept of cost improvement is central to good business practice, and has been for years. It is just as relevant to the health service. If good management can reduce the cost of providing particular services, then more resources will be available for additional patient care. That is simple and it is obvious. How can anyone suggest that in any enterprise the size of the National Health Service there is no scope for cost improvement?

The present Government were elected with a clear policy to improve management and cost control, and that is what we shall continue to do. We have already taken a number of initiatives. These include the work done on the development of performance indicators, on the collection and use of information, and on the audit of National Health Service performance. We have introduced Rayner scrutinies. All of these should be of great assistance to management in their rigorous and systematic pursuit of efficiency and effectiveness.

A crucial element of this is the maximum delegation of responsibility to local health authorities. But delegation in this way must be accompanied by systematic monitoring to ensure that district health authorities are accountable to regional health authorities, who are themselves accountable to my right honourable friend the Secretary of State. That is why we have introduced the system of annual reviews which hold health authorities to account for their performance, a major element of which is management of resources. The reviews enable Ministers to scrutinise the progress made by authorities in the past year towards agreed plans and objectives and to agree with the chairmen the progress and development to be achieved in the following year. That is how Ministers hold regions to account, and, as I have said, the regions in turn hold their constituent districts to account.

We have made some progress, therefore, towards achieving greater cost improvement within the health service. I stress again that cost improvements mean improvements in patient care. A fortnight ago I repeated to your Lordships the Statement made by my right honourable friend the Secretary of State for Social Services, about the National Health Service management inquiry, the Griffiths Report, to which the noble Lord, Lord Molloy, referred. At that time not all your Lordships had had an opportunity to read and digest the report. I am sure that by now your Lordships will have done so and, perhaps despite what the noble Lord. Lord Molloy, says, there will be some agreement that it does represent a valuable contribution to the discussion of the future of the National Health Service. The report has not been totally rejected by those bodies to which the noble Lord, Lord Molloy, referred in his opening remarks.

As I have described, the Government have already taken steps to make health authorities accountable for the services that they provide. The Griffiths Report points the way to a yet more effective management system. The theme running through the report is that a clear management responsibility should be identified for carrying out all National Health Service management functions and that this responsibility should be devolved as near to the patient as is practicable. Surely this makes sound common sense in the interests of both sensible management and better patient care.

There are those people who have suggested that the report will lead to the end of consensus management. That is not so. Of course, the vast majority of decisions will be reached by consent, anyway. But if we are to escape from what Griffiths called lowest common denominator decisions and long delays in the management process, there must be a clearly identified general management function which applies to decisions which cannot be reached by consent. Griffiths also stressed the importance of a clear line of accountability within the National Health Service. I cannot emphasise too strongly that this is not a prescription for hundreds more administrators or more tiers within the National Health Service. The report recommends that managers should be drawn from the existing disciplines and professions which are already engaged in the management of the National Health Service.

There is one emphasis within the report to which I should particularly like to draw the attention of your Lordships. It is one that should have been present throughout the history of the National Health Service, but which has, I think, at times been disregarded. It must be more apparent in the future of the National Health Service. The report observed—and it reflects what I said at the beginning: It therefore cannot be said too often that the National Health Service is about delivering services to people. It is not about organising systems for their own sake". Later it stated: Our advice on management action is not directly about the nature of the services provided to patients. But the driving force behind our advice is the concern to secure the best deal for patients and the community within available resources … I commend that thought to your Lordships and all those who consider the substance of this report.

My right honourable friend the Secretary of State has begun to consult the health authorities and professional and other interests involved within the National Health Service. I have no doubt that those consultations will be fruitful and that we can soon begin to make improvements in the National Health Service management along the lines recommended by Mr. Griffiths and his team.

There are few things certain about the future, but we all must do our best to ensure that the problems which will undoubtedly arise do not take us completely by surprise. The pace of medical and technical advance makes accurate forecasts of the capacity of the health service extremely difficult. But now, as in the future, the resources available to devote to the health service will depend ultimately upon the state of the economy in general. However, it is a safe assumption that available resources will never outstrip demand. That demand will, to some extent, be determined by demographic factors, such as changes in the age structure of the population.

The demographic changes projected for the future are complex, with falls as well as rises in the number of old people in relation to the rest of the population. The number of people over 65—which has risen by more than a third over the past 20 years—will not remain more or less stable as a proportion of the population until about the year 2010. Thereafter the number will increase as the post-war baby bulge reaches retirement age. Within that total, the numbers of elderly people aged over 75 will increase quite rapidly during the 1980s— by about 20 per cent. between 1981 and 1991—but the rate of increase will tail off in the late 'nineties. The demands on the health service from this demographic growth must therefore increase, in particular during the next 10 years.

Being old is by no means equivalent to being dependent—

Noble Lords

Hear, hear!

Lord Glenarthur

However, there is a link between numbers of elderly people and demands on the health service. At present, patients over 65 already represent a quarter of cases in the acute specialties and 40 per cent. of the occupied beds. Yet an increase of 50 per cent. in the numbers of those aged 85 is forecast for the next 20 years. The most recent provisional forecasts suggest that even larger increases may occur—perhaps over 60 per cent. All these facts are quite crucial to any discussion of the future of the National Health Service. This factor of age was brought home to me very forcefully at first hand yesterday when I visited Guy's Hospital and saw some of the patients on the medical wards there.

Of course, the National Health Service should not be seen as standing on its own. It is not isolated from the rest of the community, and so I should like to say a few words about the voluntary sector. In this country we are blessed with a strong, vibrant, and very generous voluntary sector. The voluntary organisations active, for instance, on behalf of elderly people, the mentally handicapped and the mentally ill, already make an irreplaceable contribution to providing the necessary support for them. This compliments the statutory services. The rational partnership between the public sector and this voluntary effort is an example of the flexibility that we shall need to sec developed further in years to come.

At the beginning of my speech I stressed many of the Government's achievements for the National Health Service. Those achievements form the basis of looking to the future, but let there be no doubt that we shall face difficulties in the next 30 years, just as we have faced them in the last 30 years. We have made significant progress for all the priority groups—for elderly, disabled, mentally ill and mentally handicapped people—and yet services are still sometimes inadequate or unsuitable.

We are making steady progress in reducing waiting lists, although our progress was somewhat interrupted by industrial action last year, and yet waiting lists and times are too long in some specialties and some localities. We are making important headway in extending to many more patients the benefits of medical and technical advance and yet the provisions of such acute treatments as coronary surgery and haemodialysis in chronic kidney failure still falls short of need. We have done much to achieve more equal distribution of resources yet there still remain geographic imbalances in standards. There still is much to be done in persuading people to adopt healthier life styles.

Nevertheless progress is being made. Let me give three examples. First, primary health care in inner cities. We received a report from a study group chaired by Professor Acheson highlighting the problems of providing primary health scare in inner London. Another report, from a committee chaired by Dr. Harding, indicated that similar problems arose in other inner city areas. We commended those reports for action locally, because that is where the primary responsibility must lie. But we recognise that health authorities in inner cities do face particular difficulties. My right honourable friend the Secretary of State announced last week that we were making available an additional £9 million in total to these authorities.

We have already given a total of £1 million to health authorities in inner cities to help meet the costs of training health visitors and district nurses, as recommended by the Acheson report, and we will continue to give help on that. We have made a further £1 million available to health authorities this year for projects in the primary health care field in inner cities, and further money will be available for that in future years. We have introduced a new improvement grant scheme to meet 60 per cent. of the cost of improving poor quality general practice premises in inner city areas, compared with the present grants of 33 per cent. We expect this scheme to cost some £2½ million over the next three years.

These steps are only part of our continuing efforts to tackle the problems of primary health care in inner cities. We are resolved to strengthen primary health care, in partnership with health and local authorities and the professions, and will continue to concentrate help on the most needy areas. This is a long term investment in the future. The results are not always immediately apparent, or dramatic. They do not stand out as shiny new hospitals. But the impact on health care will be significant.

I should like to mention bone marrow transplant treatment. I am glad to say that my honourable friend the Minister for Health was able to announce the provision of a further £150,000 this year—equivalent to £500,000 in subsequent years—to the London hospitals who provide the majority of bone marrow transplants. At present, facilities fall tragically short of growing demand. This will enable them to carry out more transplant treatment.

Thirdly, a further piece of excellent news is the outcome of the 1983 national children's dental health survey, the preliminary results of which we announced yesterday. Substantially fewer children in this country are suffering from tooth decay compared with 10 years ago, the time of the previous national survey. Among 5 year-olds, 48 per cent. now have had tooth decay compared with 71 per cent. in 1973. This is a remarkable improvement, although it is not so marked among older children. We are certainly not complacent about the results, as too many children are still suffering unnecessarily from dental disease and there is still some way to go. But it is certainly encouraging.

Returning to general matters, it is not enough simply to call for more resources to remedy these and other deficiencies. It is a simple fact of life that cannot be over stressed that the money available for the National Health Service ultimately depends upon the performance of the national economy. The Government are determined to maintain soundly based economic revival to sustain the resources necessary for the health service; but the economic framework in which we live is inescapable. That is why we must—and we will—continue to put the emphasis on improvements in the use of existing resources to provide better services.

The health service has always shown itself capable of adapting its practices and programmes to meet conflicting pressures. New patterns of treatment have been developed to meet the requirements of demographic change, technological advance and modern concepts of care and support. We need this flexibility in the future if we are to meet more fully the present challenges and those that are still to come. That will not be easy but progress seldom is.

So I welcome this debate today. We need nationally a constructive debate on the future of the National Health Service. We all want a modern health service, a service equipped to meet the challenges of the 1980s and the 1990s. We already know what some of the problems will be. Your Lordships will have noticed that the Labour Party is not slow to describe those problems. What it can rarely do is put forward sensible, economically sound proposals to meet those problems. Generalisations will not do.

Calls for unlimited additional resources will not do. We have put forward our strategy and have made significant progress towards meeting our objectives. Let us debate and build on that progress on the basis of a sound appreciation of the facts and a compassionate awareness of the problems.

4.6 p.m.

Lord Diamond

My Lords, I, too, should like to offer the thanks of your Lordships' House to the noble Lord. Lord Molloy, for introducing this debate on a topic of such importance. It is right that we should discuss a subject of such topical importance by virtue of the reductions in cash limits which have given rise to the debate but which the noble Lord, Lord Glenarthur, did not, I think, waste a moment of your Lordships' time in referring to.

In addition to offering your Lordships' thanks to the noble Lord. Lord Molloy, I should like also to extend to him my personal thanks. Although, if I may confide in your Lordships, I have some difficulty with my eyesight, after listening to the noble Lord I am much reinforced in the view that there is nothing whatever wrong with my hearing.

I shall not be talking to your Lordships about the most important topics to which both the previous speakers have already referred—the services offered by the health service, which I have enjoyed over many years and to which I want to pay tribute. There is nothing I can break that the health service cannot mend with considerable skill in a reasonably short time. I wish to express my deep gratitude and to repeat my often stated appreciation of those women of great skill and great caring who form our nursing profession and with whom I came into close contact when I was for six years a member of the General Nursing Council.

Many speakers, including several from these Benches, will be talking about the details of the services provided. I wish to go back to the decisions made by the Government, which showed how they were choosing to spend their money. No one suggests that the Conservatives are against the health service in the sense that they wish to destroy it; but that is not what government is about. Government is about choosing. If I may say so, gouverner c'est choisir.We are all familiar with that. What did the Government choose when they were faced with difficult decisions which face every Government?

I am sure that there is no need for me to fill in the background. We are talking about a continuing Government which have been in power all the relevant time. Of course, this House was dissolved. Parliament was dissolved. But the government were not dissolved. Government Ministers have to keep in the closest touch with their departments throughout a general election. The Government continue, and have continued, much to the satisfaction of noble Lords opposite. That is the first point that I wish to underline.

Nor do I need to remind your Lordships of the differences between what is called controllable and uncontrollable expenditure, or demand-led expenditure; namely, that kind of expenditure which means that, having committed yourself to a certain principle of support, you are required, as a Government, to provide the money whatever the total may be if the number entitled to the benefit rises. One example is the unemployed. Another example arises in the health service. If in one year there was a totally unexpected number of epidemics, totally out of line with previous experience over many years, one would be committed to paying the increased cost of the National Health Service.

However, there is nothing new in this whatever. There are two well-established safeguards. The first is the preparation of accurate, realistic estimates based on experience going back over many years. If I may be allowed to say so in regard to my old department, it should be noted that Treasury officials are quite brilliant at making accurate estimates. The second safeguard is the contingency reserve. As mortal human beings we do not claim, any one of us, to be able to foretell everything that will happen. Therefore, whether we be a housewife planning monthly, weekly or annual income; whether we be a business proprietor preparing budgets for the business; or whether we are a Chancellor of the Exchequer preparing Budgets for the nation, we all provide a contingency reserve to cover those matters which we cannot foresee.

That is the background to the comments what I wish to make. I shall begin with March this year, when the Government were faced with difficult choices and were grappling with the problem of what to do in this, their undoubted last Budget before a general election. It was clear what they would have liked to do. They would have liked to make a reduction in taxation as they had promised, and so redeem their promises, particularly to their own supporters. That, of course, would have meant a reduction in the revenue available to the Government to cover expenditure. They would have liked to maintain the public services which the public enjoy so much and which, during a general election, they would be concerned to ensure were maintained. They would have liked not to increase their borrowing requirement excessively, because that would destroy or damage enormously the whole of their financial posture and policy. Those were the three difficult objectives which the Conservative Government would have liked to achieve in March this year, when they were considering what to do about their Budget.

They had to make a choice. What did they choose to do? They chose to pretend that they could serve all three purposes at one time. They chose to pretend that, by cutting the contingency reserve, they could achieve that objective. The contingency reserve is a sensible, percentage reserve which is put in to cover unforeseeable expenditure. Last year it amounted to £2.4 billion. In March, when the Government were considering what the contingency reserve should be for this year, they should have provided £2.5 billion on the basis of the increase in total expenditure. What did they provide? It was £1.5 billion. These are the only figures with which I will bedevil your Lordships this afternoon. In short, they provided £1,000 million too little to cover the likely additional expenses with which, on the basis of previous experience, the Government would be faced.

Was that a solution to the problem? Of course it was not. It was merely a demonstration of the Government's culinary expertise. It was merely making an attempt to do the impossible. There was perhaps a desire to save time, and in the time saved to win a general election, when all this could be either swept under the carpet or dealt with in some other way. But nobody seriously expected that the Government could get through the year on the resources that they were providing—and that is what turned out to be the case.

In March they provided £1,000 million too little for unanticipated expenditure. In July they were trying to explain away why unforeseen expenditure was causing an overspending of £1,000 million—exactly the same figure. I do not believe that it can be explained away. We have the examples of uncontrollable expenditure that were given to us when this matter arose on an earlier occasion in your Lordships' House. One example was unemployment pay, and the other was agricultural support. I am bound to ask your Lordships: What is new about unemployment under this Government? Why could not the figures have been prepared accurately? As regards agricultural support, that is a problem that arises year after year. I remember it as far back as 1964, when I was first appointed Chief Secretary. It goes on year after year. The Government have a great deal of experience to enable them to answer questions under both those headings as regards what the likely expenditure will be in the following year. If they underestimate slightly, they have the contingency reserve, which will easily cover any slight excess.

The reason why we are facing this situation in the health service and why we are having this debate today is that before the general election the Government chose to ignore the warning that they were receiving. It is the Chancellor of the Exchequer himself who has told us that information about the level of expenditure comes almost daily into the Treasury. It is he who has told us that this trouble first arose in the first quarter of this calendar year, and continued into the second quarter. I can be reasonably certain that the red light was showing already in March, when the Government published their figures, including the reduced figure for the contingency reserve.

It cannot be claimed that this argument went by default during the general election. Time and time again the Government were asked what their plans were after the general election for maintaining the public services, and in particular for maintaining the health service. Not once did they explain that it would have been unnecessary to cut back on so many programmes, as these financial cuts require, had the normal reserve to meet contingent unforeseen expenditure been made. Not once did they explain that, had they provided realistic forecasts revealing any necessary cuts before the general election, the Government would not today have been in this difficulty.

Nor did they attempt to put matters right after the general election. After the general election it was open to the Government not to force all these cuts upon the variety of public services but to say, "We will not proceed with our tax reduction programme so as not to reduce our income, so as not to make us cut our expenditure". They did not so choose. They chose to re-enact the tax savings, which are savings in the hands of the taxpayers, and reductions of income available for social services, which are in the hands of the Government.

The Government now seek to maintain that they are not cutting back health service programmes because they are maintaining the health service in total, undiminished, as compared with what was in the Estimates before the general election. That is an absurd claim. When a voter asks at the time of a general election whether or not the health service is to be maintained, he is not asking about a statistic appearing in a White Paper running into an incomprehensible number of noughts; he is asking about the particular service which he is enjoying and wishes to continue to enjoy, and about what he needs, and he wants to know whether that will continue to be maintained.

Not once did the Government say, as they should have said. "The probability is that your particular service will have to suffer some diminution in the interests of other services which are going over the top". Instead the voter was told, as we have been reminded by the noble Lord, Lord Molloy, "The health service is safe in the Government's hands". In short, before the general election the Government chose to ignore the red light. During the election they did not tell the nation their full intentions. After the election they chose tax cuts to the promised maintenance of social services.

It is a sorry tale of withholding part of the truth for electoral advantage. It is on a par with the new employment figures, where we are denied the knowledge of what the comparable figures would have been on the original basis. From my own experience on a certain Royal Commission, every respectable provider of figures regards it as a duty, if changing the basis on which figures are prepared, to continue the series on the old basis so that people can continue to make comparisons. Therefore, the health service patient has suffered a further setback to the satisfaction of his urgent needs and the Government have suffered a further blow to their credibility.

4.23 p.m.

Lord Wallace of Coslany

My Lords, as official spokesman from these Benches it falls to my pleasant lot to thank my noble friend Lord Molloy for raising this vital issue today, an issue which is worrying many people throughout the country. I also look forward to hearing the maiden speech of my noble friend Lord Ennals for two reasons. First, he was lucky enough to follow me in Norwich North. Unfortunately, the Boundary Commission decided that his stay would not be too long. But we welcome him to this House and he is to follow me again today; not that at this Bench I boastfully claim to know better than he does, for he has great experience in this field.

I should also like to compliment the noble Lord, Lord Glenarthur, on his speech. Yes, he read it beautifully, so much so that I was bemused and thought that I was listening to a series of commercials. That is all it was—broad claims of achievement: "Everything is all right in the health service; we will do even better". But everything is not all right in the health service. This is something that many of us who are perhaps closer to grass roots level realise.

To some of us the National Health Service is a very emotional subject indeed. I did not intend to relate this, it is not in my notes and I must be careful not to get worked up over it; but, like many other people, my family has personally benefited from the health service. It so happens that on a cruise in 1979on the "Canberra" my wife fell and broke her hip. The nearest port of call was Tarragona and she was then to be taken to the University Hospital in Barcelona for treatment. She was landed from the ship and placed in an ambulance, but the ambulance drivers demanded money before they would drive her to the hospital. When we arrived at the hospital I was told that it would be better for me to stay there than elsewhere, and I soon found out why. First, my wife was X-rayed by the radiographer who I saw was smoking a big cigar. She appealed to the radiographer to put it out because she felt ill. Later I found out why I had to stay in the hospital—I was the nurse. Every morning at about five o'clock I was up washing my wife and attending to her toilet needs before going out and searching for some breakfast. Nursing care was minimal. Then, after three and a half weeks in hospital there was the long drive in an ambulance to the airport and from there a flight to Heathrow.

When we touched down on British soil, the situation began to alter. First, we were taken to the wonderful medical centre at Heathrow, where my wife was properly prepared for the long journey by ambulance to our local Queen Mary's Hospital. When we arrived at Queen Mary's, a team of doctors was waiting and the consultant was on the other end of the telephone waiting for some information from his team. A team of nurses was also present. That was the situation and from then on I had no responsibility. However, the important point is that when my wife was in the hospital bed, and still in pain, she looked up and said, "Isn't it nice to be home!" "Home" was the National Health Service where she knew she would be properly cared for after that very traumatic experience.

It is small wonder that many of us are very concerned and worried about what is happening to our service today. We all know, and we might as well be honest and truthful to say so, that the National Health Service has been faced with financial problems for many years, but it has coped. In the early mismanagement days we made do, we mended and got things done, and we achieved patient care. The service became the envy of the world for its standard of care.

However—and I say this with the greatest respect—the decline of the National Health Service began in real earnest with its reorganisation into a three-tier structure. This reorganisation of the National Health Service by the Government of 1970–74 was an absolute disaster, saddling the service with a costly bureaucracy and a financial burden beyond its capacity to cope, and—mark this!—from which it still suffers. In my view, the problems which the National Health Service faces today started with that misguided, badly thought-out act under Sir Keith Joseph, whose department, as far as departments are concerned, is a somewhat political albatross.

Then, to some extent, a degree of sanity returned in the last Parliament—and I want to give the Government credit as a fair "do"—when we returned to a two-tier system of administration. However, by then the service was punch drunk and although the second reorganisation was estimated to achieve eventual economies and savings (about which we still have to hear), the interim period, still prevailing, has resulted in a loss of valuable, experienced staff, particularly in the senior nursing field, and the new administration has not yet had time to settle down to the extent needed to face the severe financial restrictions now being imposed.

Time and time again we have been told that, under the present Government, the National Health Service will be safe and protected by them, and we have heard it again today. But I cannot help remembering the opposition that the Labour Government of 1945–50 faced in this very Chamber when they introduced legislation to bring into effect the ideal of a National Health Service freely available to all, irrespective of class, colour or creed. A great ideal! The fact is that the Conservative Opposition at that time voted against it. I know: I was there. Is the National Health Service safe under the present Government? One can only deal with what has happened since 1979. In the first full year of government led by Mrs. Thatcher the National Health Service budget was cut by £147 million; in the second year by £20 million; in the third year, it is agreed that allowance was made for growth, but it was at some expense to the pay increases of the health authorities' workers. Now further growth is extremely small and more financial restrictions are being placed on the service, leading to further hospital closures, lengthening waiting lists for hospital beds and congested, extended queues for outpatient treatment.

There is no shadow of doubt that the standards of health care are falling, and will continue to fall, as a result of the cuts being made, as already indicated by my noble friend Lord Molloy. The warning comes from the BMA, the Royal College of Nursing and many other professional organisations of high standing. Age Concern is naturally worried about the increasing age of the population and the effects the cuts will have on the elderly. The cuts now announced by the Government cannot be expected to come much from administration, which accounts for about 2½p from every pound devoted to the National Health Service.

I speak with some experience here, and certainly at hospital level the administration is small and being stretched at present to its absolute limit. The bulk of administration costs arises at regional and ministerial levels. I ask the Government and the Minister what economy measures have been taken in that field which is so busy imposing cuts at patient level? The rapidly worsening situation in the National Health Service has inevitably led to an expansion of the private sector, albeit aided and abetted by the Government by tax concessions, relaxation of controls on private hospital developments and other measures. Of course, not all private schemes plough back profits into further expansion. Many are profit-making concerns. Private treatment is selective in the sense of ability to pay and the range of treatment available. In other words, what one is suffering from, or whether one is elderly or classified as chronically sick, are important considerations. Costs vary. These are approximate figures, and I may be corrected on this, but it costs approximately £600 to £1,000 a year for membership of medical insurance schemes. I understand that the fees are now going up.

I stand at this Box and once again say that of course in this democratic country the individual has a right to choose, but there can only be one priority in health care and that is medical need and not ability to pay. At the moment, and let us face it, priority can be bought. People are told that if they go private they can reach the head of the queue, be seen before the out-patients and will receive preferential treatment. That is why so many people are beginning to support it, led by the alarm and despondency felt in the NHS. It is morally wrong that in sickness priority can be bought if one has the money. It is morally and socially absolutely wrong. I find it ironic that the bulk of the medical and nursing staff in the private sector have been trained at great public expense, mainly in the National Health Service. I ask again, as I have asked before, what measures are the Government taking to effect recovery of public money so expended? Is there to be a levy on the private sector? I had a hint from a former Minister that that might be so. I have not heard any more.

Not only that, but National Health Service premises and equipment are being used by National Health consultants working part-time in private practice. That is, of course, allowed, but that is not the point. What charges are being made for such use? I know that in some cases no charges are being made. Are the Government satisfied that adequate adminstrative facilities exist for full recovery of such charges? One public auditor has already drawn attention to the fact that thousands of pounds have been lost in one health district due to lack of recovery of charges that should have been made for private practice.

I want to say a brief word about the blood bank. I welcome the imposition of administrative and transport charges on supplies of blood to the private sector. That is fair enough. One cannot charge for blood as that is something that one almost cannot face. However, there is public concern over the matter which might be eased by a charge. Nevertheless—and this is the point which worries me—most people donating blood, excluding some who support the private sector, do so because they feel they are helping the National Health Service. I sincerely trust that the revelation that blood is now being supplied to the private sector will not have an adverse effect, as it could. I appeal openly to blood donors not to misunderstand the situation, because blood is urgently needed for treatment in hospitals.

The National Health Service has pioneered considerable research and the cuts are having a serious effect on future development. New technology has produced a revolution in the treatment of disease, but lack of finance means that many hospitals cannot bring new hope to their patients. Fortunately the position has eased somewhat as a result of public voluntary effort. Local hospitals are a vital part of the community and of community life. Leagues of friends, individuals and collective efforts have secured considerable public support in raising funds to obtain badly needed new equipment which otherwise would not be obtained owing to lack of public funds. This, let us face it, is one encouraging factor in a very difficult, worrying, severe situation.

The cuts in staffing levels—with the demand for nearly 5,000 jobs to be lost by next March, although that is rather downgraded by the noble Lord, Lord Glenarthur—is bound to have a serious effect on patient care. Here is another point student nurses already near the end of their training are facing a bleak future. It is rather strange that parents who have met me quite casually, not knowing who I was, have said that their daughter was a student nurse and that they were getting a bit worried because she appeared to have no prospect of employment. It may astonish your Lordships that one case of which I heard recently was that of a nurse who was trained in a famous hospital; on completion of training she eventually managed to get a job—in a butcher's shop: not exactly the type of surgery she expected to deal with.

It might well be that the favourite sphere for reducing staff will be the ancillary workers. What many people fail to realise is that these people are an essential part of the hospital team. Cut the ancillary workers and immediately the workload of the nurses is increased, leading to reduction of patient care. This fact must be realised by the theoretical planners, from whom heaven preserve us! The noble Lady, Baroness Gardner of Parkes, may have heard that harsh remark somewhere else.

In spite of the Government saying that efficiency savings will help the service, the so-called savings imposed on the health authorities, particularly in the London and outer London areas; mean cuts in real terms; and the severest cuts are in the south-east area. I live in the Bexley health district. The health authority first had a cash allocation for the present financial year cut by £300,000. Then, half way through the year, a manpower cash cut of 0.5 per cent. was imposed; but, by that time, a number of the existing staff vacancies had been filled. This now means that the 0.5 per cent. has become 2.1 per cent. and, before March, will almost certainly reach 4 per cent. to 5 per cent., because of the short period existing before the deadline of next March.

The whole trouble is that the manpower reduction imposed by next March has upset time-scales in health district areas and the notice is far too short for adequate arrangements to be made. Therefore, economies have to be forced in another direction and patient care will suffer. Are not the Government capable of rethinking that particular point? Desperate efforts are being made in this health district to avoid reduction of patient care and services generally, but the situation is becoming impossible. A further hospital closure is under review. At Bexley Mental Hospital, one ward has been closed and patients transferred to the others, the net result of which is more patients to available staff—the situation that we should all deplore. In addition, to save money and staff, a continental breakfast only is now being served. The urgently needed secure ward is unlikely to be opened for lack of cash provision for staff.

Generally, overall in the health district a reduction of some 160 staff has been demanded. At Queen Mary's Hospital, a hospital which is very close to me, one ward has now been closed and its beds transferred to others, which means an overall reduction in beds available. Accident and emergency provision is under constant threat of suspension. An extension of Queen Mary's maternity unit, provided to cope with the scheduled closure of the Woolwich Mothers and Babies Hospital, may not fully open due to lack of staff provision. And the muddle goes on. At the local angle, this is only the tip of the iceberg. The future is frightening to those involved or to those who care deeply about their local health service, which, in the words of the present chairman, an estimable lady, is being run on a shoestring.

While we discuss the National Health Service, we must not overlook the social services which are such an essential part of health care. Here, again, there is a real threat to vital services as a result of the Government's policy of rigid control measures in local government finance dictated by Whitehall. We are all told so frequently that it is all a question of financial priorities or that the money is not there. It is a strange thing, but much of the move for the National Health Service arose from the last world war, because the old system was not capable of dealing with expected casualties, military and civilian. On that theme, in a newspaper last Monday I read that the wreckage of a Tornado aircraft, costing £16 million, had been recovered; and, recently, two Harrier jump jets had crashed, each costing £7 million. They will be replaced; squadrons must be kept up. Priorities, my Lords? Do we not live in a strange world?

Now, the theoretical planners have come up with another bright idea from management, that of appointing executives instead of consensus management—similar, I assume, to those expensive people in local government. It is a change to be reviewed with great care. After all, the National Health Service, with its complications and sensitivity, cannot be run like Woolworth's or Marks and Spencer or even like a grocer's shop. That greater efficiency at management level can reasonably be asked for I would entirely agree, but one must remember that the further reorganisation has still to settle down. In any case, we are dealing with a public service which, to the consumer, the patient, is extremely personal and sensitive. Parliament must go into this suggestion deeply and carefully before a final decision is reached. Personally, I do not like the idea at all, but that is not to say that it is not a good idea. It is worth discussion.

Privatisation—Oh, what a horrible word! Can we not get rid of it? I do not know whether it appears in the Oxford Dictionary but it is a horrible word. It is creeping into the National Health Service—well, not exactly creeping; it is being forced, regardless of local circumstances, by the Government. Cleaning, catering and laundry services for health authorities have to go to private tender next year. These are ancillary services of the health service and, in themselves, are specialist areas. It has not been unknown in the past for such aspects of cleaning as washing down walls to go out to contract. But, even so, simply because they are dealing with hospitals, contracts have to be negotiated and operated with the greatest possible care. Catering for hospital patients, including special diets, is a complex business. Laundry services can involve high risks unless carefully controlled. To a great extent, this applies also to cleaning—especially in operating theatres and treatment areas. Instead of exerting pressure, the Government should in the main leave decisions on going out to contract to people in the local areas and not make demands for demands' sake. We are getting far too much these days of the "Whitehall knows best" approach.

The House will note that mainly I have deliberately refrained from quoting statistics or percentages. As an old politician, I am only too well aware that these can be manipulated to suit one's purpose on either side of the Chamber, whatever party one belongs to. What I have done is to dip into the personal experience of many years, not only when, like many others, I was fighting for a national health service, but also when involved at management level going back right to the start in 1948. To me, it is extremely sad to see such a great ideal reduced almost to fighting for its future existence. There is one area where we do not want to go back to Victorian values: that is, the re-creation of two nations of the sick and handicapped and the aged. We are perilously close to it at the present time. Rather, let there be greater extension of community care, more development both in the acute services and in preventive care.

Much still needs to be done in the field of mental health for the disabled and the elderly. Do not remind me that it costs money. I know it costs money, "big money", as they say on a certain television programme. But it is a challenge, a challenge to the people, and I am sure that the people will respond. My views in that direction have already been proved by the magnificent voluntary effort that is going on behind the scenes and to which I am glad the noble Lord paid some degree of tribute.

In conclusion, in the dark days of the last war, the prospect of a welfare state and of a comprehensive health service was an inspiration and, to many of us, a new dawn. The National Health Service is now suffering severely, and—make no mistake—public anxiety is growing. All I can do is to utter this plea. In spite of all our problems—and we have plenty—may we all work together to get back to that great ideal of a comprehensive health service readily and freely available to all, irrespective of class, colour or creed.

4.50 p.m.

The Lord Bishop of Southwark

My Lords, I must apologise, first, for the fact that I shall be unable to stay until the end of this debate. I did not realise it would last as long as it is going to last; and, of course, the number of speakers is a reflection of the importance of the subject. I am very sorry I shall have to leave. I have not had to do this before; and I particularly apologise to the noble Lord, Lord Molloy, who has introduced the debate.

In discussing the future of the health service I suppose it is inevitable that one cannot ignore the present entirely. That will have been evident to your Lordships from the course of the debate so far. Two things have come to the fore repeatedly as I have been preparing for this debate in South London, and I want to mention them very briefly first, more as a commentary than anything else on some of the things which have been said already and reflecting the sort of conversations I have had with quite a wide spread of people working in the health service, including people like hospital chaplains, who may perhaps be said to have rather less of an axe to grind.

One is the complexity of the issues surrounding the so-called cuts. We have already heard a great deal about that, but in London in particular they clearly derive from three sources at least, and it is important to keep this clear. There is the redistribution of funds between richer and poorer regions, London being the invariable loser. Then there are the half per cent. efficiency cuts and the more recent emergency cuts. To their credit, many people in London recognise the justice of RAWP, and having worked most of my life in the North-East of England I am very grateful for that.

What comes through most clearly is the hurt which has been caused by the additional cuts coming in the middle of the year, so to speak. These have sometimes necessitated draconian measures to make immediate savings, because, like oil tankers, you cannot bring this great ship of the National Health Service to an immediate halt or to a fast change of direction. I do not think that is quite the same thing as refusing to face the need for efficiency in a large organisation. That is one point which has come through to me very clearly.

The second point is that it has been borne in on me again and again how low morale is and how widespread that feeling is at the present time. I wish I did not have to say that. It is true among all kinds of people working in the health service: certainly in hospitals, and to some extent even in primary health care and among general practitioners. It is the cumulative effect of constant reorganisation—some of it still incomplete—shortage of staff, devaluation of administrators in general over a long period, and now a succession of ill-explained cuts. That really has been enormously depressing. The evidence from doctors, nurses, administrative staff and many other workers in South London is united on this point.

It is for these reasons that we have already heard explained at much greater length and in more detail than I am able to do the fact that we need to develop a fresh national consensus and commitment for the next decade. I want to suggest three main questions which I believe must be resolutely faced in any debate about the future—questions which I know do not admit of easy answers but which may be easier to answer if there is a general willingness to go behind the rhetoric of party politics, because the issues have to be faced by any party which is in power.

The questions I constantly hear being asked are these. First, what value do we as people place on a National Health Service? Secondly, what are the main choices which face us now if we are to develop a strong, relevant and efficient service for the rest of the century? Thirdly, what resources are available to sustain such a service? Is it true that expenditure on the health service, as a percentage of gross national product, cannot rise above its present level without alienating large numbers of voters?

First, what value do we place on a National Health Service? Someone who has spent almost all his life working in the health service described it to me, in words which were very similar to those used by the noble Lord. Lord Molloy, as "the greatest piece of social engineering the world has ever seen." That is high praise indeed—and it did not come from a political motivation, and I do not think he had been talking to the noble Lord, Lord Molloy. It was simply a conviction born of experience—and, I might add, comparison with the highly expensive and somewhat unattractive forms of health care to be found in advanced and more wealthy countries like Australia and the United States. But he went on to say that morale was indeed now very low because, he said, people are feeling so unsure about the future of this service. This is a man with great experience, and I think we have to weigh his words very carefully.

So the fundamental question is: what values underlie our attitudes to the health service, both its creation and its maintenance? This really goes much deeper than any party policy, because I believe that the success of the last 25 years was probably in large part due to a shared recognition of the equal worth of each person in our community and a desire to make available to all the best treatment that could be given at that time. That conviction, however difficult it was to put into practice, does have many roots in the Christian tradition, and it is about our responsibility for one another. I recognise that there are quite important philosophical questions about the best way of exercising such responsibility, and there are those who argue that the voluntary principle must always be paramount; but many of us would argue that we exercise our freedom responsibly also by making adequate provision for certain things nationally and comprehensively as well. These two things are not mutually exclusive.

As I read recently, the provision of public resources and services is one way", though not the only way, in which a community expresses its common life across their divergent experiences". Is there still a sufficiently full and genuine commitment to these values in our country? I believe there is, but those who work in the health service seem to need reassurance rather badly at the present time, for whatever reasons, as do many of its patients and users. The good news given to us today by the noble Lord the Minister needs to be more widely heard and understood, for this very reason. That is, I think, my first and fundamental question.

The second is: What are the main choices which face us now if we are to develop a strong, efficient and relevant service for the rest of the century? The right honourable Enoch Powell, after having served as Minister of Health a few years earlier, wrote in 1966: The unnerving discovery every Minister of Health makes at or near the outset of his term of office is that the only subject he is ever destined to discuss with the medical profession is money.". He went on to say: From the point of view of its recipients, Exchequer money is for all practical purposes unlimited … All discontents, all deficiencies, all inadequacies can be externalised and rationalised by a single, anthropomorphic explanation: it is the fault of a miserly Minister, or Treasury or Cabinet". I am sure that we can all identify with the feelings behind those words. They simply are true.

The reality, of course, is that there is a continual series of uncomfortable, difficult choices to be made, ranging from these major decisions that we have heard about this afternoon, such as whether the health service itself should be enabled to develop new services, should remain as it is or even should decline, to questions about the balance to be struck between primary care and specialised services—very important questions at the present time, because of the demographic changes that are taking place—between the growing needs of the very elderly and the mentally ill; questions about uneven provision of health care nationally, and so on.

There are three considerations which affect these choices and I want to be more specific, because I realise that this is where the difficulty lies. These considerations have roots in the Christian tradition. The first is that we owe it to one another to use our bodies responsibly, as given to us by God for the good of all mankind. From this point of view, resources which help health education and primary health care must have a very high priority. They also have some very useful economic consequences later on in the process, but the basic reason is the one I have given. So, too, legislation which will help to reduce expensive demands on the health service, such as the compulsory wearing of seatbelts or greater restrictions on the advertising of cigarettes and alcohol, has a place as well. Part of the price of a good health service in future may indeed be a very slight further diminution in the freedom to do just what we like with our bodies, though I want to say that personal self-discipline remains the fundamental key.

Secondly, death is not the ultimate disaster to be avoided at almost any cost. We have to accept—and one day I may be at the receiving end of that decision—that access to certain kinds of advanced medical technology will not be available for a long time, and ought not to be generally available at the expense of treatments which could bring relief and a better quality of life to many more people.

Thirdly, associated with this is the need to hold fast to the conviction that every patient is a person, infinitely precious in his own right and, in this understanding, precious to God most of all. The consequences of this have to do with the quality of care that we offer and the willingness to make that care available to those who do not seem very important in society. I am thinking particularly of, for instance, the mentally ill, the handicapped or the aged. There is enough evidence now to show that the quality of life for such people can still be, and often is, substantially improved, if we are prepared to put a little more effort and priority in this direction. So a motto that all of us might carry in the back of our minds is, "It might have been me".

Lastly, what resources are available to sustain our health service in the future? I recognise absolutely what the noble Lord the Minister has said, that resources are always finite. We all know this in our heart of hearts, though it is sometimes difficult to say this publicly. Demand will always go in advance of supply. That is the law of the game, particularly in the field of medicine. At a time of recession, and indeed of international tension, there is an even stronger limit, therefore, to growth and development. But what concerns many of us, regardless of our party political allegiance, is the assumption, or so it seems at times, that taxation must even now somehow be reduced at the expense, if needs be, of a strong and viable health service. I do not believe that the majority of our people actually want this. Let me illustrate this and then I will close.

A few days ago, a consultant told me of a relatively well-off patient who said to him from his hospital bed something like this: "I am deeply grateful for the skill and the care which I am receiving here along with the others in this ward. I gather that you are in great difficulties in this hospital and are going to close several wards and make some staff redundant. I have also seen for myself the strain under which junior doctors and nurses, in particular, are working, especially at night"—and I have seen that myself, too—"Can I make some financial contribution without becoming a private patient, which I could not afford to be and do not want to be?"

The consultant then said to me that he wondered whether all patients could be charged for their board in hospitals where circumstances changed. Would it not make a great difference, he thought. But, of course, that would introduce appalling complications for, I suspect, relatively small results, as well as raising the spectre of the means test and all that. The short answer to that patient could have been: "You already pay towards this treatment in your taxation. It is good to hear how much you value it, not only for yourself but for others in this ward and on the waiting list. Therefore, we hope that you will not mind paying a little more in taxes, since you are willing to give it, in order that the service may be sustained and yet further improved".

I believe that that patient represents the majority of us and therefore, even if no economic recovery of any significance takes place in the next few years, it may be necessary to say to those who can most afford it—and that is probably most of us—"We ask you to pay a little more, in order that so great a service may remain strong". We should still be paying less than almost any other developed country in the world.

5.8 p.m.

Lord Ennals

My Lords, I am deeply conscious both of the honour of being a Member of your Lordships' House and of being able to take part in a debate which is close to the nation's heart and is certainly very close to my heart. So I am grateful to my noble friend Lord Molloy for introducing the debate. I welcome the opportunity of following the right reverend Prelate and I agreed with every single word he said. Also, it is a special pleasure to be able to follow my old friend—old in the sense of years of friendship—my noble friend Lord Wallace of Coslany, who preceded me as Member of Parliament for Norwich. North.

Apart from spending five years as Minister of State for Health and then Secretary of State for Health some 10 years later, I have been an all too frequent inpatient and out-patient of a succession of hospitals over countless years, mainly due to the results of war injuries. I know that I owe my life not just to the dedication of doctors and nurses, but to all those who work in the National Health Service. Nothing that I can ever say will be able to express my sense of gratitude to those who have given so much service to our nation and our people.

The noble Lord the Minister was very kind when he said that he was looking forward to my speech. I doubt whether that was really true, but certainly he understood my dilemma when he asked: how was I going to make my maiden speech without being controversial? I shall try, but I am basing it on the principle that what is incontrovertible must be non-controversial. I shall do my best to stick to that principle.

My first, simple point is that good health is the greatest human blessing and that ill health is often the greatest burden that we have to bear. Secondly, that of all the public services in our land the National Health Service is the most appreciated by all our people. Thirdly, that we spend on health in Britain almost the smallest percentage of gross domestic product of any country in the Western world. Fourthly, that we spend the smallest proportion of our health expenditure on administration of any country in the Western world. This is largely because we have a tax-paid National Health Service—and long may it be so. Fifthly, that pound for pound we get the best value in health care delivery that is available to any country in the world.

I believe we have reason to be proud of all these factors. Sixthly, I suggest that National Health Service expenditure and manpower is being cut—that is what the Chancellor of the Exchequer said, so it must be so—at a time when, according to a Gallup poll in the Daily Telegraph which gave absolute credence to the point which has just been made by the right reverend Prelate, 90 per cent. of the public think that more money, not less, should be put into the National Health Service. Also, two-thirds of those who were asked said that they would prefer to see more paid in taxation and more put into health and social services. I believe that that probably cannot be said about any other service available to our people. My seventh point is that at a time when the National Health Service is faced with yet another management reorganisation the service is facing the most serious financial crisis of its 35 years of life.

When the debate is eventually, after many long hours, wound up I want to ask the question why, if we have to have—and I believe we must—cash limits that impose controls upon the total amount of expenditure that is made, do we also have to have manpower limits which take away the abilities of local people who know the local scene because, as my noble friend Lord Wallace of Coslany said, "Whitehall knows best". I do not think it very often does. These cuts impose terrible problems, moral problems, upon doctors and nurses, but especially upon doctors.

I want to take one example. It is estimated that some 2,000 or more kidney patients die each year because insufficient treatment is available for them. Kidney dialysis facilities need to expand, it is estimated, by about 10 per cent. per year for about 10 years just to meet the existing need. There is nothing new in this. It is the problem I had to face when I was Secretary of State. The death toll is expected to rise still more sharply as a result of the latest round of health service cuts. Doctors may have the beds, the equipment and the skills, but the lack of nurses may mean that the wards cannot be staffed. As a result of this failure of supply to meet the demand, doctors are having to make invidious choices between which patients shall live and which patients shall be allowed to die. This is a terrible dilemma to place upon the medical profession.

My eighth point is that we all know that a growth rate of roughly 1 .3 per cent. is necessary just to stand still:0 . 8 per cent. for demographic factors, 0 .5 per cent. for higher costs of medical technology. We all know, too, that since the Chancellor's statement in June, part way through a financial year, the National Health Service is being required to cut back its services at a time when demand is growing. There never will be a time when demand is not growing. I agree with the noble Lord the Minister that we shall never, ever, be able to meet the demand. It is a question of how much of the demand we can meet and how much we have to hold back.

I want, therefore, to make two pleas to the Government: first, to give a higher priority in national spending to the National Health Service, as I believe the public would support them in doing, and to recognise that not to do so is false saving in the long term, and sometimes in the short term. Those who do not get treatment now may need more treatment, and more expensive treatment, later. Short-term cuts are often very expensive from a long-term point of view. It is no wonder that there have been anguished cries from the British Medical Association and the Royal College of Nursing. I have the full script of the statement that was made today by Sheila Quinn, the President of the Royal College of Nursing. My noble friend Lord Molloy has given some quotations; I shall not give others.

But it is not just a question of the unions protesting about jobs. The real concern at the present time is the quality of patient care in hospital after hospital, in community service after community service, the length and breadth of our country. Nobody, be he Minister, be he a member of the House of Commons or the House of Lords, be he a nurse or a doctor, can deny that there is this deep concern.

My second and final plea to the Government is to remember—this is another non-controvertible and therefore non-controversial point, so fully documented by the Black Report—that poverty contributes directly to ill health. Recent figures published by the Department of Health and Social Security family expenditure survey showed that 15 million people—more than one in four—were living on the margins of poverty in 1981 (I have not chosen 1981; they are the most recent statistics for which the family expenditure survey has figures), compared with 11 .5 million in 1979. I did not even choose 1979; those happened to be the years chosen by the Department of Health and Social Security when publishing their report.

Some of the highest increases were among people living below supplementary benefit level, which is taken by the Government as the official poverty line. The number of people in families in this category where the head of household was unemployed increased by 220 per cent., just in that two-year period. Huge increases were also recorded in other groups of people living below the poverty line. Households with children living below supplementary benefit levels rose by 73 per cent., one-parent families by 50 per cent. and households without children by 59 per cent. Perhaps the Minister who is to reply to the debate will be able to give us more up-to-date statistics which may show that all this has got better since 1981. But there is no doubt that the consequence of that sort of poverty is not only hardship now; it is ill-health later, which has to be paid for—and paid for by our people.

I conclude by assuring the Government, and especially the noble Lord the Minister, that, as long as he and his colleagues defend the National Health Service and the welfare state, they will enjoy—or endure, as the case may be—non-controversial speeches such as that which I have just delivered. I wish to thank the noble Lord the Minister for his statement of commitment to the National Health Service and its present methods of financing. Words do count, but actions speak louder than words. I am grateful, my Lords, for your courtesy in listening to my maiden speech.

5.20 p.m.

Baroness Cox

My Lords, it is my great privilege and pleasure to congratulate the noble Lord, Lord Ennals, on his informative, eloquent and enjoyable maiden speech; it was indeed incontrovertibly non-controversial. I am sure your Lordships will agree that his speech bore all the marks of his great experience in many fields and this experience will surely enable him to make many wide-ranging, valuable and frequent contributions to your Lordships' House. I therefore speak for us all when I say that we anticipate those speeches with great pleasure.

I must turn from congratulations to apology, because I deeply regret that I shall have to leave before the conclusion of this debate due to a long-standing and immutable commitment. I am very sorry, and I shall read with great interest those parts of this debate which I shall have to miss.

I should like to contribute to this debate on the future of the NHS in my capacity as a nurse. In so doing, I will touch briefly on three topics. First, I wish to record the appreciation which many members of the nursing profession feel for certain aspects of the Government's policy on health care. Secondly, I will indicate a number of ways in which nursing's contribution to the provision of health care in the NHS must develop in the years ahead and the implications of these developments. Thirdly, I must refer to a number of issues which are apparently causing nurses grave concern.

Of those aspects of the Government's policies which many nurses appreciate and support, I will single out four examples. First, going back in time to 1979, the Conservative Party while still in Opposition promised to honour the Clegg Commission's recommendations. This they did when they won the general election. It is not unknown for Governments to change their minds, and the fact that the Government kept their word was greatly appreciated and has not been forgotten by the nursing profession. Secondly, during the Conservative Government's first term of office, they did protect the NHS —certainly in comparison with other areas such as education. There is, of course, a fundamental difference, in that education has experienced a decline in the numbers of school children whereas in health care there is a steady increase in demand. However, there was an expenditure increase in real terms on the NHS which must be recognised. Whether it was enough begs many difficult questions.

Thirdly, the nursing profession is very grateful to the Government for setting up the pay review body to recommend appropriate salaries for nurses and those in other professions relating to nursing. Although some of the health service unions grumbled about the "no strike" clause, the Royal College of Nursing had no such reservations, as it is already committed in principle to a stance against taking strike action, because that would harm those who are most vulnerable; the sick, the physically and mentally handicapped, and the mentally ill.

In this, the Royal College of Nursing sets an example to other health care staff and indeed to social workers who are prepared to take industrial action even if such action causes suffering to those dependent upon their services. Therefore, I should like to emphasise that the nursing profession is grateful to the Conservative Government for establishment of the pay review body, and it is hopeful that that body will recommend remuneration commensurate with the responsibilities carried by the profession.

Fourthly, many nurses do support the Government in their concern to promote efficiency in the NHS and to maximise cost-effectiveness. I believe it is fair to say that anyone who works in the NHS must recognise that there is some avoidable waste and unnecessary expenditure. Therefore, there is no fundamental disagreement about the goal of ensuring that resources are used as responsibly and efficiently as possible. The problems lie in the Government's proposed means of achieving this goal. Before discussing that point. I wish to turn briefly to my second topic, which is changes in the contribution of nursing to the NHS in the years ahead.

Clearly, nursing must respond to changes in patterns of mortality and morbidity. I will refer only to the most obvious example. All industrial societies are experiencing a growth in the proportion of people who survive to old age. Similarly, thanks to developments in medical science and in the quality of health care, many more people now survive those illnesses or accidents which would previously have been fatal. However, they may be left with some degree of handicap or dependency. We therefore know that there will be an increase in the number of people subject to the frailties of old age and of young people with chronic infirmities of some kind. Many of these people will need some form of care.

Thus, the timeless functions of nursing—helping people who cannot help themselves with the essential activities of daily life —will be in more rather than in less demand. Another predictable development is the continuing growth of high technology medicine. This will make demands of a very different kind for those nurses who work with physicians and surgeons in the care of patients undergoing sophisticated treatment.

A third growth area lies in the field of preventive health care; in areas such as health visiting, midwifery, and occupational health. The fourth change promises an increasing emphasis on community care. It is current policy to discharge as many people as possible from institutional care into the community. This has far-reaching implications for the health and welfare services. The large numbers of psychiatric or elderly patients who would previously have been cared for in an institution but who are now living in the community run a very real risk of isolation and physical neglect unless adequate investment can be made in the community services.

Similarly, pressure on hospital staff to discharge post-operative patients as quickly as possible places more strain on both the hospital and the community nursing services. The hospital staff have to cope with a more rapid turnover. It means that nurses have to work under greater pressure, looking after a higher proportion of patients in more acute post-operative conditions with fewer less dependent convalescent patients. Also, the community nursing services must increase their workload by taking on larger numbers of patients for home care during that part of their convalescence which would previously have been spent in hospital.

It can thus be seen that over the coming years the input of nursing into the NHS must grow. Already nurses account for nearly 50 per cent. of the NHS work force. Failure to appreciate the importance and magnitude of nursing's contribution will have adverse effects on health care. It will lead to a further deterioration in the morale of a dedicated profession which has set an example to the nation in its principled and altruistic refusal to take industrial action. And it is a matter for regret that, to date, the profession has suffered as a result of its moral standards. For example, there is the low ceiling of salaries for those with major responsibility for patient care—the ward sisters and charge nurses, whose top salary is still only about £8,000 per year. That is an indictment of previous arrangements for salary negotiation.

This leads me to my final topic: some of the concerns which are now worrying my nursing colleagues. Time allows me to single out only three. First, there is inevitably the issue of the cuts. As I have already indicated, many nurses would agree that there could be some savings in the way in which the NHS is currently run. However, they are acutely anxious about the means being adopted to achieve these savings. I am not the only speaker to express dismay over the timing of the required reductions in spending. To announce these in the middle of a financial year after great time and trouble has been spent drawing up strategic plans was extremely unfortunate, and makes the Government appear inept. It also makes responsible planning difficult, if not impossible.

The leaders of the nursing profession have stated unequivocally their willingness to co-operate with the Government in achieving greater value for money in the NHS. Nurses do recognise that resources are finite, and they wish to see them used to the best advantage in the provision of the highest possible standards of health care. But the immediacy of the imposition of the cuts must create difficulties for those who are responsible for services which are already rolling, and it is this aspect which is causing most frustration and dismay. Had there been a little more time for consultation and time to prepare for the required adjustment to the budget, they could have been made with less damage to current services and to the morale of all who work in them.

The second issue which is causing widespread dismay, and indeed anger, I am afraid, in the profession, is the Government's recently announced policy of manpower cuts. The cuts being required are considerably greater than the ostensible figure of 0.5 per cent. This is because there is the additional loss of all funded vacancies on the arbitrary date of 31st March 1983. This is a matter of the utmost importance. For nursing, it can mean the loss of posts far exceeding the 0.5 per cent. figure. Many health districts had a large number of vacancies on that date for a variety of good reasons. They include posts being offered to recently qualified student nurses, who were on the point of taking up staff nurse posts in early April. They also include a number of agency nurses necessary to provide flexibility in a service where demand fluctuates.

Just to give one example, in intensive care units high-dependency patients require high levels of nursing staff. However, bed occupancy fluctuates dramatically and unpredictably. A policy which gives an opportunity to call in agency nurses when needed is cost-effective, and is one example of a satisfactory partnership between the NHS and the private sector. However, the loss of those vacancies which were available for agency nurses on a pre re nata basis must damage this policy of flexibility. Also damaging is the loss of nursing hours which were carried by overtime working on 31st March. While everyone recognises that the provision of patient care on an overtime basis is not satisfactory, it may be inevitable in areas where it is notoriously difficult to recruit staff, such as the care of the mentally ill, the mentally handicapped and the elderly. Once again, to write off these nursing posts is potentially disastrous, for they are often in the fields readily acknowledged as Cinderella areas because they have long suffered relative deprivation in facilities and staffing.

Over and above these problems is an additional problem: a problem which appears to nursing to be indefensible—the explicit refusal to allow the filling of vacancies which would promote greater efficiency. I refer to the refusal to allow new appointments to replace agency or overtime staffing. This is seen as totally unacceptable by nursing. Although we have acknowledged that there is a case for the use of some agency staff, it must be limited, because agency staff cannot provide the continuity of patient care and the quality of nurse-patient relationships which are crucial to good nursing practice. Neither can agency staff provide the teaching and supervision for student nurses, who spend such a high proportion of their time working on the wards. So a policy which protects agency staff at the expense of the recruitment of establishment staff must be detrimental to the care of patients and to the education of student nurses. This cannot be emphasised too strongly, and I hope, on behalf of the nursing profession, that your Lordships may see fit to support them in this concern.

Finally, for nursing there is the most recent bombshell, the Griffiths management inquiry report. These are still early days, and the nursing profession can as yet make only a preliminary response. However, the initial reactions have been predominantly those of dismay. While it is readily acknowledged that there are many aspects of the report which can be accepted and supported, the inquiry team's failure to accord much recognition to the part played by nursing as a major caring profession is considered unacceptable. For example, the report seems to underestimate the contribution that nursing management makes to the health care services, although the revenue expenditure of the nursing service exceeds 40 per cent. of the total revenue spent.

More specifically, the nursing profession's anxieties concerning the Griffiths Report include the disturbing and demoralising effects of yet another major upheaval in the NHS following so soon after other major changes. The 1982 restructuring of the NHS is barely completed. The formation of unit management groups and their policies is still in the process of implementation in many districts. The timing of the imposition of yet another major change appears to nursing to be insensitive. It seems to ignore the likely devastating effects on a service where morale is already desperately low.

Another concern is the inappropriateness of applying an industrial model of management in a service where demands are virtually infinite and resources are inevitably finite, and where it is notoriously difficult to apply business criteria of effectiveness. Although some crude indicators of cost-effective performance can be applied, these are subject to inevitable limitations, in that human beings in conditions of extreme vulnerability cannot be likened to industrial products or to consumers in the ordinary market situation. It is doubtful whether the very general measures indicated by Griffiths to assess how well the service is being delivered at local level will give any better basis for feed-back than those which currently exist.

Another concern relates to the fact that the recommendation for the establishment of a full-time NHS management board refers to a multi-professional team. It is not clear whether nursing would be included in this. If not, then the profession will urge very strongly that nursing should be represented on this board for the reasons already indicated. Very briefly, other problems relate to uncertainly about lines of accountability, and the apparent disappearance of nurses from current positions in which they can participate in decision-making. For example, if the recommendations of the Griffiths Report were implemented at unit level, it seems that for the first time nurses would not be managed directly and district nursing officers would be left with merely an advisory role.

Similarly, there is acute anxiety about the loss of nursing's influence at the top level. The health service supervisory board proposed by Griffiths includes the chief medical officer but excludes the chief nursing officer. This disastrous omission must be remedied. As the President of the Royal College of Nursing has pointed out: Internationally the United Kingdom's nurses are known and admired for the fact that they speak for nursing at the highest level and are always involved in all aspects of care. In this country nurses belong to and work with a team of equals. I now feel very sad for the status of nursing and for the NHS when this latest development as recommended by Griffiths is communicated to our colleagues abroad. I must emphasise that nurses are concerned to retain their place in the arena of policy-making, not for reasons of self-interest or professional aggrandisement, but because it allows a direct input into discussions and decisions from those who carry a primary responsibility for direct patient care and who disburse such a high proportion of NHS funds.

I conclude by making a very general point. It was not for nothing that the noble Lord, Lord Briggs, called nursing "the major caring profession". For myself, when I returned to nursing after a decade in the academic world I was again and again forcibly struck by the extent to which nurses really do care about patients and about trying to provide the highest possible standards of professional service. In every discussion, at every level from the patient's bedside to the highest stratum of policy-making, the touchstone of concern is the wellbeing of those for whom nursing is professionally responsible. Given this commitment, nurses are generally very well disposed to work with and to support a Government which are seen to promote the interests of the NHS.

Many voted Conservative in the last general election, which is perhaps a testimony to the fact that they believed, on the strength of the Government's record during their first term of office, that the NHS was still in safe hands. It would be a major tragedy if the Government now alienated and antagonised this body of dedicated and principled men and women. I therefore implore the Government to take very serious note of the representations made to them by nurses, midwives and health visitors. If the Government were to lose their support on the basis of policies which are themselves perhaps open to serious question, the repercussions could be disastrous both for the Government and for the NHS. How much better to build on the good will and the dedication which exists, and to move forward together with the support of these key professions to create a stronger and happier NHS, which is both more cost-effective and more humane!

5.41 p.m.

Lord Hunter of Newington

My Lords, may I first add my tribute to the noble Lord, Lord Ennals. In the BMA publication the Handbook of Medical Ethics, there is reference to the fact which is so central to this debate. It states: Within the National Health Service resources are finite". It also states: It is clearly the ethical duty of the doctor to use the most economic and efficacious treatment available". It is strange, therefore, to note a complete absence of guidelines from the department in relation to these matters, as a result of discussions with the medical professions. Some doctors operate on the principle that they must be completely free to prescribe in any way they wish and believe it is wrong that there may be resource restrictions on their freedom to advise their patients. The majority recognise the reality. To many of us who were connected with the health service the hard fact that the resources likely to be made available would always fall short of hopes, and sometimes needs, became evident in the early 1970s when there was a massive cut in the capital building programme. But if one reads the 10–year hospital building programme of 1962 there is just a hint of what was to come.

The next landmark, if I may call it that, was the Resource Allocation Working Party report initially on recurrent expenditure. It has been referred to several times this evening. This is a fascinating study which illustrates the interface between political decision and practical reality.

The present cuts which have stimulated this debate are on top of six years of RAWP reallocations. Although there have been many modifications of the original proposals, RAWP was concerned with the needs of administering bodies, not patients. The whole process must be greatly refined to get allocations to districts, although the RAWP formula is reasonably adequate for the purposes of allocating money between the Department of Health and the regional health authorities and for equalising the geographical distribution of resources. This is, of course. a political decision, but it has important medical relevance. Unfortunately, the recurrent reallocations may have given rise to a less effective use of resources when reallocation was not of sufficient size to make the desired developments possible or where the necessary capital building programme had not taken place.

It is the declared objective of the Government to use three performance indicators. The first of these is effectiveness. Is expenditure achieving results? The second is efficiency. Are resources being used as efficiently as possible? As has been said, given 75 per cent. expenditure on staff, this must refer to manpower usage. The third is the standard of service: equal geographical and speciality access. This was one of the main objectives of RAWP. Perhaps the Minister will tell us how these assessments are getting on and whether any other main headings have been added to the list.

Effectiveness surely must be discussed with the medical profession. Efficiency surely also involves that profession. Now, as has been said, we are faced with proposals for management restructuring of the NHS. This of course fundamentally means the hospital service. There is little place for such organisation in general practice. I have always believed in firm management, but to many this really means a further reorganisation.

The NHS lost good people during the 1973 reorganisation. They retired early. A good many more people went in 1982. Those who have just started to build up the vital district authorities on which the whole future of this service depends are already a little bruised from directives and instructions, some of which arrived even before they could get started. To have a further reorganisation at district management now could delay the developments we all desire. Or perhaps the health service supervisory board will introduce changes with tact and discrimination. I think we all know that these changes must come.

But what of general practice—the source of massive, uncontrolled expenditure? It is obvious that cash limits of the ordinary kind are not suitable. There is a growing feeling in the medical profession that some rationalisation of expenditure is not only desirable but possible without loss of efficacy; but I believe that it is important that savings which are made are seen to be available for other developments.

Further, what is the reaction to the special pleading for services which we have seen in recent months? It seems deplorable that special handouts are given to those who sometimes achieve maximum publicity. The effect of such action is not only bad management, but disturbing for the district and regional authorities, and their authority. This is forcing those authorities to keep going a commitment, whether they wish to support it or not. Please do not reorganise again by abruptly changing the managerial structure in the hospital service. It will further confuse if introduced at a time when there is a sensitive situation with the medical profession, some of whom will immediately feel that their clinical freedom is being threatened. This might only raise the temperature and perhaps make progess impossible. We have barely digested Data for Management, the Korner Report of 1982.

5.49 p.m.

Lord Auckland

My Lords, it is a pleasure to follow the noble Lord, Lord Hunter of Newington, who has considerable experience as a surgeon, and also to have heard the very wise speech of my noble friend Lady Cox with her experience in the nursing services. They were preceded by a most distinguished maiden speech by the noble Lord, Lord Ennals.

The House will be indebted to the noble Lord, Lord Molloy, who with his characteristically forthright manner initiated this very important debate. We have certainly had no shortage of debates on the National Health Service either in this House or in the other place. I think that what worries Members of this House and. I am sure, Members of the other place is whether these debates really increase the favourable lot of the patients who come under the care of the National Health Service or indeed of any other service. I believe that it is certainly the intention, wish and supreme effort of all Members of both Houses to achieve this.

I believe that there are two main divisions—if I may use that word—inherent in this Motion. There are the short stay patients in the general hospitals, and the medium long stay patients in the mental hospitals. I shall in the main devote my brief contribution to the latter. But I believe that there is one worry which was very much inherent in the speech of my noble friend Lady Cox: what will be the future of nurses who have finished their training, become staff nurses, married and now have a family? I declare an interest. I have a daughter in that situation. I should like to ask my noble friend the Minister what is likely to be the lot of this category of nurses in the future within the ambit of the cuts in the National Health Service.

With medicine becoming more sophisticated, advanced and technological it is absolutely essential for the future of the National Health Service, and indeed for private medicine for that matter, to obtain back—if I may use that colloquialism—the skills of these nurses who have had all the splendid training of teaching hospitals in London and elsewhere in general, district and psychiatric hospitals. This is one of the most important aspects of looking to the future of the National Health Service. I emphasise the word "future" because it is in the noble Lord's Motion.

Just one word about the report of the inquiry chaired by Mr. Roy Griffiths. I think it will almost literally be one word. It is not an easy report to digest, particularly for a layman: but I hope that when it has been digested there will be a separate debate on it. It is an important report. It should not be condemned out of hand. As my noble friend Lady Cox and others have so rightly said, for the nursing profession it is a very difficult report to assimilate, to say the least. It is not surprising that there is considerable anxiety as to its implications.

As I asked when the statement was originally made, what consultation has there been with the General Nursing Council? I too heard on the "Today" programme the interview with Miss Sheila Quinn, who was not too favourably disposed towards the report, to say the least. It is said that this is not another reorganisation of the health service. Perhaps that is so. I have said this before. In the years that I have been in your Lordships' House I have sat through many reorganisations of the National Health Service. They are all very well meaning. They have been conducted under various political parties. But one is bound to be somewhat cynical about whether those who work in the profession—the nurses and the doctors—can put their hands on their hearts and say, "I have benefited by this Royal Commission or this report".

I am unhappy, as are many who work in the health service. I have merely served on hospital committees, as have members of my family for many generations past. Anybody connected with medicine must be bewildered and disappointed that this report has come out so quickly and in a form which is far from easy to understand. Having come not too far behind the very elaborate report of Professor Merrison—even though this had very different terms of reference—it seems to be yet another lengthy document which those who work with such dedication in the National Health Service have to spend time to study.

I should like just to make one or two observations about mental health. I shall be a little parochial. There is the problem in Epsom about the psychiatric hospitals. I know that the noble Lord, Lord Molloy, has another Question down on this next month. I did however visit St. Ebba's Hospital, with which I have had connections for nearly 30 years on the house committee, although with the reorganisation under the Salmon Report I no longer have official connections with the hospital. My understanding is that there is no question of the six psychiatric hospitals being disbanded. Any land which is sold will be used for buildings or amenities for those who are put into community care. I had a lengthy talk with the head of nursing. I hope that my noble friend the Minister will be able to confirm that this is the case. Obviously those nurses and doctors who work in these hospitals will be concerned about what is to happen to them—

Lord Molloy

My Lords, I am most grateful to the noble Lord because what he has said I find most heartening. I hope that it turns out to be true that the land, for example, of the Epsom cluster, despite the adverse factor of its being near to great airports and being an enticement to industrialists and others, will in fact be used for the building of new and better hospitals.

Lord Auckland

My Lords, that is my understanding, but of course it is for the local health authority and the Minister to confirm. Speaking as one who, as I say, has known the area for many years, I should certainly hope that that is the case. There is now more concentration on community care, on day release patients, and today there is far less need for the conglomeration of the security type hospitals in such numbers. Obviously there are some patients who must be kept in conditions of security, but there are many others who can be released for community work and who can be trained for such work.

I have been very struck and moved, as no doubt have been others among your Lordships, by a poster which appears at some railway stations. On the poster is a picture of a small boy sitting on a chair in a hospital surgery. Next to him is a chair which is empty, and a teddy bear is lying on the floor. In the caption the small boy says: They have cured my cancer. Please will they cure Peter's? I believe that there is a message here, and while I recognise that within the health service there are economies which can be, and which must be, made—anybody who has had any dealings with the NHS must recognise this—I think that in the treatment of diseases such as cancer and the kidney complaints to which the noble Lord, Lord Ennals, so movingly referred, there must be priority. If we can cure youngsters of cancer, if we can cure young people of kidney complaints, then we can get them out into the community and to work.

Obviously there is a dilemma at times when economies are needed; but I believe that there is much greater need to look more closely at where the economies should be made. It is essential to have a useful working community, and I think that there is a danger of making false economies. Clearly this is a matter for someone who has much more experience than laymen such as myself.

Finally, I would just say this. Our health service is catering for between 45 million and 50 million people—many more people than it was catering for when the late Mr. Aneurin Bevan set it up following Sir William Beveridge's report. Therefore it is difficult to see how the health service will ever become completely efficient in financial terms. What we must do is make absolutely certain that those who work in the health service, in particular in the therapeutic side, are used to the most efficient level of their ability, and that sight must never be lost of the tremendously important part which they play in the health of the nation.

6.5 p.m.

Baroness Lockwood

My Lords, this debate is about the future of the National Health Service, and we are grateful to the noble Lord, Lord Molloy, for introducing it. However, from the contributions that have already been made, it is clear that the debate is also about a crisis in the National Health Service—a crisis in the financing of the service, and a crisis in confidence within the service. I suggest that there are three contributory factors involved here. The first is the continuing development of medical science and techniques. The second is the demographic changes with an increasing number of elderly within our community; and the third is the Government policy of financial constraint.

The noble Lord the Minister made reference to the first two factors, but as the noble Lord, Lord Diamond, indicated in his brilliant analysis of the Government's handling of this year's financial estimates, the Minister made very little mention of the Government's own financial constraints on the service and the difficulties that are arising, especially since the cuts are being introduced in the middle of a financial year.

The first two factors are not going to go away and they must be taken account of in our planning for the National Health Service in future years. The third factor involves a choice—a choice of priorities within the competing demands of society; and I hope that as a result of today's debate some of those priorities will be changed.

However, before I deal with the financial side of the question, I want to say one or two things about my first two points, beginning with the development in medical science. No one would want to put any barriers in the way of development and research within medicine, though even here it is sometimes necessary to introduce priorities on a cost basis. But I think that once the results of research and advance have been shown to be beneficial to those in need of care within our community, we have as a society a moral responsibility to ensure that that knowledge and development in science is applied to the needs of the sick. I believe therefore that in this connection all of us must he concerned by some of the reports that we have seen in recent weeks of the problems that have faced consultants in the speciality of renal and kidney diseases.

I am sure that we all enjoyed and admired the speech of my noble friend Lord Ennals for its knowledge and its non-controversial content. He made reference to the shortfall in this area of medicine. As one who has benefited considerably from the health service through the provision of a specialist service, through the provision of artificial limbs, I must say that I find it very difficult to accept that the same almost routine, though excellent, service cannot be made available to those who require different kinds of replacements, such as kidney replacements. Of course, it is more difficult in the case of kidney replacements. There have to be donors. But there do not have to be donors for the substitute, the kidney dialysis machine, which is very much in shortfall at present. Those of us who are concerned about the National Health Service would like to think that, at least in this area, our provision would be comparable with that of comparable countries in the European Community. If it is right that we give priority and support to the development of new techniques, it is right that we should use those techniques and provide the resources for an adequate service.

My second point relates to demographic changes. The increasing number of elderly in our population has been mentioned by other noble Lords as well as by the Minister. Although, over the next 30 or 40 years, the number of dependent elderly in our community will be offset from time to time by the increasing number of people of working age, due to the various bulges that have gone through our population since the end of the war, the fact is that, in the next 10 years, as has already been stated, there are going to be an increasing number of over-80s who will make great demands on our services. One fear is that it is this group of the population that will be most at risk from the cuts now being introduced.

Certainly, in my region, the Yorkshire region, there is concern about the provision for the elderly and for the mentally ill. Very often of course the two go hand in hand. The provision for the geriatric and the psychiatric person is involved in the same hospital. One of the most evident reactions to the cuts in the provision within the Yorkshire region has been the proposed closure of the Clayton geriatric hospital in the Bradford area where the nursing staff staged a sit-in in protest. All of us would agree that a sit-in is no way to run a hospital, even if those concerned take every possible step to ensure that the sick and the elderly do not suffer. But when the combined weight of opposition by the local Members of Parliament, by the local council, by the doctors in the major hospital in Bradford and by other doctors and medical practitioners within the area as well as by the relatives of the patients in the hospital, fail to bring about any change in policy, it is not surprising, although we would not condone it, that sometimes this kind of extreme action is taken.

I do not advocate the hospitalisation of the elderly as an ideal situation. A much better and cheaper way is to keep older people within their own community with adequate back-up services. This does not mean care by women relatives. It is a service that cannot be put on to women members of our community who are then left to cope. It is a service that needs to be adequately dealt with by the community as a whole. This has repercussions for local authorities in the provision of their own community care services. I hope that, at a later date, when we perhaps discuss the suggestions for rate capping, this kind of service will be borne in mind. I emphasise that where older people have been in a certain hospital for a number of years, where they have become part of that hospital, then we have to think carefully before we shuffle them around, as experience in certain areas in the past has shown.

I come now to my third point of financial and economic constraints. I accept that it is important that the health service is as efficient and cost effective as possible. It is important that it is well managed. A number of noble Lords have referred to the report of the Griffiths Inquiry. Like the noble Lord, Lord Auckland, I hope that this, in itself, will be the subject of debate in this House in the future. At the moment, I would make two points. My first is in support of what the noble Baroness, Lady Cox, has said in connection with the Royal College of Nursing. I believe that the Royal College has a very strong case at present in pressing for a nursing representative on the new health services supervisory board. I hope that the contribution that the nursing profession can make will be taken into account if there is any reorganisation of management in the health service.

Secondly, I think, as the Minister has stated, that the Griffiths report is about delivering services to people. I am sure that Mr. Roy Griffiths would be the first to accept that services cannot be delivered properly if the current round of cuts is to be imposed. As a senior manager within Sainsbury's, he knows perfectly well that adequate services to the people depend on adequate capital for new capital projects and adequate funds for on-going services. He is very well aware of the importance of the high street service, the high street shop, as it were.

I hope that we can take into account wider considerations when we are thinking in terms of some of the local hospitals that might come up for cuts as a result of the financial stringencies. The wider considerations need to involve not only some of the points already made but also the point about a local service that is readily available and to which people can go without wasting too much time, without wasting man hours that may be used productively in a person's own work, by sitting in a waiting room in a large hospital.

Furthermore, there is the problem of transport. Usually, it is the elderly within our community who have problems with transport. Or it is women within our community who have these problems because they do not have the use of the family car. It is usually women who have to take children or other relatives to hospital when need arises. To take a child to a local hospital for preliminary services is much easier than taking a child to a large hospital. I hope that some of these considerations will be borne in mind—the kind of considerations that we were discussing last week in our debate on unemployment. When the noble Lord, Lord Byers, introduced the debate, he referred to a report of the Select Committee on unemployment. That Committee had recommended that we could help to solve some of the problems of unemployment by expanding the ancillary work in the health service. However, here we have a situation where we are not going to expand the ancillary services: we are going to cut the ancillary services. All the costs involved in making not only doctors, nurses and the frontline workers redundant, but the ancillary workers redundant, also needs to he borne in mind. Redundancy payments, the payment of unemployment benefit, the loss of taxation, and so on, are all considerations which ought to be borne in mind.

Finally, regarding services, I should like to refer to a local situation. In the Calderdale area there was a proposal to invest in a new capital project by replacing existing laundry services. In order to make this economic it was suggested that there should be a combined service for the Calderdale and the Dewsbury District Hospitals. That has been rejected and the authority has been forced to put the laundry services out to tender. I am not totally opposed to private services. As my noble friend Lord Wallace pointed out, there have always been private contracts within the health service. However, where we have an authority that is prepared to look for long term savings and which takes an initiative of this kind, I believe that we should give it support.

I conclude on a note in support of what the right reverend Prelate the Bishop of Southwark said in his very moving speech this afternoon in relation to the priority we give to the health service. The right reverend Prelate asked whether the current level of expenditure, as a proportion of total expenditure, was finite and would it be possible to increase that level. In my view it would be possible to increase that level. I believe that people would be prepared to pay more in taxation for an adequate National Health Service. It surprises me that people who feel that there is virtue in those who are prepared to spend more on their own private medicine should not also accept that all of us as a community are prepared to spend more on this service. Therefore, I, too, would ask that the Government have a new look at what the National Health Service needs in the coming decade and how much it is likely to cost in real terms. Let us put the situation to the British people. I am sure that we would get an affirmative answer, "Yes, we are prepared to pay more providing the service is adequate for those who need it"

6.24 p.m.

Baroness McFarlane of Llandaff

My Lords, I, too, should like to thank the noble Lord, Lord Molloy, for the opportunity to consider the future of the National Health Service. I should also like to add my congratulations to the noble Lord, Lord Ennals, on his maiden speech. I had contact with him during the time when he was a Minister, and I recognised his real commitment to the National Health Service. I am sure your Lordships must feel fortunate as regards the experience and wisdom that he brings to this House.

I am a nurse, and today I had intended to he with my colleagues at the Royal College of Nursing annual general meeting being held in the great hall of my own university, where I hold the chair of nursing. Instead, I have come to your Lordships' House because the whole concern of that meeting and the weight of the address of the president, Miss Sheila Quinn, was the subject of this debate, namely, the future of the National Health Service. I think it right that the concern of the nursing profession should be expressed here. Without exception over the last few months, nurses, midwives and health visitors have expressed to me their concern about the future of the service. The Royal College of Nursing, the Royal College of Midwives, the Association of Nurse Administrators and the Health Visitors' Association (of which I have the honour to be a vice-president) are all united in their concern about the future of the health service. I might add that it is not always that those redoubtable bodies are in unison.

I sit in your Lordships' House in a different place from the noble Baroness, Lady Cox. However, I should like to endorse everything that the noble Baroness said in her speech, and this again underlines the concern of the nursing profession and how united we are in that concern. I of course speak from a position of bias, but I would contend that nurses, midwives and health visitors are, on the whole, reasonable people. They are not given to hasty reactions; rather, they are brought up in methods of coping with crisis. In fact, I would sometimes criticise my colleagues for making virtue of making do when they ought not to make do.

I would remind your Lordships that in the past many nurses have restrained themselves from the ultimate industrial sanction of taking strike action. It is those same nurses who have sacrificed their personal interest who are now showing concern at the effect on their charge of the cuts, the manpower targets and, in the latest event, the Griffiths Report. They are concerned about how those matters will affect the quality of the service that they give. In what Miss Quinn this afternoon described as "a continually changing hotpotch of measures" that have been demanded of the health service over the last 15 months, we see grave cause for concern.

The National Health Service is an institution of our society. I believe it is a reflection of the measure of our civilisation—a compassionate society. Protestations that the National Health Service "is safe in our hands" are not enough. Those protestations have to be measured against performance criteria, and those include the standards of patient care which we are able to support, and staff morale. The nursing organisations and the individual nurses to whom I have spoken support the objectives of the Government in general principle. In fact, Miss Quinn said this afternoon that the Government are right to maximise value for money so long as efficiency savings are directed into improving patient care services. Nurses wish to see a more efficiently managed service with a more equitable distribution of resources.

I was interested to hear mention of the Royal Commission on the National Health Service. I had the privilege of serving on that commission. As I travelled down in the train today I refreshed my memory of the second research report of that commission, entitled Management of Financial Resources in the National Health Service.That report and the report of the commission identified so many of the deficiencies in the management of financial resources and in the management of the service that we still have with us today. The research report came out in 1978 and the report of the Royal Commission in 1979, and some of these same difficulties are still with us.

I believe that the strategies that the Government are now using and proposing to use in the objective of achieving efficiency may well militate against that other great criterion, effectiveness. I would suggest that some of these strategies will make the service less effective and in the end erode its efficiency. Perhaps I may again refer to what Miss Quinn has said today. She regaled us with the cuts and the programme that has taken place over the last 15 months. She said: July 1982—the DHSS asked regions about district plans for making efficiency savings of half a per cent for the then current financial year and for 1983/84, and 'to strengthen the setting of manpower targets' … January 1983—regional allocations for 1983/84 were announced together with guidance for their use; these allocations showed a 1.2 per cent increase for the year. June 1983—long term revenue resource assumptions were issued, this circular asking health authorities to assume a growth rate of half per cent per year over the next ten years. July 1983—revised cash limits for 1983/84 were announced, superseding those announced in January and reducing the figure of 1.2 to just 0.21 per cent. At the same time the DHSS called for a reduction of between 0.75 and 1 per cent in overall staff numbers from the total employed at 31 March. 1983". One may well ask how one can manage a service in the light of those very rapid changes, and today many speakers have expressed their concern at this way of management.

To turn to the manpower targets, it has been said that it may well seem ludicrous to charge that a reduction of one half of 1 per cent of the staff of the biggest employer in Western Europe marks the end of the National Health Service as we know it. But the head count of employees at 31st March took no account of the base line from which it was starting. It ignored the effects of reorganisation and the unfilled posts due to reorganisation. It ignored the fact that, in order to effect economies, some authorities were holding posts unfilled. It ignored the fact that authorities were holding posts for new developments.

In saying that 45,000 extra nurses were available to the health service, no account was taken of the fact that more than half of that number was absorbed in the needs of a shorter working week. The view expressed by the Minister, the right honourable Kenneth Clarke, that there is overmanning in some parts of the nursing service, has caused a great deal of anger in the service. The General Secretary of the Royal College of Nursing has challenged him to show where that overmanning is taking place. As I go round the National Health Service what impresses me more is the gross undermanning in the nursing service in many places, and that I think is far more noteworthy. I, Personally, have sat in a geriatric ward and listened to half of dozen patients calling for help at the same time, with the only two nurses fully engaged in helping patients elsewhere. I cannot believe that in that kind of circumstance there is overmanning.

This kind of deployment of manpower can only produce one thing, and that is a deterioration in care. Again in geriatric wards, I have witnessed care that neglects, for instance, the promotion of continence in elderly patients because there are insufficient staff for anything more than custodial care. I must ask your Lordships: what kind of care do we wish to see in our National Health Service? Nurses do not make foolish predictions about the imminent collapse of the National Health Service, and I am not doing so tonight, but, despite the assertions that we have had, I believe that we are witnessing a cancerous erosion of its excellence.

In addition to the cuts and the manpower targets, we have the Griffiths Report, to which frequent reference has been made in your Lordships' debate. I must underline that it ignores the role of the nurse in the management of the service. Yet two-thirds of the National Health Service workforce is composed of nurses. It ignores the work of the Nursing Division at the Department of Health and Social Security. The Chief Nursing Officer is not mentioned as a member of the Health Services Supervisory Board, and yet the Chief Medical Officer is. I find it difficult to advance an argument in favour of that distinction. I think that, perhaps unwisely, the Griffiths Report invoked the shade of Miss Nightingale to support the case for a chief administrator. It suggested that Miss Nightingale would be walking the corridors of our hospitals looking for who was in charge. I have no doubt to whom Miss Nightingale would turn.

I believe that nurses are extremely concerned about a more efficiently managed health service, but we would not be altogether convinced that the details of the Griffiths Report would be in favour of the National Health Service. In our time we have had the implementation of the Salmon Committee Report, which brought many good things into the nursing service, including the right of representation at every level of the health service. But it imposed on nursing what, to my mind, was an unsuitable form of management because it was an industrial model of management, and we found ourselves with rigid hierarchies that it has taken us many years to overcome. I believe that with the Griffiths Report we may have a similar industrial model of management imposed upon us, and all the work on suitable models of management that one can study, even in different industries, demonstrates that for different types of service different models of management are needed.

Therefore, I want to ask the Government to reflect and consult, to he more selective in their strategies, and to time them better. The nursing profession has increasing evidence of deteriorating standards of care and of understaffing. We are frequently in situations where no trained member of the nursing staff is present in the ward and students are left, unsupervised and inexperienced, to carry out the work of the ward, and there is undermanning in community services and mental handicap services.

I want to suggest, too, that it is in nursing education that some of the gravest effects are being felt as well as in standards of patient care. Authorities have cut down the numbers of staff they are seconding to training. It is one of the easiest economies to make, to reduce the numbers of nurses in continuing education courses. Until recently I was chairman of the Joint Board of Clinical Nursing Studies. Its work has now been taken over largely by the English National Board for Nursing, Midwifery and Health Visiting. There we were seeing an increasing take-up of short courses, rather than longer courses that would adequately prepare nurses for their function.

We are seeing a decline in the number of nurses being put forward for necessary professional education and an erosion in the amount of education they are getting. But, more than that, staff are failing to take up places in training courses because they fear the loss of a job at the end.

Added to this, untrained staff-are taking the place of trained staff in wards. This has a deleterious effect on nursing education; student nurses are having to learn from untrained staff. We know that in learning to nurse there is no substitute for learning in a clinical situation. Thus the standards of care are, by this default in education, being eroded.

I, too, was most impressed by the contribution of the right reverend Prelate, the Bishop of Southwark. Many of us are in the nursing profession because we subscribe to that Christian tradition which he so ably outlined. We believe that many of these values have impregnated our society. I plead with the Government to enable us to hand these values on to future generations and not to hand on a tarnished jewel.

6.42 p.m.

Lord Ferrier

My Lords, I too thank the noble Lord, Lord Molloy, for introducing this important subject, though I will not conceal the feeling that the earlier debate was a great disappointment. We seemed to spend so much time beating up over old complaints and not looking to the real title of the debate which is to consider the future of the National Health Service. It enabled my noble friend Lord Glenarthur to give a number of figures which are as dry as dust to many people, although they have been illuminated by some of the later speeches. The noble Baroness, Lady McFarlane of Llandaff, and my noble friend Baroness Cox have shown how much they care; but earlier we did not make it clear beyond peradventure that we all care. It is quite wrong to repeat the old claptrap about the Government creating unemployment on this or that. They do not. It is all wrong to say that private medicine is being introduced for this purpose or that. I thought very much of that when I was listening to the right reverend Prelate's speech. The noble Baroness, Lady Lockwood, also picked out this point. The right reverend Prelate felt sure that more people would pay more if they felt that would contribute to an improvement of the National Health Service.

As someone who must have been among the earliest subscribers to BUPA I am glad somebody brought out the point about paying for the National Health Service—we all pay for the National Health Service. It is a dreadful pity that the Socialists attack private medicine. The result has been completely counter to what they had in mind: the proliferation of these private hospitals which are creaming off money which, as the right reverend Prelate suggested, might be used to maintain the National Health Service.

We must ensure that a message goes out from the House of Lords that we all care. Caring is not the sole right of the Socialists. If one has a large family and an invalid wife, of course one cares. Everybody cares. I should like to take the point made by the right reverend Prelate that the National Health Service must now be in a jam because of the proliferation of private medicine.

I believe that the private beds in national health hospitals and the private hospitals are making a conscious contribution from people who feel that because they are better off than others they are prepared to take the load off the National Health Service if they can do so. We need to achieve an improved feeling throughout the National Health Service. My right honourable friend Mr. Fowler and my noble friend Lord Glenarthur should not always be having to apologise, to excuse and to explain. Can we not say that it is amarvellous show, and that we are all proud to be members of this nation with its National Health Service and that we want to make it work? To make it work it must be more economically run. How can it be more economically run? Is there anything more that you and I, the doctors, the receptionists and the telephonists, can do to help with all the endless detail which contributes to the welfare of the sick? We should send that message out and perhaps the noble Baroness who is to reply will say whether she agrees with that.

I have two technical points to propose. I have touched on one: namely, the question of private hospitals and private medicine. I believe that private medicine, if it is properly channelled into the whole outlay on health, can contribute to the success of the National Health Service.

My other point was, oddly enough, brought to my mind today by a circular I received from the Institute of Complementary Medicine news briefing. This is something that is right down the street of the noble Lord. Lord Winstanley, because I remember that in 1976 he took part when the House of Lords started off this move towards the fact that there are other sciences which can contribute to the welfare of the state, including the cost of national health. I trust that my noble friend will remember that it was here that we started what has become a very important part of our consideration of the nation's health, which has recently received the support of His Royal Highness the Prince of Wales. I urge that the problems of reducing the incidence of back pain, with all its concomitant pain and distress, of loss of health and of work, of loss of earnings and of productivity, should be put in the forefront of the nation's thinking.

When I asked: "How can we all help?". I may say that I consulted one of my married daughters—we have a large family—and her contribution was, "Do the receptionists do enough? Some of them 'do' like anything; some of them don't". She also asked why so many doctors' surgeries are (as she called them) "dumps" with their ancient newspapers and the like. I believe that it can be done if the doctors, receptionists, and everybody feel that the nation is behind them; and that we are prepared to put ourselves out to see that the National Health Service goes from strength to strength. This can be done as our economic condition improves. Those are the two points that I wanted to make that about private medicine and that about supplementary medicine. But I repeat that I do believe that it would be well worth our while ensuring that it should go out from this place that we are proud to have the National Health Service and that we are prepared to go to many extremes in order to see that it is properly supported and properly carried on.

6.53 p.m.

Baroness Robson of Kiddington

My Lords, may I first join in the congratulations expressed to the noble Lord, Lord Ennals, on his maiden speech in this House. I do this with particular pleasure because for some years I was an employee of his. I should like on this occasion to say that rarely have I worked with a Secretary of State who was so approachable—and this is a great and desirable characteristic in Secretaries of State. Also, I think that he was perhaps responsible to a large extent for highlighting the position of the Cinderella services within the National Health Service. Few people have done as much as he has done for the mentally handicapped and the mentally ill. We are very grateful to him. I am also grateful to the noble Lord, Lord Molloy, for raising this subject, because I believe that we are meeting at a time when people in the country are concerned as never before about the future of the health service. I was very interested in the noble Lord, Lord Ferrier, saying that what we have been talking about is the past. Let us talk about the future.

I really want to devote my time mostly to the future management of the NHS as it is envisaged in the Griffiths Report. Some noble Lords have suggested that, hopefully, we shall have some time to discuss the Griffiths Report in depth. I sincerely hope that we shall be able to do that. But what makes me nervous is that I feel a certain amount of urgency on behalf of the Government and of the Secretary of State to get on with the job and to rush it through. Therefore, I hope that the House will bear with me if, as a former administrator in the service, I make a few comments on the report.

However, before I get to the report I want to quote some statistics and some polls. I think it was very interesting that the Sunday Times MORI poll suggested that for every 15 adults in favour of spending more money on the NHS only one was against spending more money; that for 50 per cent. wanting a cut in defence there were only 12 per cent. who were against. For the first time, I believe, we have a climate in the country where we obviously are aware that the resources at our disposal are not infinite. Whether our financial difficulties are created by the international situation or by the financial policies followed by the Government, we have limited resources. We understand that. What we do not accept is that the views of the electorate who provide those resources should be ignored. And that is what is happening. The majority of the people in this country would like to spend more money on the NHS.

It is also worth mentioning that whatever system of delivery of health care is provided in a country, whether it is private insurance, as in some countries, or whether it is state-provided through the National Health Service, as we are lucky enough to have in this country, all nations are experiencing difficulties in meeting the escalating costs of technological advance and ageing populations. It is not only because we have the National Health Service system. We, in fact, are doing very much better than the systems followed in other countries. It is true, too, that within our own nation even the private sector health insurance is in difficulties because of escalating costs and the need to raise premiums.

I should like to turn to the proposals of the Griffiths Report. Generally speaking, I think that we on these Benches welcome the general sentiments of the report as a skeleton outline of what inevitably will be yet a further reorganisation of the health service, albeit only at the managerial level. But let no one be deceived into thinking that it will not be disruptive of the service. What we must ensure is that in the process we do not throw out the baby with the bathwater; in other words, that all the benefits that have come to the service through consensus management, through functional management, through creating good professional relations—all those things—must be preserved, so that we do not go in for a reorganisation which does not take account of the good that has been done. This is a very difficult exercise.

We must also remember, above all—and this has been mentioned by many noble Lords—that in introducing commercial management principles (and the noble Baroness, Lady McFarlane, particularly mentioned this) into the NHS, it is a caring service and not a commercial enterprise in the ordinary sense. This is my fear about the Griffiths Report. What I welcome most in the report is the statement on page 2, where it is talking about the general management body at the DHSS. It says: a small, strong general management body is necessary at the centre (and that is almost all that is necessary at the centre for the management of the NHS) to ensure that responsibility is pushed as far down the line as possible, i.e. to the point where action can be taken effectively". I quote this with some feeling as someone who has been involved in the health service for well over 15 years; and at each successive reorganisation successive Governments have expressed the desire to move the decision-making down the line. It has been my experience that with each successive reorganisation more and more decisions have been centralised, the latest example of which concerns the recent manpower cuts. It is no good talking about decentralisation so long as this amorphous, over-large body in the DHSS is taking decisions for the people who have been appointed to take decisions; and that applies to health authorities, let alone managers within the service.

But I have many worries about the Griffiths Report. I will leave the matter of the supervisory board, because that has been dealt with so adequately already by the noble Baronesses, Lady McFarlane and Lady Cox. However, I have enormous worries about the management board itself. First of all, I am worried about its composition. It is suggested that there should be a commercial-type manager, a commercial-type personnel director, members of the DHSS and some NHS membership. As an administrator, it has been my experience, with all due respect for the good will of civil servants in the DHSS, that even they do not understand what it is like to run the health service "at the coal face", because they are not involved. Therefore, I would hope that the composition of the management board would take adequate account of representation from the NHS.

I am also concerned about the relationships of the management board, between the Secretary of State and the statutory regional authorities. The regional authorities are servants of the Secretary of State, and there is a direct relationship between regional health authorities and their chairmen and the Secretary of State. I have heard it said that the management board at the DHSS should stand in an advisory capacity to the Secretary of State; in other words, there would be the Secretary of State and the supervisory board, the regional chairmen, and out there somewhere on a limb would be the management board. How can you manage under those circumstances? What is wanted as a chairman of that board is a very high-powered, thrusting person. Where are you going to find a person prepared to take on that formidable job if all he is going to be in the end is an adviser to the Secretary of State? If, on the other hand, the management board comes in between the Secretary of State and the regional health authorities, then there will have to be many more discussions about the implications of the Griffiths Report.

Unlike some Members of your Lordships' House, perhaps, I welcome most warmly the suggestion in the report of the appointment of a general manager at the unit level. Incidentally, this is something which is also in line with the Royal Commission's recommendations; but a lot of questions arise. First of all, it is essential that that managerial post should be open to any of the chief officers at the unit. It could be a nurse, a doctor, the administrator or the treasurer, depending on who is the most capable of fulfilling the function. I agree with Griffiths that it is important to have one final person where the buck stops. That is not to denigrate the need for consultation consensus within the unit. If this person, whoever he or she is, is appointed as general manager, will this be a new appointment? One understands from what one hears that it is going to be the elevation of one of the members of the management team. If that is so, is that person going to be duly recompensed for his extra services, and is he going to be able to do the two jobs? In my experience all the chief officers at district and unit level are fully occupied in running their own departments and doing their own jobs; so I would suggest that an additional post here is necessary.

Secondly, if it is given to a doctor, if the decision is to have a medical administrator appointed as head of the unit, great problems will be created because each consultant has a contract with the region and not with the district health authority. Would he therefore require a second management contract with the district health authority? That obviously must be necessary, because a contract as the administrator of the hospital must be on the same basis as other contracts of employment within the service—able to be terminated for lack of performance. Therefore, a lot of thought has to be given to the possible appointment of the medical administrator. Also, the medical profession themselves will have to think very seriously about whether they are prepared to take on such a responsibility, because it means that their responsibility will be wholly to the district health authority and not to their professional colleagues, in the way they are used to.

When it comes to the appointment of a general manager at regional level I have many more reservations, although I can see that in order to create a proper line management one person is required to be responsible or to be the spokesman. But consensus management of all the disciplines at regional level is really almost more important than anywhere else because the duty of the regional health authority and its officers is financial allocation, strategic planning and monitoring performance in line with the strategic plan. They are not managers in the true sense, and it may be that their relationship to the Secretary of State should be direct to the supervisory board at the Department of Health.

Those are the problems we have to consider, and the problems that are raised by the report are immense. I agree with what my right honourable friend Dr. David Owen said in the other place—and I quote from Hansard, at col. 465 of Thursday, 27th October: Rather than implementing the general manager principle across the whole of the NHS—one more reorganisation being globally applied—why does not the right hon. Gentleman carry out pilot studies in a few areas where he feels that consensus management is not working?

Lord Mottistone

My Lords, would the noble Baroness allow me to interrupt her? Am I right in thinking that one can only quote Ministers? I do not think it is right to quote another Member of another place, unless it is done as a paraphrase.

Baroness Robson of Kiddington

My Lords, I apologise. I had forgotten about that ruling, and I should have paraphrased what he said.

Lord Winstanley

My Lords, if the noble Baroness will allow me, there are devices whereby that rule may be got round. May I suggest that the noble Baroness had already got round it?

Baroness Robson of Kiddington

My Lords, I thank my noble friend very much for his defence. Quite apart from the management, on the new proposed management structure for the NHS—and, as I say, I have talked about some of the aspects because I feel there is an unhealthy urgency on behalf of the Secretary of State to change everything yet again—the report has much to recommend it, but it should be looked at very carefully and introduced very slowly.

There are many other questions that are left to be answered about the future of the NHS, and one of the most controversial is the position of the family practitioner committees within the orbit of the NHS. My noble friends and I raised this subject before at Committee stage and in debate on the last Health and Social Services and Social Security Adjudications Act, and I know that the Griffiths Committee were not charged with this remit. But we are now facing a kind of third reorganisation of the NHS within ten years, without tackling this problem. In fact, in the 1982 reorganisation we made the problem more difficult by making the family practitioner committees into special health authorities.

To the general public, the NHS means the hospital service, the community services and the general practitioner services. They cannot see the difference, and neither can I; and I am fairly sure that the latest financial cuts in the National Health Service had a lot to do with over-spending on the only open-ended expenditure in the NHS—the FPCs. Following on from what my noble friend Lord Diamond said about having an adequate contingency sum, if the Government had had an adequate contingency sum the main line of the NHS would not of course, have been penalised by cuts to pay for over-expenditure in one section of the NHS.

So I believe that until we tackle the problem of the family practitioner committees, until we have the courage to bring them into the service, we shall not solve the problems of the NHS, particularly in the inner cities. We can plan as much as we like, we can communicate with the FPCs, but until they are within the same orbit I do not believe that we shall solve the problem.

What we are doing with Griffiths is, in a way, going back to the kind of organisation that existed in hospitals pre-1974. Therefore, if your Lordships will bear with me, I should like to make a very special plea for the preservation and independence of Queen Charlotte's Hospital for Women, as a centre of excellence, because we have exactly that kind of management. We have a house governor who is the manager, and we have a board of governors who are working to give the best service to the patients. We want to remain like that and not to be absorbed in a bigger conglomerate, where interest in guaranteeing the best care at birth for future generations will be only one of the many criteria uppermost in the authority's mind. We believe that the only possible way to a reduction in the cost of the NHS in the future is to make sure that every baby is born healthy.

7.14 p.m.

Lord Mottistone

My Lords, it is indeed a pleasure to follow the noble Baroness, Lady Robson, because I agreed with a lot of what she said, particularly the earlier part where she was commenting on the management side of things. There were one or two rather more controversial remarks towards the end. I should like to congratulate the noble Lord, Lord Ennals, on a splendid maiden speech, which was skilfully controversial, without actually being so. I hope that we shall hear lots more of him in the future, and I am sure that we shall.

I agree with him and with the noble Lord, Lord Molloy, to whom we all offer thanks for this debate, that the National Health Service is indeed an organisation of which we can all be justly proud. It is fair to say that the country will always be in debt to noble Lords opposite and their forerunners for introducing the service in the 1940s. Indeed, as a very poorly paid junior naval officer, and later as an inadequately paid more senior officer bringing up a family of four, I derived immense benefit from the care of the dedicated general practitioners with their complementary hospital service.

Like many noble Lords, I look forward to similar care in the future, especially in my declining years, when I am quite sure I shall not be able to afford any kind of paid service. For that reason, I shall always wish to see the health service preserved in more or less its present form. But also for that reason, I am deeply concerned that, without a greater understanding by those who run it of the need to balance the books, the NHS, like, for example, the Common Agricultural Policy, may gradually destroy itself from within.

The problem is that, without the discipline of competition in the market place, people can fool themselves into thinking that limitless money must be available for their pet projects. Many modern pet projects are extremely costly in proportion to benefit—like, for example, if I may dare say it, heart transplants. This is partly the result of impressive scientific advances during the past 30 years, which were mentioned by the noble Lord, Lord Wallace of Coslany.

It is significant that, since the Second World War, there has been a quite remarkable scientific development right across the Western world, and not only in medicine. That has had the most unfortunate effect of creating so many opportunities that the challenge of financing them is almost impossible to cope with.

For example, new warships are costing between two and three times as much in real terms as they did 30 years ago to perform, roughly, the same basic functions. It may offend some of those associated with the health service if I make any comparison with defence expenditure. But the defence services are in many respects similar, in that they will always be a total Government responsibility, as I hope the National Health Service will be, and they will always be without proper competitive disciplines.

Your Lordships may remember that, when my noble friend Lord Trenchard was Minister of State for Defence, he warned us—I thought very convincingly —that, at the present rate of increasing real costs, we shall be down to minuscule fighting services in the next century unless we do something about them. I greatly fear that, unless we take real steps to impose stringent disciplines upon ourselves at all levels in the NHS, we shall also be down to minuscule health services in the next century.

For that reason, I greatly welcomed the action already taken by the Government in the last Parlia- ment, as well as in this one, to reduce the administrative structure of the health service and to introduce annual reviews of regional health authorities, and there is some evidence that these reviews are leading to a more cost-effective approach to their problems by those authorities. I have also greatly welcomed the Government's intention, which was recently announced by my noble friend the Minister, to implement many of the recommendations made by the Griffiths team for establishing a coherent management process throughout the whole of the NHS, from the centre down to unit level.

Having heard this debate I trust that my noble friend, in implementing those recommendations, will have listened carefully to what my noble friend Lady Cox had to say about nursing management and, indeed, to some of the points made by the noble Baroness, Lady McFarlane, on the same subject. It is in that area that the Griffiths team's recommendations need a careful look. However, all these are steps in the right direction and it is to be hoped that they will have a positive effect in changing the attitudes of the myriads of people involved, who have grown up in an atmosphere of consensus management instead of positive leadership, and of inadequate restraints on health expenditure. Those people have also grown up in an atmosphere of centralised wage bargaining. This is another trap for subordinate managers detected by the Griffiths team, but in my opinion not fully avoided. As my noble friend the Minister said, staff costs account for about 75 per cent. of revenue costs. Therefore the effectiveness of management at local level under the Griffiths proposals might be largely nullified unless wage bargaining is properly localised. Perhaps my noble friend could give thought to the establishment of something like a joint industrial council which is restricted to establishing minimum earnings levels and a limited area of terms and conditions for central discussion, leaving the regions or, even better, the districts free to negotiate real terms locally.

There is a point to this suggestion. I have a daughter who qualified as a state registered nurse some three or four years ago. I regret to say that she is not practising now; she is earning her living as a retailer. One of the reasons for this is that, when she had qualified and had worked her basic time to get her St. Thomas's badge, she found that the increase in her pay was so minimal that there was no incentive for her to stay. She said that it would have been very much better if she had been paid less when she was in training—I did not give her an allowance; there was no question of that—so that she could have had a positive increase when she qualified. And when she looked further ahead she found that the increase in pay if she became a sister was again minimal—quite disgracefully minimal—in view of the relative responsibilities she would have to undertake.

It could well be that this kind of wage bargaining would be handled better at local level since there would be a much greater degree of flexibility. Management would be seen by the employees to be managing and to be doing something positive in encouraging people to get on with the job and stay with the outfit instead of its all being settled from above by some grandee in the Department of Health and Social Security. I very much sympathise with what the noble Baroness, Lady Robson of Kiddington, had to say on the subject. It is my experience that the further management gets from what might be described as the coalface the less it understands what really matters. This is a fundamental point. If the best part of a million people are employed in the National Health Service—I understand that to be so: 800,000, plus a couple of hundred thousand people employed in the auxiliary services—you are faced with an immense problem if there is centralised wage bargaining which is organised by powerful trade unions at the centre. Therefore I strongly suggest that wage bargaining should be pushed as low as possible. I know that my noble friend will not particularly like what I am saying, but I hope that he will give thought to it.

The other point, as I have already mentioned my family, is that I was delighted to hear my noble friend the Minister mention voluntary support for the National Health Service. My wife is a voluntary worker in the children's hospital of the Westminster Hospital. I shall not repeat what she has had to say because somebody might trace it back to her, but I will say two things. First, my wife is very well aware of a great deal of waste—waste of all sorts: waste of materials, waste of people, the unnecessary employment of people. This grew up during the years in which Governments gave too much money to the National Health Service. The service employs lots of extra people who are not really needed. However, my wife reckons that we are short of nurses. It is important to recognise that nurses are the key to the problem and that all the other employees need to be managed as tightly as possible. This is not to say that nurses do not need to be managed as tightly as possible, too, because they are human and everybody who is human needs managing. But nurses are the people who provide the contact point with the patients. As many other people have said, this is the key point about the National Health Service.

I shall say no more on that subject. There is no doubt that, probably as a result of inadequate management structure and insufficient decentralisation of authority, local health bodies have failed to explain adequately to their local communities and to their employees the reasons for all sorts of changes. I am referring here to communication between management and their own employees and very much to communication between management and the outside world—their customers who are going to be their patients in due course. An example of this is the closure of hospitals, either temporarily or permanently. This leads in some cases to unreasonable local concern because no explanation for a closure has been given.

In many cases there is also lack of dialogue and failure to establish what the best overall solution to a problem will be. It is unreasonable of people to complain when there is a proposal to close a hospital just because it happens to be their pet hospital. With the greatest respect to the noble Baroness, Lady Robson of Kiddington, somebody has carefully thought out that this is the best thing to do for the benefit of the customers. If they have made a mistake about it and if there is a better way of going about it, which may be the case, there should be an open dialogue. But what often happens is that the first you know about it is when you read an announcement in the newspaper, and that is the end of it. Then people get hot and bothered, organise protest groups and bang on the doors of Ministers—all unnecessary and silly things if you have good communication in the local area. And communication in the local area is not effective unless people have got the right measure of authority. That is why an improved management system, with proper leadership, is the key to that kind of problem. But, having achieved that greater authority and better management at local level, a substantial improvement in informing and consulting must be forthcoming. both within the National Health Service and with its customers.

In conclusion, I turn to the question of overworked general practitioners. These dedicated and skilled people are entirely at the beck and call of their patients. Some of the latter use their doctors unreasonably. This can only be at the direct or indirect expense of other patients, or potential patients, who are perhaps less forceful than the greedy ones. This is clearly a misuse of valuable resources. This summer I had the good fortune to go to the Channel Islands. As some of your Lordships may be aware, the Channel Islands observed for some time after 1947 the working of what was then our imaginative new National Health Service. This led the doctors and the States in Jersey to investigate the arrangements in other countries, notably New Zealand, Australia and Sweden, as well as the arrangements in the National Health Service. I believe that the noble Baroness, Lady Robson of Kiddington, spoke about the Swedish method, of which she disapproves. However, the people in the Channel Islands do not disapprove of it. Their investigations caused them to establish three basic principles. They were, first, that payment for a general practitioner's services should he for an item of service and not a capitation fee; secondly, that such payment should be paid in part by the patient and in part by the States; and, thirdly, that there should be no direct contact between the doctors and the States in fixing their respective charges and recompense.

The thinking behind this arrangement was that they had observed in the Channel Islands—because Guernsey has something not dissimilar—that if the payment was entirely by the Government, as it is in mainland Britain, the patient often abused the system to the detriment of other patients, and that if the payment was entirely by the patient, as in the United States of America, the doctors abused the system.

Obviously any change to a charging system for general practitioner services on these lines would require much consideration and would no doubt involve a lot of people making many objections, but in the interests of ensuring in the long term that the National Health Service can be kept solvent, can make use of all scientific advances and make all the economies which can be made, and also in the interests of ensuring that the services are fairer to the ordinary customers or patients of the general practitioners, I commend this system for serious consideration by my noble friend the Minister and hope that he will give thought to it. I hope that, in taking this into consideration, my noble friend the Minister and his advisers will not suffer from the well- known complaint of "not invented here", because that is one of the things which sometimes nullifies the best ideas before they really get going.

In conclusion, I believe we might all agree that the key point is that the National Health Service must continue; it must be given the opportunity to use the best modern scientific developments that it can, but it must be so organised and run that it is as cost-effective as it possibly can be, in order to survive into the next century.

Baroness Robson of Kiddington

My Lords, before the noble Lord, Lord Mottistone, sits down, may I ask whether, in his comparison between the National Health Service and the defence services, he took into account that the projected growth for the NHS is, if anything, under half of 1 per cent. whereas that for the defence services is 3 per cent?

Lord Mottistone

My Lords. I have had a long battle with a brother-in-law of mine who is a professor of medicine, and, up until about the 1970s, we agreed that the defence services were getting more money overall than the health service was. But when I last looked at some figures with him, which must have been six or seven years ago, the health service had overtaken the defence services. Without checking, I cannot confirm what the noble Baroness has said, but I suspect that, if one looks at the figures closely, one will find that there is not much between them. In any case, they are doing different things; the defence services, after all, are protecting the lives of millions of people whereas the health service is protecting the lives of only hundreds of thousands of people.

Noble Lords

Oh!

Baroness Fisher of Rednal

One is killing and the other is curing, my Lords.

Lord Mottistone

I thought that noble Lords opposite would not like that remark!

7.32 p.m.

Lord Prys-Davies

My Lords, the National Health Service gives service to man when he is at his most vulnerable. I fear that I may not be in my place when my noble friend Lord Molloy and the noble Lord the Minister come to wind up this debate. I have to return to South Wales to keep an appointment tomorrow morning and I apologise to my noble friend, to the Minister and to the House.

I was closely connected with the National Health Service in Wales from 1968 until its reorganisation in 1974. For a short period I was answerable to my noble friend Lord Ennals, who was then Minister of State at the Department of Health. His contribution to the business of the House will, I am sure, be most valued as has been demonstrated already by his excellent maiden speech today.

Your Lordships may recall that 1968 was the year when unacceptable conditions in hospitals for the mentally handicapped came to light as a result of a report of a committee of inquiry into conditions at a Welsh hospital. The report made disturbing reading, and every knowledgeable person suspected that the hospital in question was not a black sheep; that it was not an exception but that most hospitals for long-term patients in the United Kingdom were also understaffed, that the quality of care was relatively poor, and that the patients were sometimes at risk of being neglected.

That report came to light in 1968. In 1983—15 years later—the position in the long-term sector in England and Wales, although improved—we recognise and acknowledge the achievements—is still a cause of concern. Hardly a year goes by in which the field is not strewn with an adverse report. It would be wrong of me and unfair to allege complacency on the part of the department. But the general approach of the department, at least as illustrated by the noble Lord the Minister in his speech, is far too comfortable. One wants to be fair to the Minister, and one considers whether he fully appreciates how difficult it is to bring about reforms, to bring about a change of direction, in this sector of the service. One wonders whether the Minister fully appreciates the difficulties which—day in, day out—face the men and women working in the long-term sector.

I believe we are asking a lot of men and women when we ask them to give a lifetime of service in this sector, doing work which most of us would not undertake. One of the aims of the NHS when it was established 35 years ago was to eradicate inequalities in health care and to provide health care for all, free of charge, when the service was required. The country willed that end, and I agree with the noble Baroness, Lady Robson of Kiddington, and my noble friend Lady Lockwood, that having willed that end, the country will also will the means to achieve that end.

Some areas of the country are plagued with more sickness, ill-health and physical poverty than others. Indeed, the right reverend Prelate the Bishop of Southwark touched upon this point in his speech. Yet those areas with the most sickness and poverty are not provided with the necessary additional skills, medical and nursing services to bring them to parity with others. I also acknowledge that there is the difficulty in a free society of attracting staff to work in the disadvantaged areas.

Dr. Tudor Hart of Glyncorrwg in South Wales, in his now famous article in the Lancet for 27th February, 1971, wrote, In areas with most sickness and death, general practitioners have more work, larger lists, less hospital support and inherit more clinically ineffective traditions of consultation than in the healthiest areas; and hospital doctors shoulder heavier case loads with less staff and equipment, more obsolete buildings and suffer recurrent crises in the availability of beds and the replacement of staff. These trends can be summed up as the inverse care law; that the availability of good medical care tends to vary inversely with the need of the population served". Dr. Hart was speaking of inverse care law from knowledge and experience he had gained in the Welsh valleys. Wales has a higher proportion of persons who suffer from chronic illness. In the mining valleys of South-East Wales the proportion of middle-aged men who suffer from permanent illness is alarmingly high. According to the 1981 census, 25 per cent.of Rhondda men aged between 50 and 64 were permanently sick and could not offer themselves as being available for work. These were not counted as being unemployed; they were unemployable. And Rhondda sis not alone. The figure for Merthyr Tydfil was 22 per cent. So at least one in five middle aged men in the valleys of South Wales are permanently sick.

What is the result of the failure to take account of the heavy incidence of sickness and relative poverty in areas such as the South Wales valleys? What is the consequence of the failure of the Government to make any serious effort to apply the recommendations of the Black Report, referred to by my noble friend Lord Ennals? I think the figures I am now going to give will give your Lordships an insight into the consequences. Last month, in the face of growing public unease and concern, the mid-Glamorgan health authority set up their own committee of inquiry to investigate the report that over the past few months about 13 patients had been refused admission to the Prince Charles Hospital in Merthyr Tydfil, one of the black spot areas. These persons were dead within days of having been refused admission.

Admission had been refused by junior medical staff working under heavy pressure and acting on authority delegated to them by their seniors. The authority found that the main difficulty arose because of the shortage of beds and junior doctors working under pressure having been forced to act as doorkeepers. While junior doctors will no longer be expected to act as doorkeepers at this hospital in Merthyr Tydfil, nevertheless, the gatekeeping or door shutting will continue to be exercised at this hospital; and many who need a bed will be denied entry because of insufficiency of beds. The main problem in the Prince Charles Hospital, in this black spot area of Wales is partly due to its lacking between 70 and 100 beds in geriatric specialities, and elderly patients are therefore seeking admission to acute medical beds. That is a problem which money ought to be able to solve. Yet, the mid-Glamorgan area health authority must cut back its services under the Government's injunction. Other area health authorities in Wales are faced with similar problems. They are cutting back in order to keep within their budget and shedding desperately needed staff to comply with demands for further cuts.

I have been on my feet for 11 minutes. I will conclude by asking the Minister three questions, and they relate to the Black Report. We have a special interest in the Black Report. First, how many of the recommendations of the report have been implemented? Secondly, which of the studies recommended by the report have been commissioned and when will those studies be published? Thirdly, what guidance based on the report has been issued by the department to the regional health authorities in England, and by the Welsh Office to the area health authorities in Wales?

I have been discussing the position in Wales and in the valleys of South Wales in particular, but I should like to set this in a world perspective. The World Health Organisation has formulated strategies aimed at providing health services for all by the year 2000. This is a challenge. This country has potentially a superb National Health Service, which should be capable of achieving that aim. It has great strengths. But if it is to realise its potential, to fulfil its promise and to make the necessary advance, it needs a whole range of investments, in staff, buildings, community facilities, and it needs innovation, a sense of direction and high morale. What worries me is that the Government are failing to create the conditions which will enable this necessary development to be achieved.

7.47 p.m.

Lord Milford

My Lords, I am going to he very brief. I am not going to make a speech; I am taking pity on your Lordships who may sit so late tonight. I will just ask the Government one or two questions, which I hope the debate may answer.

Our National Health Service gives better medical care than ever before, and it is the envy of the world. Yet, is not the proportion of our national income spent on illness lower than that in any other European country? One can get hospital treatment at less cost than in any other country, but is this because pay is so very low in our National Health Service? Does not our National Health Service mostly focus on medicine and treatment after the person is already ill? Should not we spend more on preventive medicine? Would not this alter the whole future prospects of this country? At present there is a high waste rate of ill working people, which could be avoided by more concentration on preventive care, linking it up with better housing and working conditions, which would also help to bring down the number of sick.

What about the drug industry? In 1982 these private concerns produced a profit from their drugs of £300 million. Would it not help the finances of the National Health Service if they were brought under national control? Take the case of not being able to afford kidney machines, which is very much in the news now.

The main aim of the Government seems to be to balance the exchequer. All has to balance the exchequer rather than paying full attention to the peoples' needs. Surely, is not spending what is needed on the health service a terrifically good national investment? Would it not add to the public wealth and lead to more demands for employment? The Government always seem to come back to. "We cannot afford it". Again, monetarism before people. But when already we have enough arms in NATO to blow up the whole of mankind, is not a superb, flourishing health service more valuable than one or two Tridents?

7.49 p.m.

Baroness Gardner of Parkes

My Lords, last month I had the privilege of attending, with the noble Lord, Lord Wallace of Coslany, a meeting of the Council of Europe on the subject of health, which was held in Paris. It is indeed a fact, as the noble Baroness, Lady Robson, mentioned earlier, that all Western European countries are experiencing difficulty in providing and maintaining their health services at present. Most of those present agreed that there was need for one visible responsible person to whom those who wished to find out something about the health service or had some complaint could take their case. I think that is a point I shall go into further later.

Although I have had extensive experience in many different parts of the NHS, this debate has been long and there are many more speakers so I shall restrict my comments to my own profession of dentistry, as I am the only dental health general practitioner in your Lordships' House and I have been in National Health Service practice for over 25 Years. My noble friend Lord Colwyn is another member of the dental profession.

Dentistry is that part of the National Health Service which has been too successful. Dental decay—or, to use the technical term, dental caries—is vanishing. In his introduction, the Minister pointed out the rapid decline in dental decay in younger children; but this is applicable to all ages now. The profession believes that the use of fluoride toothpaste has been a major factor; but dietary improvements and better dental hygiene have played their part. For example, in some areas children requiring fillings are so scarce that they have to be bussed to the teaching hospitals because there are no local children available. This falling demand for dental treatment is creating under-employment and even unemployment in the profession. Each week in my surgery one or more dentists come in looking for a job.

The repairing pattern of dentistry of the past is therefore changing. Future dental needs will be related to periodontal treatment—gum treatment. As natural teeth are retained in the mouth for much longer periods the equivalent period of time for gum treatment and dental periodontal care will be required. This will be necessary to prevent the loss of the bones supporting the teeth and also to prevent the development of chronic gum conditions which can produce such evil-smelling breath that even one's best friends would keep their distance.

National Health Service dentistry has always been based on piecework. Dentists are paid on an item of service basis. That has been a visible and measurable means of assessing payment and work done. But it is obvious that sooner rather than later a change will have to be made as more preventive gum treatment and instruction in oral hygiene replaces the earlier reconstruction work. The present system whereby patients chosen at random are checked by regional dental officers to see whether work has been done satisfactorily, and on the quality of the work, is effective for visible treatment. But how does one assess prevention? How can one prove that the work has been done? The department and the profession must work together on this problem for the future.

What of the present in dentistry? There are things that require change now in order to be fairer to the patients and the profession. Fees are calculated on a national basis. No allowance is made for unavoidably high overheads. The dentist paying rent and rates of, say, £120 per week is paid the same amount for each item of service as another dentist whose rent and rates are £20 a week. The first man has to do £100–worth more fillings or other dental treatment before he even meets his overheads and reaches the point where the other man is starting. Usually rates of pay for ancillary staff are also less in the areas of lower rent and rates. Staff in London, for example, expect and receive a London weighting which the dentist himself does not receive.

Members of the pharmacists profession tell me that they suffer from an exactly parallel difficulty. As the gap between the big city and rent and rates elsewhere has grown, so the dentists in the larger cities are finding themselves forced to turn towards private dentistry as a means of survival. The patients, particulary in the inner-city areas, are losing their ready access to comprehensive NHS dental treatment. The dentist, of course, provides all his own equipment at his own expense. Few patients realise this. They think it is all provided by the NHS.

How many members of your Lordships' House are aware of the newly increased amount paid to a dentist for a NHS dental examination? The gross fee is £2.40. If surgery overheads were £50 an hour, the dentist would need to examine 20 patients an hour—one patient every three minutes—simply to meet those overheads. Patients take about half that time to walk into the surgery, take off their coats and sit down. That leaves 1½minutes for the examination. If overheads are £100 an hour—and they often are—40 patients would need to be examined each hour. That is not even time for them to do more than open their mouths. To claim the £2.40 for examining a patient, a complex computerised form must be completed and sent in by the dentist. This examination fee of £2.40 is unrealistic and inadequate. As prevention and instruction in oral hygiene become the norm a more realistic basis of costing must be devised.

For too long we have had a swings and roundabouts agreement between the DHSS and the profession. As time passes, those dentists who have looked after the same patients well for years find that more and more of them come in just for a check-up. The reliable and caring practitioners are destroying their own financial situation. The present system is rather like the common agricultural policy—it encourages over-production. Under present arrangements patients' charges do not encourage regular care. Those who do have regular care are disadvantaged.

The examination to which I referred is free to the patient but the adult patient pays the first £13.50 of routine treatment costs. The many patients who are regularly having one or two items of treatment are meeting their treatment fees in full. Once one requires treatment worth more than £13.50 the NHS pays the balance, although there are separate items and charges for crowns and specialised treatment with a present ceiling of £95. So the patient requiring treatment to a value of £13.50 is paying 100 per cent. of the patient charge. If more treatment is needed—say, £27 worth—he is paying 50 per cent., and if he is receiving treatment worth £54 it becomes 25 per cent.

The less one cares for one's teeth, the better value for money one gets from the NHS. The number of patients receiving treatment worth more than £1,000 for the ceiling payment of £95is quite significant. They are receiving very good value for money, but if one needs a small denture one pays £22 out of the £26 that the Government give.

The British Dental Association has carried out research and recently published its findings which clearly indicate that patient charges affect numbers attending for treatment—particularly those caught in the poverty trap and those just above that level. There is of course exemption for social security and similar cases. I know that the BDA will press the case for not bringing further increases in patient charges in 1984 and I support them in that. My plea to the Minister is to look into the present changing patterns of necessary treatment, to plan for the future of dental health and to consider varying patient charges so that patients will be encouraged to attend regularly but not be disadvantaged.

The vast bulk of dental treatment given in the United Kingdom is provided by general dental practitioners. Dentistry is a demanding profession in terms of time and concentration. The economics of general dental practice today mean that practitioners must be too intent on delivering immediate care to their patients to be able to think enough about the changes necessary to provide dental care for the future. Thought is necessary: plans must be made. The recent Griffiths Report found that the NHS is slow to make changes—slow even to recognise the need for change.

I have heard some nostalgic comments today on the good old days of the health service. I think there is a failure to understand that the health service is alive and well but ageing. Changes are necessary. There has been too great a resistance to the introduction of new ideas. Certainly there is need for a much more rapid response in dentistry. As an example, I quote the nonsensical situation that the National Health Service cut the fees for gold crowns by £20 just at the moment when the gold price went up. There was no machinery for quick action and quick correction of that sort of anomaly.

Redundancy was mentioned by the noble Baroness, Lady Lockwood. As yet this has not been considered for general dental practitioners. Efforts are being made to deal with the oversupply of dentists by cutting back on training levels, but it may well be that redundancies will face the profession. I welcome the proposed new management structures for the health service as set out in the Griffiths Report. I hope that these will prove effective in making clean, clear and quick decisions; and, more importantly, seeing that these are implemented to the benefit of the patients in the National Health Service.

8 p.m.

Lord Richardson

My Lords, any of those doctors who had mutual work with the noble Lord, Lord Ennals, when he was Secretary of State would expect his maiden speech to be of the quality that it was today and would not presume to congratulate him because that is what one would undoubtedly expect.

I want to follow what the noble Lord, Lord Ferrier, put to your Lordships—namely, that we should talk about the future. After all, that word comes in the Motion of the noble Lord, Lord Molloy. I want to talk about the essential future of the National Health Service and of the medical profession, which lies with the great teaching hospitals of this country. Without them there would be no young doctors, and without them there would be little progress in bringing relief to us all in the future.

When I speak, I speak, I am sure, for all the teaching hospitals in this country, although their problems will vary from place to place and from centre to centre. I have consulted the Dean of the Faculty of Medicine in the University of London—the chairman of the committee of all deans of the London medical schools, Professor Le Quesne. After consultation with his colleagues, as he put it, he has confirmed the information that I received from my personal friend and the dean of my own hospital, Dr. Brian Cremer, concerning the very great threat and difficulties which confront the teaching hospitals' medical schools and which will increase over the years to the point of bringing about their extinction if nothing is done. I shall tell your Lordships—I hope briefly—of some of the difficulties that are special to these teaching hospitals.

The cuts and the difficulties come from two directions. They come from the Department of Education and Science through the University Grants Committee and also from the direction of the NHS. The consulting staff of teaching hospitals have not only a teaching function and a clinical function but a function to add to knowledge. To take the one hospital about which I have detailed personal knowledge, as a result of the UGC cuts in the past three years three out of 12 clinical professorships are unfilled as an economy measure. One of those is the Professorship of Haematology—blood diseases. Leukaemia (one thinks of Windscale) and renal transplants are of great concern not only to individuals but to the public as a whole at the present time. Cancers and innumerable other major anxieties of national life, such as exposure to radiation and toxic substances, also come under the purview of a chair of haematology. Without a leader to a department, that department will begin to fail.

That is one element in the difficulties. The other is that for the sake of economies the teaching hospitals have had to require various senior lecturers and readers to leave their posts early and not to be replaced. Some of the great teaching hospitals in London are also now being required to take special hospitals into their complex. In my view and in the view of many people, that is an excellent thing, but it is costly. There is no evidence that any help is coming to them for that extra cost.

A further anxiety is felt by the teaching hospitals. In the control of manpower, it is now said—I emphasise "said", because I believe there is a question mark over this, and I ask the noble Lord the Minister whether he will help me in this matter—that in the near future districts will be able to close the honorary appointments in the NHS of lecturers and senior lecturers. They do not pay them. The pay is from the UGC—from the DES. If that is so, it seems quite extraordinary. Of course they take up resources but nevertheless they are doing clinical work that is presumably entirely necessary. As I say, I am told that this may vary in various parts, but I know that it is a major anxiety. If it came about, it could add considerably to the threat of disaster.

I have already said that the clinicians in the teaching hospitals have a research function to add to knowledge. Unhappily, a very famous rectal surgeon died earlier this year—Sir Alan Parks. His original work has relieved patients all over the world. He has not been replaced. People may well say that that is fair enough because economies have to be made. But his research team is at risk. The great work that he was doing may not be carried on. Surely there is an instance where an economy that on the face of it is reasonable can be profoundly damaging to the progress of medicine and indeed can have an economic factor in it, because progress does not invariably lead to over-sophistication and increased costs. I could go on but I shall not, except to say that all the things that have been said about the difficulties that face hospitals in a general sense apply equally to the teaching hospitals. In that sense, they are in no way different from anybody else and they are equally vulnerable.

Pressures have come from RAWP. The noble Lord, Lord Wallace of Coslany, said that the South East Thames regional authority was particularly pressed. Within that region, within that pressure to get better distribution—and that again is fair enough—there are internal pressures that are coming on the teaching hospitals. So from the NHS side the teaching hospitals themselves are under some form of pressure and threat.

This same regional authority—the South East Thames Regional Health Authority—has sent around for discussion a consultative document on resource allocation. If that is implemented over the 10–year period for which there are projections, it will amount to the extinction of St. Thomas's Hospital in particular as a national centre—not as a hospital, but as a centre that can give service nationally, and indeed, internationally.

So, my Lords, I hope that I have said enough to convince you that the teaching hospitals have in their medical schools a very profound cause for anxiety regarding the future. I am not putting in a particular plea for special treatment necessarily at this time, but I am putting in a very strong plea—as strong as I can make it—for consideration of what is going to be the consequence for the practice of medicine and indeed for the National Health Service. If we do not get the young men and young women properly trained and clear in their minds about what they should do following from the advancement of knowledge, if we do not get increased help to patients through increase in knowledge and technical advancement, what will happen to the National Health Service? Personally I profoundly believe that what I have been trying to say to your Lordships is completely fundamental to the substance of this debate.

8.12 p.m.

Baroness Fisher of Rednal

My Lords, I should like to add my tribute to the noble Lord, Lord Ennals, on his maiden speech. I first met the noble Lord, Lord Ennals, when he was campaigning for MIND as its director-general. The wholehearted support which he gave to that campaign when he was employed by the organisation was followed up when he had the opportunity to put into practice what he had been compaigning for. It was a delight to listen to what he had to say to us today.

I should like to follow the theme of poverty which he put forward, and I wish to concentrate my remarks on the inner cities. I appreciate that some remarks on this point were made by the noble Lord, Lord Glenarthur, when he spoke from the Dispatch Box. When we talk about inner cities it is so easy to think of a small conglomeration of people with perhaps a few problems of the kind which they could solve themselves if they stood on their own two feet. But that is not what inner cities are all about. There is great social deprivation in all our great cities in this country, and this arises among two main groups: the elderly who are living alone, and one-parent families. There is tremendous social deprivation in those two categories.

There is also very poor housing and overcrowding. If any one of your Lordships wants to see poor housing, I am sure that the right reverend Prelate the Bishop of Southwark could within walking distance of this House show you the most appalling housing conditions.

All the inner cities in this country contain highly mobile populations. The young people have all got on their bikes and are going around the country looking for jobs. They go to the cities and find that there are no jobs there, either. When they go to the cities they become very lonely people, and in many cases, so as to assuage the loneliness, they become addicts of one description or another. This, again, is a problem of the inner cities.

We also have immigrant populations in our inner cities, and they have the varied and different attitudes of the ethnic groups. Here the medical profession find a very difficult problem with the immunisation programmes, which are very important because epidemics do not stop at a certain street, they spread very rapidly. We also have in the inner cities mainly working class populations, and all the research shows that the higher infant mortality rates occur in this particular group.

So what do we do to solve the problems of the inner cities? If I heard the noble Lord, Lord Glenarthur, correctly, he specifically said that £9 million had been specially allocated. I would ask: How much is that per city, and what good will it do? I am not suggesting that it will not do any good, but it will not cover even one small part of the many problems in the inner cities.

In the National Health Service people in the inner cities have great difficulty in getting on GPs' lists. London has a peculiar and a very acute problem, with thousands of people who are not on a general practitioner's list because the doctors have closed their lists. They have enough patients, and they have closed their lists. These doctors cannot cope with any more because, as other noble Lords have pointed out, they are the hard-pressed doctors with patients who have very complicated problems. What does the patient do when he has no general practitioner? He has no alternative but to use the hospitals. This is a most inefficient use of the NHS, since the hospital service is a very expensive form of primary care. But if a person cannot get on to a National Health Service doctor's list, he or she has no other alternative. The noble Lord, Lord Glenarthur, stated that statistics showed that there had been an increase of over 2 million in the number of out-patients, and he gave dates, which I was not able to note. Might it not be worthwhile the Government looking at the out-patient figures to see whether the increase has been due to the difficulty in getting on to a general practitioner's list?

I would ask: What encouragement are the Government giving to the setting up of more health centres in the inner cities? I have some personal knowledge of health centres in the city I come from, and I know that they prove to be of the greatest advantage to people who live in inner cities. At the centres there are multi-discipline teams working together. There is the general practitioner, the social worker, the psychiatric service, the health visitor, the nurse in practice; and in some of the centres on a sessional basis there is also a probation officer and a marriage guidance officer. All these services are geared to help the general practitioner in some instances when it is not purely and simply a straightforward medical case.

The health centres are proving to be those centres about which the noble Lord, Lord Glenarthur, spoke. They are using the non-medical services supplied by many of the voluntary organisations which provide social support groups. I shall refer to only two or three. We have Home Link operating to my knowledge. We also have the refugee centres for battered wives and the alcohol addiction centres. One has therefore this team of medical people, together with all the other basic services, and a voluntary grouping, working in conjunction, trying to help solve what are difficult and intractable problems for people living, as the noble Lord, Lord Ennals, said, in many instances, below the poverty line.

I should like to follow up what my noble friend Lord Wallace said. If you have a good primary care service and the general practitioner is offering the best service possible under the National Health Service, those services will not be used correctly if the social services of the local authority have had to cut back on home helps, meals on wheels and day centres. The doctor is left giving a most inefficient service. That is not value for money. We hear so often about value for money. But it is a waste of general practitioner money if he cannot get back-up services. What does he do? He cannot allow the old people to remain without those services. He has to take some action.

I had a point to make about value for money regarding nurses, but the noble Baroness, Lady Cox, and the noble Baroness, Lady McFarlane, have most efficiently set out the case on behalf of nurses. There is a practical point concerning the privatisation of laundry work. Before coming down here I looked yesterday through the Yellow Pages for the area in which I live to find out where all these laundries are that will take over the work. I must say that I had the greatest difficulty in finding a large commercial laundry in the city. Everyone recognises that women have washing machines. There are also launderettes. You do not nowadays see huge laundry vans going around dropping parcels off at people's houses. All these marvellous laundries we are told about no longer exist.

I can give an example of a large private hospital, adjacent to where I live, which opened about 18 months ago. It has appealed to the National Health Service laundries to take in its linen because it is thoroughly dissatisfied with the poor service from the one laundry that it has been able to find in the city. If we are to get all this privatisation going, I should like to know just where the laundries are. They are very capital-intensive, with the machinery now available, if someone wished to open one. I think, however, that I can say that they are all closed down.

We have heard about some of the wonderful medical places of excellence where all kinds of marvellous things take place. I am not decrying those places. It is, however, very unsatisfactory that thousands of people have to wait years and years for comparatively minor operations to restore them to fitness. Many are women awaiting gynaecological treatment. This means that, in the long run, there is no value for money because the general practitioner has constantly to keep feeding them with all kinds of tablets. When we talk about centres of excellence, one has to remember that there are others, not so glamorous, that are seriously in jeopardy.

I should like to outline two cases in Birmingham. We have what is called the children's diabetic home-care unit. It is designed for young children and their mothers, and instructs on care of babies and toddlers who are diabetic. It provides the support that comes from parents meeting together and receiving expert advice on how to care for very young diabetic children. That unit is in serious danger of being closed. It is not glamorous, but it is an essential service for parents.

At the other end of the scale we have in the city a foot clinic. That does not sound very glamorous, but it keeps the old people on their feet. It is surprising to discover the volume of letters sent to Members of Parliament from people who want to keep the clinic going. Is it not value for money if the elderly people can keep walking and participating? Is that not what we are talking about? It is not a case of being able to buy marmalade cheaper at one shop than at another. Value for money also means that so long as people can care for themselves and look after themselves, there will be no costs arising for the rest of the social services.

I should like to give, if I may, a little plug on behalf of the million or so readers of the Birmingham Post and the Evening Mail—not a Labour weekly. They have shown over the last few years a great generosity in response to many hospital appeals. Through those appeals, many thousands of pounds have gone to the children's hospital. An amount of money was also collected for the leukemia ward at another hospital. However, after all the thousands of pounds had been collected the hospital could not open because it could not be staffed. That is a slap in the eye for anyone who works hard to raise money. The Birmingham Post and the Evening Mailhad their own appeal for what I must pronounce carefully—an ultra-sonic scalpel. In three and a half months the readers raised £150,000, through raffles in clubs, marathon walks and coffee mornings, to purchase this piece of equipment. There was not one in the city at the time and it was necessary to borrow one from a London hospital. In the city, being pragmatic, we decided that we wanted one for ourselves. The appeal reflected great credit on all concerned.

At the moment, the Women's Own magazine—the magazine I look at when I have my hair done—is appealing for finance for the bone marrow hospital in London. The most reverend Primate the Archbishop of Canterbury is giving support, through the pages of the magazine, to that appeal. Must so many essential pieces of hospital equipment have to depend on charity appeals such as raffles in pubs, marathon walks and coffee mornings? Is that what the National Health Service is really all about?

I should like to conclude with a quotation. It comes from a long letter sent by a senior consultant and a chairman of a medical staff committee who enumerate all the cuts taking place in their authority. Their final two sentences read: The public should know that we are no longer able to offer proper medical care. Those who cannot afford private care will be cheated of their right to treatment". Those are not the words of Ken Livingstone, or anyone like that: they are those of two very senior people in the medical world.

That is only one quotation. If one looks at the daily papers one sees that men and women eminent in medicine are expressing clearly their concern about the cuts in the National Health Service. The very eminent speaker before me was the noble Lord, Lord Richardson. I had the privilege of being a member of the General Medical Council when the noble Lord was its president. The noble Lord expressed anxieties.

Indeed, when we hear at first hand the concern of the nursing profession being cogently expressed by the noble Baroness, Lady Cox, and the noble Baroness, Lady McFarlane, surely the Government must take this debate very seriously. My noble friend Lord Molloy has given us the opportunity to express our concern, and our concern is shared by many, many thousands outside the House who are very worried about the future of the National Health Service.

8.31 p.m.

Baroness Macleod of Borve

My Lords, ever since 1948 and the appointed day of 1st April I have been not only interested in, but have had something to do at various levels with, the National Health Service. So to me it was especially interesting to hear the very valuable contribution made by the former Minister of Health, the noble Lord, Lord Ennals, this afternoon. I very sincerely congratulate him on his speech. As he will know, but perhaps other Members of your Lordships' House will not know, he did not succeed my late husband (because he was Secretary of State from 1952 to 1956) but they both held the same job. Indeed, perhaps it was during those four years that I learnt the most about the health service. Certainly since then I have been, as the noble Baroness, Lady Robson, would have said, "at the coal face". Therefore, my contribution this evening is very basic, very down to earth and I am afraid that my speech will not be on the high ministerial level of the speeches that we have heard throughout the afternoon.

I thank the noble Lord. Lord Molloy, for introducing this very important subject. He had asked us to discuss the future of the health service, but it was a pity that I did not detect once in the 36 minutes of his speech a single word about the actual future of the service. However, the noble Lord did say that we were spending more and getting less. I hope that those of your Lordships who were here this afternoon and heard my noble friend Lord Glenarthur took note of the very illuminating figures that he was able to give us regarding the number of people who are now treated by the National Health Service. It seems to me that, although we are spending more, we are also getting a great deal more.

What of the future? My comments in this connection come under just two headings. First, we must stop wastage; and, secondly, we must increase responsibility. The noble Lord, Lord Mottistone, referred in his speech to stopping wastage. It needs to be stopped at all levels by all those employed by the National Health Service and, indeed, by the patients of the National Health Service. A friend of mine who is a Member of your Lordships' House told me only yesterday that the person who comes in to clean for her once a week was wearing a pair of surgical gloves to do the housework and the washing up. My friend asked her where she had got the gloves and she said, "Oh, it is quite easy. My sister works in one of the hospitals. She just brings me a packet along". It was not one packet but many, many packets. That is wastage, it could also perhaps be called thieving. It is going on throughout the hospitals and millions and millions of pounds are being lost.

Another source of wastage about which I am sure many of your Lordships know more than I do, concerns drugs. Last night I was sitting between two chemists. I asked them how many people obtain their prescriptions free in their two chemist shops. One said that it was 87 per cent. and another said that it was 86 per cent. In these days that has got to stop; I do not think that it is necessary.

I am of an age when one was proud to make ends meet, to pay one's way and to meet all the costs that one was able to meet. I am informed—and reliably informed because I have done quite a lot of homework on this matter—that the elderly people in this country are wasting more drugs than any practitioner has any idea of. They are throwing them down the sink or they are actually hoarding them. I gather that it is mostly done by elderly people. Unfortunately, I am also told that the medical profession renew their prescriptions absolutely automatically without realising or going into whether these elderly people are either taking their medicines or, indeed, need them.

Therefore, the patients themselves must be made much more aware of the cost to the country of throwing away untouched pills and untouched medicines. By the same token, although there is a set up that they are supposed to follow, the medical practitioners must also be made far more aware of the cost of over-prescribing. When one realises that the Chinese have to pay for all of their prescriptions, it seems to me that even at a very much lower level most of the elderly people could pay for their prescriptions. I should like the Government to take that thought away and to think about it. I do not say that the elderly people should pay the whole amount that is paid by people under 60 who are not pensioners. However, in my view they would take far less medicine and he far more careful of the drugs that they ask the doctor for, if they had to pay, for example, a nominal 20p or 25p per prescription.

We then come to public participation which has been mentioned by several speakers. I did not realise that I was a gambler until quite recently I discovered that a couple of the daily papers were running what is technically gambling. However, I look through my paper and I see whether my card matches whatever appears in that paper. I do not think that I have ever gambled before in my life. This nation is a nation of gamblers and I am wondering—although I know it has been mooted before—whether, at a time when we are in financial straits, we should not have a public lottery. I do not expect that that will find favour with the Government, but as people seem to be gamblers at heart, I think that it might be helpful.

The noble Baroness, Lady Robson, has—fortunately for me—given me the opportunity of making a plug for a hospital—namely, the South London Hospital for Women. This unique and essential hospital has 240 beds, is multi-disciplined and has been in existence for 70 years. As noble Lords will know, it is staffed and maintained completely by women for women. It is not only for we English women that I want to plead for that hospital—as I did at the end of July when I was able to ask an Unstarred Question in your Lordships' House. I also want to plead for that hospital on behalf of the women of the ethnic minorities who are living among us. It is part of their religion that no man should be able to have anything at all to do with a woman in the medical sense. Therefore, if this hospital is closed, they will have nowhere, so far as I can see, to go. But it is the multi-discipline of this particular hospital, which is completely unique in the whole country, for which I plead. Indeed, I do not know whether or not it is to close. Nor, indeed, do the staff of this hospital.

I understand that its closure was announced by the Minister in the other place last week, and I first heard about it on the radio. There is no reason why I should be informed because I have nothing to do with the hospital, except that I have an outside interest in it. But the staff of the hospital have not been informed by a civil servant, a Minister or anyone. Therefore, there seems to be a lack of communication somewhere and the staff are very upset.

I shall not go into the Griffiths Report because the noble Baroness, Lady Robson, did so and very well. The noble Baroness also mentioned another method of participation, which I should like to suggest. It is that in some circumstances the public sector and the private sector should be able to share expensive equipment. We all know the vast cost of scanners, lasers and various other pieces of up-to-date equipment that are now used in hospitals. To my certain knowledge there are private hospitals situated very close to National Health Service hospitals, and both hospitals have the same piece of equipment. If they were to come together over one or perhaps two pieces of vital equipment, a great deal of money would be saved.

I should like to conclude by thanking my noble friend Lord Glenarthur for referring to the public sector. Perhaps he will not mind if I tell him that the Leagues of Hospital Friends, of which I happen to have the honour of being national chairman, last year raised and spent in National Health Service hospitals well over £12 million, and nearly half a million people give their services voluntarily to help those in the National Health Service. Therefore, this must be far more of a national service. The health service, administered from the Elephant and Castle, should try to reach the basic people. I know that through the DHAs much is being done; but more communication is needed, and I hope that this debate will result in more communication from them to us at the grass roots.

8.43 p.m.

The Countess of Mar

My Lords, the noble Lord, Lord Molloy, is not present at the moment, but I should like to have recorded my thanks to him for introducing this subject to us. For over three years in the mid-1960s I worked as a nursing auxiliary in the casualty department of my local cottage hospital; it was called the "blood and bones" department. Conditions were far from ideal, for patients with possible fractures were examined by one of the general practitioners on call, ferried by ambulance to the local general hospital a mile up the road to be X-rayed, bundled back into the ambulance and returned to us for diagnosis and treatment. Patients with complicated injuries often had to be transferred a further 20 miles to the Birmingham accident hospital. Here is a prime example of waste of manpower and resources within the National Health Service.

I have spoken about a place I know. There are several more than I know of. In the 1970s there were a number of plans to build large district hospitals which would cater for all eventualities. One such was planned for the Bromsgrove and Redditch district. It would replace three existing hospitals, all of which were housed in inadequate buildings. Sadly, because of the cutbacks, this hospital has not materialised. Others in other districts have been built, but cannot be brought into service because of staff shortages. We have already heard a great deal about that this evening.

A major problem created by the recent agreement on junior hospital doctors' hours is that in localities where such split units exist, there simply will not be the manpower to cover the needs of the service. Consultants are to be asked to makeup the shortfall in hours, but, as with junior doctors, their numbers are frozen and many of them are already working a greater number of sessions than those for which they contracted. They also have emergency case loads. The quality of patient care is bound to deteriorate and some consultants are concerned that it could well break down totally if some realism is not injected into the proposals. Is it not a bricks without straw situation?

If the National Health Service could have provided in 1967 what it does today, I should not now be standing in your Lordships' House. The treatment of acute renal failure was then only in its infancy and, as with all new facilities, equipment and expertise were lacking. The physician who diagnosed renal failure in my brother apologised to me for having to "play God", as he put it. My brother was 22 and had no dependants, and so was expendable. The noble Baroness, Lady Robson, has already spoken very adequately on this matter, so I shall not elaborate any further. But, I am sure, your Lordships will know what my feelings must be.

I have the distinct impression that this Government regard the National Health Service as a huge factory, the doctors, nurses and ancillary staff as units of production, and the patients as units of output. Over the last few years, and increasingly in this year, we have been blasted by figures which to most of us are totally incomprehensible. The service was reorganised in 1974 with disastrous effects as far as the practical side of the service was concerned. There was a massive increase in the number of pen-pushers in thickly carpeted offices. This Government decided to abolish one administrative layer and to introduce unit management 14 months ago. That was all very laudable, but what has happened? There seems to have been little decrease in staff, and there are still too many tiers of decision-makers. Those involved in unit management are impotent because they have been given no budget for 14 months, though they were supposed to increase the speed of decision-making.

Qualified medical practitioners and consultants are increasingly concerned by the involvement of laymen in technical matters, particularly as medical problems cannot readily be defined and are frequently not understood by the layman. Those demanding financial cuts seem to be incapable of discriminating between those districts which have already improved their efficiency and those which have dragged their feet. Worcester is towards the bottom of the district income table. In this fiscal year—and I am sure that the noble Baroness, Lady Macleod, will be pleased to hear this—it has already cut its drugs bill by £50,000. My own general practitioners have been through every patient's records to check whether he or she needs the pills which he or she is being regularly prescribed. Yet Worcester is still expected to make the same percentage cuts as other less efficient districts with a higher per capita income.

I should now like to turn to the so often forgotten Community Health Service. Historically, community health doctors and nurses were attached to the local authorities. They were transferred to the area health authorities with the reorganisation of 1974, but, because the report of the Committee on the Child Health Services, known as the Court Committee Report, was awaiting publication, no action was taken fully to integrate the community health staff into the National Health Service.

The Court Report was published in 1976, and still no one has decided what is to be the role of the service, its career structure or training programme. There can be no doubt about the value of the Community Health Service working in close collaboration with general practitioners and hospitals. Its staff are, as their name implies, working with pre-school and school children in the community; not in surgeries and hospitals where patients go when they realise that they are ill. Prevention and early diagnosis of physical and mental illness and abnormality, inoculation against infectious diseases which used to be killers, and the support Community Health Service doctors and nurses give to teachers and parents are immeasurably valuable.

This is the only field of medicine where women doctors are in the majority. At this point, once again, I should like to say how pleased I was that the noble Baroness, Lady Macleod, mentioned the South London Hospital for Women, because this also applies. They tend to work on a part-time or sessional basis. This enables them to return to the nation the benefit of their costly training in combination with their domestic responsibilities. The cuts are affecting them too, as they are being asked to work full-time or to leave the service. I cannot help but say it—what a waste! I ask the noble Baroness, when she winds up the debate: please give this valuable section of the health service some definite hope that they will soon have a career structure, a training policy, and that married women doctors will not have the gate to this field slammed in their faces.

As to the future, it depends entirely on what we want. Do we want to turn the clock back to Victorian times, as the noble Lord, Lord Wallace of Coslany so aptly put it? I am sure that that is the last thing that members of Her Majesty's Government would want. Do we want our National Health Service to be a last resort where patients are seen only when they are seriously ill? Do we want to see all the expertise gained and the technological progress over the last 25 years wasted? Again, I am sure not.

We have heard repeatedly this evening of the concern that current services should be maintained and improved. The growth of private health schemes proves that a large number of people are prepared to pay more for better health care, and I have a feeling that many who cannot afford the private subscriptions will be willing to pay a little more for an efficient service. After all, the health of the nation is such a large part of the wealth of the nation.

8.50 p.m.

Baroness Ewart-Biggs

My Lords, your Lordships will be relieved to hear that I am not an expert on the National Health Service so my speech will consequently be very brief. I am grateful to my noble friend Lord Molloy for giving us all an opportunity to reflect our fears and doubts about the future of the National Health Service. I wish only to make three very brief points. I am sorry if I repeat anything that another speaker may have said as I have not been here for the whole debate. As it happened my daughter had an appointment with a doctor this evening so I had to absent myself from the debate.

I should like to counter one or two of the myths about the National Health Service, make a few comments on the problems of the Victoria District Health Authority (the district in which your Lordships sit) and finally to suggest one economy for the National Health Service. First, it is important when thinking about the future of the National Health Service to remember the fundamental principle upon which it was founded; the principle to provide free access to medical care on the basis of need and not on the ability to pay. This point has been made several times this evening. But it is important to remember because it makes the unequivocal case against health ever being financed from health insurance schemes simply because it is the less well off who have the most need of medical care.

Indeed, as my noble friend Lord Ennals said—I congratulate him on a marvellous maiden speech—the Black Report made it absolutely clear that in general terms the environmental and working conditions of those on lower incomes are more health hazardous than those in the higher social classes. As many other noble Lords have said, the other group in most need of care is the ever-growing number of the elderly. I believe that it is estimated that a person over 75 costs the National Health Service eight times as much in health care as someone of working age.

It is thought that for annual sickness cover a family of four would pay £600, whereas a pensioner couple would pay £1,000. As for those with long term needs—the chronically ill and the mentally handicapped—they would be extremely lucky to get cover at any price. Surely there can be no possible doubt that the introduction of a system of health insurance schemes would mean that those most in need of medical attention would be those least able to acquire it. It is for that reason that it seems very important to identify the original principles of the National Health Service to show that any change could only be to the detriment of those very people whom we, as members of a caring society, would most wish to see being helped.

There is no doubt that our health services are costing more and more. The noble Lord the Minister has said so this evening. The cost of providing health care has increased, along with all other expenditures. It is a labour-intensive industry; staff are expensive to train and employ, and medical advances mean that vastly improved treatment is available at a high cost. As the level of possibility has risen, so has the level of expectation. Moreover, there is little that can be done to accommodate the two major factors contributing to the ongoing increase of medical expenditure; namely—as noble Lords have said—the growing number of the elderly and the increase in high technology medicine. Indeed, these two factors alone are thought to require an increase in expenditure of 1.2 per cent. a year.

In addition the 1982 pay settlement has added to the bills of various regions. When referring to the pay settlement, it is important to remember that prior to that particular rise the earnings of 40 per cent. of National Health employees were below poverty level.

On another matter, the National Health Service is constantly criticised for not being highly cost effective and for spending too much on administration. But when the figures are compared with other countries, a very different story emerges. My noble friend Lord Ennals touched on this. For instance, to give one statistic; in 1980 the percentage of GNP spent in health in the United States was 9.6 per cent.; in West Germany it was 8 per cent.; and in the United Kingdom only 5.7 per cent.; while the percentage of health care financed in the public sector was 42.7 per cent. in the United States, 77 per cent. in West Germany and 92.6 per cent. in the United Kingdom. It is hardly surprising that recently Professor Abel Smith made the following comment, The National Health Service is not only the envy of the world, it is also the envy of the world's finance ministers". From these statistics we can but conclude that our health service—contrary to what is so often said—is highly cost effective at the moment, and the amount spent in administration is low compared with that in many other countries.

It seems clear from Government statements that they hope that any future growth in national health resources after this financial year will come from further efficiency savings. But it is equally clear that these so-called efficiency savings are often not what they seem; and through reductions in support staff it is, in many cases, the front line services which are affected and the doctors and nurses consequently have less time to devote to the vital clinical activities.

Finally, to give your Lordships an example of what is happening among the health districts, I shall briefly outline one or two of the problems facing our own health district of Victoria. This authority has been asked to make a reduction of £2.65 million overall. Having made valiant attempts at cutting wastage, which many of your Lordships have mentioned and which we all applaud, I understand that the authority still has to find £1,250,000. To do this the authority will be obliged to put in motion a package of ward closures, reductions of some wards to five day operation and other clinical service restrictions. It is clear that although the Victoria district is not having to face up to dramatic closures, such as that faced in South London, nevertheless it is constantly being confronted by difficult choices and for every improvement in a priority service there is a pay off in another. For example, psychiatric services are improved, but only at the cost of greater pressure on acute beds which in turn means pressure on community nursing services, social workers and voluntary agencies. In general terms there is no doubt that this district authority, in company with many others, are faced with very serious anxieties concerning the growing length of their hospital waiting list, the numbers of their registered doctors and nurses who may face unemployment and the implications for the future of not having sufficient resources to maintain their buildings.

May I say a word about one economy which I feel it is possible to make in the National Health Service? This is to do with drugs. I think that it is a sobering thought that, in 1980, only 20 per cent. of the prescriptions in this country were for approved rather than brand names. This means that, in effect, massive sums go from the Government to the drug companies in effective subsidy. Moreover, it is known that in 1982 almost £2,000 million was spent on drugs. This is not only because people get too many drugs; it is because they are prescribed in the expensive brand names. This means that there are only two other areas in the British economy more profitable. Those are advertising and oil. So this really does make the drug companies look as though they make a staggering profit.

Another disturbing factor in this field is that most research geared to patients' needs is carried out in academic institutions. The drug companies claim to be unable to afford safety evaluation for drugs with a limited sales potential. Thus, only 10 per cent. to 15 per cent. of their budget is spent on research and much of this is in the nature of general market research and thus a disguised form of promotion. What conclusion can one come to except that hundreds of thousands of pounds could be saved by the National Health Service by prescribing generically whenever possible?

As I said at the beginning, I have little experience of the NHS except through our own family National Health Service doctor. He, over recent years, has not only contributed in solving the health problems of my younger daughter, but has also assisted very much in relieving the tensions and pressures of a family. When I saw him this evening I told him that the National Health Service was being debated in your Lordships' House. He said, "Ah! the National Health Service. We could not possibly do without that, could we? It has now become a vital element to our society". I should like to associate myself pretty closely to that sentiment.

9.2 p.m.

Lord Kilmarnock

My Lords, I think that I can claim a special relationship with the noble Lord, Lord Molloy, for I first had the pleasure of congratulating him on his maiden speech in your Lordships' House. I repeat the congratulation but even more genuinely, in that last time he was attacking Europe and this time he has been defending the National Health Service.

A lot of figures have been produced this evening in your Lordships' House. One of the factors that has been mentioned is the international context of the expenditure in our National Health Service compared with the costs in other countries. A number of noble Lords have referred to this. The noble Lord, Lord Ennals, did so; but I think it is worth putting on record that the most recent OECD comparative tables available on public health service expenditure show the following percentages of GDP: 2.5 per cent., USA; 4.7 per cent., Japan; 4.8 per cent., Australia; 5.6 per cent., Denmark; 6.2 per cent., France; 6.5 per cent., Germany; 6 per cent., Italy; and 4.5 per cent., United Kingdom. Those were mainly 1980–81 figures and the United Kingdom figure was a 1979 figure. I have updated that. It is 5.3 per cent.

On any basis of comparison with other countries on public health expenditure, ours really stands up to scrutiny. On the administration costs, ours, as a proportion of the public health budget, are running at between 5 per cent. and 6 per cent., compared with 6 per cent. for Germany (which covers only the administrative costs of the complicated insurance scheme but with no hospital administration); somewhere between 9 per cent. and 12 per cent. for France (also with a complicated item of service and insurance scheme); and a whopping 21 per cent. for the insurance-based private schemes in the USA. The first point therefore is that we are not out of line; in fact, we compare very well with other industrialised nations in the proportion of our public spending which goes on health. Within that expenditure, our administrative expenditure costs are at the lowest end of the scale.

It would be a pity to spend the rest of this debate on wrangling over NHS finance, but I am afraid that, despite the plea of the noble Lord, Lord Ferrier, that we should look towards the future—and I am coming to the future—I cannot pass over the Government's record. The Government have only themselves to blame for the way in which they have been questioned, because they have not come clean, as the noble Lord, Lord Diamond, said in his speech. If they had said openly before the election, "We intend to reduce public expenditure and the NHS must take its share", they would have been understood and people would have been able to vote accordingly.

Any Government have a right, indeed a duty, to declare their priorities and put them to the test of public opinion. This Government have done this quite openly in other sectors. For example, they have mutilated education; but they said they would. One may disagree, but one cannot accuse them of bad faith. In the health service, the story is different. The claim made before the election that real growth in the health services of 7.7 per cent. had taken place over the Government's last period of office included capital spending (which rose from a very low base) and included the 4 per cent. increased demand made on hospitals and community health centres by an ageing population—that is to say, the demographic component. It included 0.7 per cent. for not easily identifiable efficiency savings. Another 2.5 per cent. was due to the effect of medical advance in hospitals and community health expenditure; and, finally, 1.1 per cent. of the supposed growth was provided by increased prescription charges.

Let us be very clear what we are talking about. We are talking about a service which is marking time or even falling back. The elected Government have every right to decree this state of affairs, but they should tell the people what they are doing and why, and not wrap themselves in a smoke screen of dubious statistics.

Turning to the future, the Secretary of State told the health authorities to assume a growth of 0.5 per cent. a year over the next 10 years for hospital and community health services. Then he entered the caveat, which I quote from his Written Answer of June 30th in another place: This is not a commitment and health authorities must ensure that their plans are flexible enough to cope with more or less resources". So there is no commitment. Neither has there been any answer that I know to the calculation put forward by my right honourable friend Dr. David Owen in another place (at column 463 on 27th October)—and I am not going to quote him directly—that the revised figures announced in the August circular have already eroded that 0.5 per cent. to 0.2 per cent. per annum, leading to a sharp contraction in the NHS after 1984. I should like to hear what the noble Baroness has to say about that.

I will not continue to bombard your Lordships with more percentages because the Government know perfectly well that whether it is 0.2 or 0.5 per cent. it is inadequate. Successive Governments have accepted that 1 per cent. inflation proof in real terms is needed merely to keep pace with the demographic trend, and probably 1.5 per cent. is nearer the mark, simply to enable the National Health Service to keep pace with the pressures from the elderly, the mentally handicapped and the effects of modern medicine in enabling sick infants to live often into middle age, and so forth.

My second question is therefore: Do the Government not agree that there is going to be an obvious shortfall? What are they going to do about it? It will be clear by now that from these Benches our quarrel with the Government falls under two headings: first, lack of frankness; and, secondly, lack of any adequate vision of how to ensure the provision of services which they know will be increasingly required. They have chosen to address the problem from the administrative end by commissioning the Griffiths Report. I will not go into that because it has already been very ably covered by my noble friend Lady Robson. We do not want to be unconstructive about this; it is not our party's line so to be. Our slogan in the last election, which will be repeated in the next, was "Caring about people, caring about costs". We stick to that, and we are proud of it.

We do not dissent, and the Alliance does not dissent, from the aim of administrative savings, even starting from a comparatively good record. But there are genuine worries about Griffiths. Production and distributive industry techniques may provide some valuable management insights, but my suspicion is that the professional's ethical accountability to his professional body and to his patients is going to come under severe strain. I should like here to back up what has been said by the noble Baroness, Lady Cox, and also, I believe, by the noble Baroness, Lady Lockwood; there is also the scandalous absence of any nursing representative on the new health services supervisory board.

I want strongly to urge the Government not to impose Griffiths in a blanket form across the country. I see from Mr. Griffiths' report on his inquiry that it undertook small-scale studies in six hospitals involving four district health authorities". That is not enough to justify the immediate imposition on the whole of the service of a new system of management. Despite claims to the contrary, it is or would be the third major reorganisation in ten years, and there must be a trial run. Let us have "pilot Griffiths" for 12 months, or even six months, in one or more regions that are prepared to accept the experiment. I should very much like to hear what the noble Baroness has to say about that.

Coming back now to manpower cuts—we cannot leave them—I think it would help us to understand them better if the Government were to be more specific about them. The indicative figure, according to Circular HC(83)16, was 0.75 per cent. to 1.0 per cent. of overall staff numbers. But, within that, posts other than doctors, dentists, nurses, midwives and professional and technical staff were expected to reduce more sharply by between 1.35 per cent. and 1.8 per cent. I wonder if the noble Baroness could inform us how that would be split.

I have in my file here a list which covers 12 district health authorities, mainly in the London area, and embraces roughly 1,400 redundancies. Some authorities have made no breakdowns of grades affected. Five have, and they show a ratio of about 45 per cent. front-line to 55 per cent. ancillary staff. The resulting toll of closures of both acute and chronic services makes a sorry story. Most of the chronic services involve geriatric beds. Regional health authorities have simply no alternative but to close small peripheral units which generally house the chronically ill. A shift to community care can hardly be seen as the answer when the Government are asking for a net decrease in real terms of 2.4 per cent. in 1983–84 expenditure on the personal social services.

An early discharge policy would impose yet other strains on these overstretched local authority services and the voluntary sector. What would be the position of health visitors, who play such a vital front-line role in the care of the elderly and the infirm and in preventive medicine? How many of them are to go? The Government must have realised by now that it is not only the health authorities which have resisted the implementation of manpower cuts. The BMA believe that patient care will suffer. The chairman of the BMA's Hospital Junior Staffs Committee wrote to the Prime Minister on 27th September saying that the reduction in medical staff was contrary to the previously expressed policy and to the agreement on the reduction of hours for junior doctors. Are they to go back to the 100–hour week and nurses to the 17–hour day? Has not the Royal College of Nursing identified hospitals where nursing levels are hovering just about the danger level? It is really nonsense to claim that patient care will be unaffected.

And it is not only a question of the redundancies, to which I think the noble Baroness, Lady McFarlane, referred. There is also the question of the 7,000 vacancies at the time when the cuts were demanded. It would be interesting to know how these break down. Mr. Clarke's office was unable to assist us, but perhaps the noble Baroness will be more informative. We want to know how many unfilled jobs there were at the "coalface" of the NHS, over and above the 4,837 agreed redundancies. This is not an academic question, because the redundancies were based on existing staff in March 1983, when many DHAs were still in the final throes of reorganisation. Some posts were therefore unfilled at that time. The total cuts will thus be much greater than those published.

Also, capital projects that have just come on stream were conceived in relation to planned manpower increases. Such projects are now in jeopardy, since the jobs required to service them were over and above the March 1983 figures, and thus will not come into existence. Some brand new facilities will not be fully utilised and some existing high technology equipment will cease to be operated. Examples include the brain scanner at Bury General Hospital and most of the intensive care cots in the special baby care unit at Guy's, costing £15,600 each. One new hospital just completed will require 200 additional staff, so if it is to become operational at all there will have to be more cuts elsewhere. All this shows the folly of imposing manpower and expenditure cuts together in the middle of a financial year, leading to the chaos that I have described.

I want to turn very briefly to the family practitioner committees. I thought at the time when we had the Bill in this House, and I still think, that we made a mistake in strengthening the independent status of the FPCs rather than bringing them more centrally into the total scheme of health planning and resource allocation. I am a great admirer of the peculiarly British ingenuity whereby general practitioners were lured into the health service as private contractors. It is a nice example of the mixed economy at work. But it still seems rather inequitable that their expenditure should be open-ended if hospital consultants are to have the type and cost of their operations rationed by business managers.

I would not be in favour of curtailing GP freedom very far, but I seriously think that we need a firm answer from the Government on, for example, what they propose to do about the Greenfield report on effective prescribing, which was referred to by the noble Baroness, Lady Ewart-Biggs. It seemed to me that the proposals were perfectly sensible. The GP had, or would have had, perfect freedom to insist on a branded drug if he wanted it; £30 million or £40 million would probably have been saved and the profits and research and development of the pharmaceutical companies would not have been dealt a crippling blow. I do not think that we should deal it a crippling blow, because the companies have done some very good research and development. This would be something which they could cope with. Can the noble Baroness tell us what action is being taken here? Again, a pilot scheme would not seem inappropriate—pilot Griffiths, pilot Greenfield. Why not?

There are lots of other points which I should like to raise with the Government, but I am not going to do so—at any rate not tonight. But, before I sit down, I should like to press them on their view of the future. The noble Lord, Lord Ferrier, referred to the future and he was quite right. This debate should be largely about the future. Where do they want to go in the long run? What ambitions do they really have for the National Health Service? What do they think of some of the suggestions in the recent Bow Group Paper, Beveridge and the Bow Group Generation, which toys with such ideas as tax relief on premiums for private health insurance schemes, and the sub-contraction back by such schemes to the NHS of certain services on an item-of-service basis?

Item-of-service is a dangerous road to go down in terms of administrative costs. And would this not really mean that a depleted NHS would have to provide those services which private insurers were either not able or not willing to provide? Of course, the Government will say that they are not responsible for the Bow Group, but the fact remains that the Bow Group has been responsible for a good deal of Tory thinking which has ended up as policy. Sir Geoffrey Howe was one of the group's brightest stars.

This is neither the time nor the place for me to put forward an Alliance health manifesto, but there is no doubt that such a document would differ considerably from both the Conservative and Labour Parties' approach. We are committed to an increase in mainstream NHS expenditure, and expenditure on personal social services and community health which would be required by the demographic trend. We would put a substantial sum aside for joint funding between the NHS, the PSS and the voluntary sector services, because we think that there is a great untilled field there from which many things would grow. We would look more critically at the funding arrangements for the FPCs; that open-ended commitment has to be restrained, particularly in the field of prescriptions.

If we have unemployed doctors, as we have, we must look seriously at the possibility of salaried GPs for inner cities and other unpopular areas. There are also obvious opportunities for decreasing list sizes and for improving the deputising services, which have been giving rise to increasing concern. We are not talking tonight about private care, but we shall want to revive the Health Services Board or something like it, to ensure that private medicine forms part of a coherent whole, and we shall want to extend the role of the community health councils to monitor the private health institutions in their areas, too. We shall attach particular importance to the obviously direct connection, which I think was mentioned by the noble Lord, Lord Ennals, between poor health and poor housing, poverty and unemployment. In fact, we shall be organising a one-day conference on the National Health Service and associated services early in the spring. I shall be happy to procure an invitation for any noble Lord who would like to attend and contribute to our debate. He will be very welcome. There is no obligation to join the SDP!

9.20 p.m.

Lord Graham of Edmonton

My Lords, I, like the noble Baroness, Lady Ewart-Biggs, begin at once by declaring that I am no specialist or expert on the National Health Service. Nevertheless, I am very grateful for the opportunity to speak in this debate. I want to begin, as many Members on all sides of the House have begun, by warmly congratulating my noble friend Lord Molloy not only upon having been lucky enough to get the debate but also for the vigorous and compassionate way in which he put forward his arguments. He enhanced in my eyes the reputation he has always had of a caring, compassionate man, dedicated to trying to improve the lot of his fellow men. We are very grateful indeed for the tone that he set.

I am also very pleased to follow two Members on the other Benches. I refer to the noble Baroness, Lady Gardner of Parkes, and the noble Baroness, Lady Macleod of Borve. The three of us represent three bits of the London Borough of Enfield. The noble Baroness, Lady Gardner of Parkes, knows far more about Southgate than I do. I should think the noble Baroness, Lady Macleod of Borve, knows as much about Enfield as I do. I have known her for 25 or more years and once had the temerity to challenge her husband in a general election. It was not a fight, because he did not feel a thing; the majority was not altered at all. So the people of the London Borough of Enfield are very well served by having three voices in this debate tonight.

I also extend my warmest congratulations to the new Member of the House, the noble Lord, Lord Ennals, who certainly did nothing to diminish the reputation he brought to this House from another place for knowledge, stature and authority on all matters connected with the National Health Service. I look forward, like many others, to hearing him again and again.

This was my first opportunity to listen to the Minister, the noble Lord, Lord Glenarthur. I enjoyed the experience very much. I have no doubt at all about his sincerity. He marshalled his facts with impressive authority and at the end of the day he put up what I am sure he would wish to have read as a stout defence of the current and prospective situation so far as the National Health Service is concerned. But he did this, I thought, in rather a churlish way by dismissing, almost in cavalier fashion, any criticism from any quarter of the present performance of the Government in their management and stewardship of the National Health Service. I have put down the noble Lord as saying, and Hansard will be able to verify it, that, when it comes to the Labour Party, when we criticise we rely on rhetoric; in fact, that when it criticises, the Labour party cannot substantiate the claims that it makes.

What the noble Lord said he was about to do was to destroy some of the myths that had been peddled by the Labour party. He accused my noble friend Lord Molloy of being guilty of spreading some of the wilder allegations. Then he made the astounding claim, so far as I am concerned, that his Government had improved substantially the quality of the National Health Service during the lifetime of this Government.

I intend to retail to the Minister some of the experiences in the London Borough of Enfield of the quality of the health service at present enjoyed by the people there. I think that they would disagree indeed. What the Minister counselled was that it was not enough to call for more money. I hope he was not implying that there was something wrong in calling for more money. I agree that that, of itself, is not 100 per cent. the solution, but, when we are looking at the future of the National Health Service, I have got three points to make.

The first point is that we need to revive the declining services. Although the noble Lord the Minister was very adept at quoting global figures and percentages, when one looks at the reality of the service, we in the part of London in which I live—that is, the London borough of Enfield and Edmonton—want to revive the declining services and we want to improve the morale of the workers in the National Health Service, meaning everyone from the lowest paid to the highest paid.

More than one member of your Lordships' House has made allusions from experience. I do not want to talk about the situation being catastrophic, but simply wish to say that a job has to be done in the future to improve the morale of the workers in the health service. We need to restore the pride of the consumer—the users of the service—and although I am not saying that people are not proud of the National Health Service, there is a job to be done in restoring the pride of consumers in the health service.

I have been deeply impressed by the knowledge born out of experience gained in working for and using the National Health Service which has been revealed during the debate tonight. I have also been impressed by and have enjoyed—because I am not an expert—the philosophical arguments which have been deployed in all parts of the House in tonight's debate. The Minister's attitude, however, invites me to indicate to the House what the National Health Service is in practice in the place where I live.

There are two different worlds. There is the world which the noble Lord the Minister knows all about, which is concerned with facts and figures, cuts and demands, requests and targets, and imperatives. Then there is the nitty-gritty world, on the ground, so far as the health service is concerned. Let me give an example. In the New Standard tonight there is an article which states: Health Minister Kenneth Clarke announced today that the Prince of Wales hospital, Tottenham, is to close and its services transferred to other hospitals nearby. He said, in confirming the recommendation of Haringey District Health Authority"— So it was a "recommendation"; one apparently assumes that the Minister does not make any moves or take any initiatives and that out of the blue comes a recommendation, "We want you to close this hospital". It is nothing like that at all.

The noble Lord the Minister and his colleagues have said to the regional health authorities, "Here is a sum of money which may be marginally more than you had last year, but you will get no more and we are calling upon you to produce for us out of the range of your work the items which you are going to cut". I can tell your Lordships that, far from being a recommendation, it was a matter agonised over by all the members of the authority, whatever their political persuasions. They did not like doing it. The people of Tottenham feel anguish and are depressed that a local hospital which has been in existence for 80 years or more is to be extinguished.

That is the reality of the situation. It is the agony involved—not a recommendation, a saving, or a line written on a piece of paper. The Minister and his colleagues ought not to take the opportunity when they can of sliding out of the responsibility for the actions which they have taken.

Lord Glenarthur

My Lords, 1 am sorry to interrupt the noble Lord, Lord Graham of Edmonton, while he is in full flow, but he really should accept that many of the decisions which have to be made are just as agonising for the Minister who has to make them. The fact remains at the end of the day that decisions come forward from the local authority. And it is on the basis of local decisions that recommendations come forward to Ministers. It is for that reason that such decisions have to be taken and why they come before Ministers to make the final choice at the end of the day. It is unfair of the noble Lord to suggest that it is only the local area which feels concern; the Minister feels it very much as well.

Lord Graham of Edmonton

My Lords, the Minister has sought to absolve himself of the main responsibility—not the only responsibility. If the regional health authority and the district were not preyed upon by the Minister and his colleagues to make cuts—agonised though they might have been before doing so—they would not of themselves have said, "We want to close this hospital". I do not deny for a moment that the noble Lord the Minister has given great thought and attention to the various moves which have been made. I simply say that the Minister and his colleagues ought to accept responsibility for what they are doing. When the Prince of Wales Hospital closes it means that their 90 beds for the elderly will no longer be there. Already in the district of Haringey there is a shortage of 265 beds for the elderly, so there will be something like 300 or 400 beds for the elderly which will not be available and which are needed in that district. Many elderly people are being cared for at home by other elderly relatives and by others when they ought in fact to be in hospital.

Part of the matrix which the Minister and his colleagues have been creating has been the determination, surreptitiously, to try to keep out of hospital many people who ought to be in hospital. Of course it is money, and I do not deny it. The Minister is under pressure from his Cabinet colleagues and others to produce cash savings and to reduce the number of those at work in the service. I do not deny the agonies that he may go through. But when the answer to the question is, "It has to be done", well, it has not got to be done. In our view the money ought to be found and could be found in many other ways.

Let me say that I understand the dilemma of the Government. As recently as 9th June they went to the country and received a clear mandate for the kind of society they wished to create—one in which there was, if not actual reductions, a very tight control on public expenditure. So the people who live in the London Borough of Enfield collectively, by a majority, voted Conservative as opposed to Labour; they accepted the philosophy. But many of them did not realise, when they were voting for that party, the nitty-gritty of the various policies. The Minister says that what he wants to do is to pass more responsibility for running hospitals, et cetera, to the local authorities. At the same time as doing that with the left hand, the right hand is saying that instead of having 62 per cent. rate support in 1979, now down to 52 per cent. in 1983, they are going to have even less money in order to carry out more responsibilities. Quite frankly, I think that is sharp practice indeed.

When we look at the reality, let me give your Lordships an illustration of the health service that the Minister defends. Last night in the Enfield district area there was not one male bed, not one medical bed, not one surgical bed and not one orthopaedic bed available; they were all absolutely full. That was in the Enfield district authority, and that is the authority which is scheduled to lose a further 133 beds. That authority has lost 300 beds since 1980. How in fact has it done that? It has been done by cuts in staffing, by temporary closures (which we know is the first step to permanent closure) and, of course, by beds built to be used not being used because they are unable to get the funding.

Enfield district was once looked upon as a well endowed district. No longer: by virtue of the losses it is one of the deprived districts—and Enfield is a very rich area by comparison to others. When we look at the gap between the needs of the people and the provisions made, that gap has been widening all the time and people are depressed and demoralised. Let us see some of the things the people in that area are supposed to believe are good for them, to provide a good National Health Service. At Cheshunt they have had 14 of their general practice beds removed. Cheshunt Cottage Hospital has been temporarily closed, but we know what "temporarily" means; it will not open again. At the Enfield War Memorial Hospital, where I have been a patient and my family have been patients, 44 GP beds have been permanently closed. At Chase Farm Hospital, which is well known to the noble Baroness who sits opposite, 16 geriatric beds have been closed as well as 12 maternity and 35 mentally handicapped, and 75 mentally handicapped beds unopened. A creche is to be closed this year, 13 paediatric beds and 10 mental illness beds are unopened, and 15 psycho-geriatric places are unoccupied.

That is the reality of the National Health Service in a tiny, not poor, part of the area. I know that the Minister will understand the agony that he brings to his political friends, because the chairman of the Enfield district authority is Bill Godfrey, who is well known to me as the Tory agent for Southgate and Enfield for many years. The chairman of the Haringey district authority is Laurie Baines, who was the leader of the Tory group in the Tottenham authority for many years. I know they do not like doing what they have been doing. Bill Godfrey gave the game away when he said, "We either do this or resign". He did not resign. That was the option. Therefore he carried out the decision.

I come to the Highlands Hospital. I have received many representations from local people who are absolutely beside themselves at what is happening to that hospital. May I quote very quickly to the House from the Enfield Gazette of last week: Council join hospital fight". That is almost unique. Hospitals have closed and other things have happened in Tottenham and Edmonton and there has not been a joint fight. But now on this question of the Highlands Hospital at Winch more Hill the council is united. Some of the Minister's political friends are very agitated indeed. The article in the Enfield Gazette stated: Councillor Lionel Genn told members that a report from the Regional Health Authority on the feasibility of closing the Department was 'a cowardly document'. He claimed that once the casualties at Highlands, in Worlds End Lane, Winchmore Hill, is closed those needing treatment face a journey on three different buses to get to Chase Farm Hospital in The Ridgeway, Enfield. 'You will have the situation where patients get infected wounds and people come to the point of having dangerous injuries instead of being walking wounded because it is most unlikely they will face the journey', … And Councillor Genn does not believe the closure is temporary. 'I find it difficult to imagine that once the unit has temporarily closed there is any chance of its opening again'. This is against the background that the people in that area, most of whom voted for the Minister's party at the last election, are to be told that, for that which they have and that which is happening, regrettably nothing can be done. Now they are up in arms.

I make one request to the Minister before I sit down. I realise I am asking something that I may be told is not the practice. I am asking the noble Baroness, Lady Trumpington, who is to reply, to take on board this one simple request. Will the Minister look at the decision to close the emergency and accident department at Highlands Hospital? A decision is to be made by the regional health authority on 5th December. There is still some time and I beg the Minister to ask for papers and to ascertain whether there is any way, or any suggestion, which will help the people, wretched and miserable as they are at the decision they have to make. If the Minister is able to give an assurance that she will at least look at the situation, the local people will be very grateful.

So far as I am concerned, the future of the National Health Service under this Government is in very dubious hands indeed. I believe that all the evidence I have given can be authenticated and, if that is the present National Health Service, what we want is a much improved service not only within the health service but from the Government in their stewardship.

9.38 p.m.

Baroness Masham of Ilton

My Lords, first may I apologise for my lateness in arriving for this debate. I had a very longstanding engagement to open officially a unit at a hospital in Kent. This was a very happy occasion and I did not want to let down the people in a National Health Service hospital at the last minute. I must hasten to add that the unit I opened only opened because another hospital had closed. I shall read the speeches of noble Lords with great interest but I was so pleased to hear the excellent maiden speech of the noble Lord, Lord Ennals.

To run the National Health Service with greater efficiency in the future is welcomed by me, but it should be coupled with a more compassionate attitude of all who work within it and for it.

The National Health Service is an enormous organisation. The pressure on the huge, high technology hospitals is machine like. To treat the hospitals like supermarkets is dangerous, as the patients feel—and become—like numbered sausages. Many people working in or related to the National Health Service are worried at the present trends. The staff feel that their jobs are at risk and the patients feel that their lifelines to health care may be cut. There is a great deal of insecurity. I hope that the noble Baroness who is to answer for the Government this evening will give some firm assurances that the future of the National Health Service is really safe. That cannot be repeated too often at this present moment in time. There is far too much buck-passing in the National Health Service. I do not count the noble Baroness, Lady Trumpington, as one who will pass the buck.

The National Association of Health Authorities in England and Wales has as the title for its conference next month, "Authority and Accountability within the National Health Service". The first topic to be taken is, "Patients first: what has gone wrong?" If the National Health Service is to have a good future—which I sincerely hope that it is—everyone inside your Lordships' House and outside who has an interest must find out what has gone wrong. I hope that this debate will show how important putting it right is. I hope that the Government will listen to what has been said this evening.

Perhaps if the noble Baroness, Lady Trumpington, was not going to wind up I should not say what I am about to say. In the past few years very many of the senior posts in the National Health Service have been taken by men. Men by their nature and their natural make-up are not so caring. Of course there are exceptions. The Salmon structure has a great deal to answer for. I think every hospital, large or small, should have a matron and a deputy. Should they happen to be males, what is wrong with calling them the "major nurse" or the "master nurse"? How is it that nearly all the private hospitals still have matrons? Matrons were identifiable to everyone and they had to take responsibility for many different categories of staff. Now everyone is broken up into different sections. Instead of a united team with its members helping each other, the staff have sometimes become disunited and sometimes frightened of each other. Sharing is the essence of caring.

Also a ward sister or charge nurse who has great responsibility should be rewarded for it. The nurse administrator posts which are now above hers, if they are really necessary, should not be paid any more than the ward sister. She or he should be of high calibre with good organising ability. A sister should not have to leave her patients to climb the ladder of promotion. I feel that this is one of the primary reasons that patients very often have not come first.

Another very serious problem is that of the junior doctors who work in the casualty and emergency departments. Very often they are dealing with life and death situations. They make decisions which a more experienced doctor might not make. This has been illustrated by a hospital in Wales recently. I wonder how many more people might have lived had senior doctors been on the spot. I am sure that this is so in many departments throughout the country.

The front line medical staff are of the utmost importance but they cannot perform successfully without the back-up services of the theatre and ancillary staff and the ambulancemen. They must be a team with continuity. I have heard general practitioners bemoan the fact that the medical officers of health were replaced by community health physicians. Some general practitioners feel that they could do much of the work now undertaken by the community health physicians. It is felt that so much of their time is taken up by administration that perhaps a saving could be made there. Could not some of the multitude of paperwork be condensed and thus save the work load of many people? Is this not some of the administration that so many people feel is blocking up the National Health Service? I hope that the inner tiers of administration will be streamlined, leaving it clear so that much of the red tape can be cut out.

There are some bright doctors now in registrar posts unable to get senior registrar posts. There is one I know of who is extremely talented, with a gold medal for his fellowship. He wants to be a vascular surgeon. So far he has been unsuccessful in becoming a senior registrar, and he is thinking of going into the RAF—not as a doctor. Would this not be a waste of a talented, enthusiastic, medically trained professional?

With no expansion in some hospitals posts have been frozen, causing great frustration to these young surgeons who want to advance. Could there be a built-in resistance from some consultant surgeons who have private practices that they do not want the young, up-to-date progressive surgeons in competition for their private patients? I hope that that is not so; but having worked with volunteers in the voluntary field, I have sometimes seen the older person feel threatened that a younger one coming up might take his position. This is a human failing.

Sometimes when there is no other way of helping patients doctors prescribe drugs to try to do something. There are sacks of drugs which go to waste each year. I believe that the Government are getting across the message that the drug bill should be kept under control. The pharmaceutical companies seem to make a great deal of money out of drugs; but they are making some useful breakthroughs with new, helpful drugs, and I for one would not be alive today if it were not for some antibiotics, which without doubt have saved my life.

So often in hospitals one hears of patients who are given drugs that they do not wish to have. I hope that in the future more consideration will be given to the patients. No doubt night staff dish out drugs so that they get a peaceful night. I have sympathy for the nurses, but the patients should not be bullied.

A few weeks ago at a conference on the prevention of pressure sores a young, concerned nurse told me that in her hospital there were several ripple mattresses which had been bought to help prevent these troublesome problems. She had been told that she could not use the ripple mattresses; it was hospital policy not to do so. Nobody seemed to know who had made the policy, and she could not find out. I hope that when the authorities have their general managers that kind of thing and such frustrations, uncertainties and waste of money will be removed. I feel that whoever will be the general managers, they will have to be superhuman; I hope that they succeed with success.

I also hope that the new Health Services Supervisory Board will have a flexible approach when it looks at the country as a whole, and will remember that the health needs of a rural district are very different from those of an inner city. Many rural districts are deprived: With no public transport, rural dispensing and domiciliary services are vital.

I quote from the words of the Secretary of State for Social Services Mr. Norman Fowler: We want all day-to-day decisions to be made as close to the patient as possible". If that is really the case, why is it that so many small hospitals, close to the homes of patients and run by their family doctors, are under threat of closure? There are some committed, enthusiastic doctors who want to keep close to their patients. One doctor said to me. "If our hospital closes I shall just have to play more golf. I shall have plenty of time on my hands". Is this good use of a doctor's time? It divorces the general practitioner from his patients and takes away a relationship which cannot be replaced.

These small, friendly hospitals have a place for low technology medicine. They relieve the acute surgical beds after the first few days when the patient can go back under the care of his family doctor. They shorten waiting time for patients when the consultant does a clinic. They provide care when the patient needs nursing but does not need high technology. They provide physiotherapy and basic X-ray treatment. They keep patients in their own environment. They save ambulance time and money. They cater for the elderly and the infirm. So often these patients become confused, disorientated and frightened. It is often said that small hospitals are expensive to run. If ambulance figures and time were added on, I wonder whether this is really always the case.

The future of the National Health Service is so important. There are so many things that one could say. Just recently, two cancer patients, one from the Northern region and one from London, one a working man and one a professional man, said the same thing to me. The system that they went through was very clinical and very correct, but very inhuman. Without being emotional, I want to say that if only there could be more human warmth and kindness, ill and frightened patients need it. They need their illness to be explained to them. It is their bodies and their life at stake.

The public do help. They give a great deal of voluntary help in many ways towards the National Health Service. I hope that this will be encouraged and that it will prosper. When I visited Birmingham recently, I was taken to a large hospital for mentally handicapped patients. The Queensway Trust, which works with the probation service, had young people on probation looking after donkeys and, with little carts, gave immense pleasure to many of these patients. The patients also had a social club. Much of the hospital had been upgraded.

I hope that the noble Lord, Lord Glenarthur, will visit these hospitals in Birmingham. The patients really were happy, and the hospitals (there were several of them) with this sort of help, have improved the quality of life of their patients beyond all recognition over the past few years. I believe that some of these patients are much happier in this sort of environment than outside in a society which may not understand them fully. It needs careful consideration. I hope that the noble Lord, Lord Glenarthur, will look into this.

As many of your Lordships may have already said, the cuts which come in the middle of the budget year made the job of the regional health authorities and the district health authorities difficult. On one hot summer day after a regional meeting, our chairman and the regional administrator were locked in a room with protesters for two hours. Feelings for the National Health Service ran high for many reasons.

I know now why the Government were so worried when I moved an amendment in your Lordships' House for national funding for supra-speciality units. How important these units are! What wonderful work the specialising staff do! My heart goes out to them when their expertise is not fully used and some of the beds lie idle with patients waiting and some dying. The demands are many. One must put a great deal into such a splendid service that gives so much to so many. It is not only money that counts. It is also good management, expert techniques, up-to-date equipment, honesty, good hygiene, wholesome food and a real spirit of dedication and caring throughout the whole system including the Government Ministers of the National Health Service.

9.55 p.m.

Lord Rea

My Lords, I must also apologise to my noble friend Lord Molloy for not being able to be here when he opened this debate as I was, speaking in a secular way, attending my flock. So many noble Lords and noble Baronesses, including the noble Countess, have made such well thought-out and cogent speeches already tonight that I do not envy the noble Baroness who has to reply to this debate. Many of the points that I wanted to make have already been made very clearly, and, therefore, I shall be as brief as I can. For example, I will not talk to your Lordships about the development of preventive medicine, about inner city problems or about the future development of the general practitioner services, which have been alluded to by several speakers already.

Some of the needs, rather than the demands, of the population of this country which are still unmet by the National Health Service were summarised skilfully by the Black Report on inequalities of health which the noble Lord, Lord Ennals, in his very clear and incontrovertible maiden speech, has already described. My noble friend Lord Prys-Davies also spoke about the Black Report when he asked the noble Baroness if she would tell him whether any of its recommendations had been carried out yet. I would remind noble Lords that 20 out of 37 recommendations would have needed no extra money but as far as I know no action has been taken to implement them yet.

Now we are faced with a critical situation in the National Health Service because of the Government's wish to prune public expenditure heavily, together with further moves to encourage private medicine and privatisation of parts of the services supporting the health service. Incidentally, I was delighted to read that both the junior and senior Ministers responsible for the National Health Service see no reason to subscribe to BUPA themselves or for their families. That is a very encouraging sign.

The National Health Service has weathered bad times before under both Labour and Conservative Administrations, and it has made many economies which have slowed down the relentless escalation of costs. But the worrying aspect of the present cuts—and this was most eloquently put by the right reverend Prelate the Bishop of Southwark—is that they are being carried out by a Government which are not ideologically committed to providing equal access to high standards of care for all, despite reassuring words that the National Health Service is safe in their hands.

The most recent manpower cuts have been arbitrarily applied without asking regions and districts if there were other ways in which they could save the money. The noble Baroness, Lady Cox, expressed this extremely well from a professional point of view and, incidentally, from the other side of the House. To cut jobs is, in any case, not such a saving as it might appear because, after all, the dole bill swallows up half the savings. In fact, one of the main tasks of the new district health authorities since the most recent reorganisation has been to rationalise and trim services and to streamline their administrative procedures. It may be necessary to cut some services. We on this side of the House fully realise that needs change and that there may be wasteful duplication or over provision of some hospital services in a district, for instance; but closing a service down takes time. It needs to be run down gradually, and local opinion has to be faced, persuaded and reassured if the closure is defensible at all.

To cut staff establishments abruptly may mean that temporary agency staff have been hired at greater cost in order to keep some services going which simply cannot be closed down because of their key importance. Again, I must thank the noble Baroness, Lady Cox, for amplifying this point. In the health centre where I work—and this may be of interest to your Lordships as personal experience—we are already beginning to feel the pinch of the cuts.

I should like to read extracts from two communications that we have recently received. The first is from the Department of Social Services in the Camden Town Area Group. It says: I regret to inform you that the Group is no longer able to accept referrals to the Home Help Service. We cannot at the present take on further commitments without putting existing clients at risk. A review of the Home Help Service is being carried out by the Council and I hope that we will be able to make available more service as a result next year. Meanwhile from Monday, 17th October, the Home Help Organiser will be instructed not to accept new referrals. All requests will be looked at again in January, 1984. This kind of decision makes it very difficult for hospitals to discharge some patients who could otherwise be perfectly well looked after at home. The lack of provision by the council for home helps, which has been forced upon it, actually increases expenditure in the hospital sector. In fact, in my view the home help service is absolutely basic to any policy which transfers patients from hospital to community. It is a service which is greatly under-valued. I think that its status and numbers should be increased to the lasting benefit of community care and the eventual saving of money for the health service.

Secondly, we have received a letter from our local consultant neuro-otologist about the tinnitus clinic at University College Hospital. As many of your Lordships will know, tinnitus is a condition in which people have a constant, usually high-pitched, noise in their ears day and night. He writes—andI summarise: At the present moment there is a waiting list of rather over 2 years to see new patients. The clinic now has no funds to buy tinnitus maskers and extended correspondence with the District Health Authority, the Department of Health and Social Security, the Under-Secretary of State and the Minister for the Disabled has revealed that no money is to be made available for the future funding of this clinic. I will do what I can to help your patient in due course but in view of the fact that the only effective treatment we now have is now withdrawn I hope you will bear with us. We have an enormous number of letters and inquiries requesting earlier appointments for patients. We hope that a report on a three year study of tinnitus which should be ready next year will persuade the Government that this is an area of disability that should be their concern. Some of your Lordships will know the distress which this condition can cause. I do not pretend that it is a life-threatening disease; but this is one example of how services which were available to patients have now been cut.

Although we have the most economical health service in the developed world with the lowest expenditure on administration, there are ways in which even its present costs could be reduced without reducing its effectiveness. Some of these have been described by the noble Lord the Minister. Some of them might actually be improved in the process.

An important area, which has been mentioned already, is the cost of drugs, which comprises 13 per cent. of the National Health Service bill. The Government seem curiously reluctant—or are they so curious?—to implement the recommendations of the Greenfield Report on Effective Prescribing, which has been mentioned earlier, and which might save some £170 million per annum. I think that even further savings could he reached if, as in Australia, doctors could only prescribe from a restricted list of between 200 and 300 drugs. As a practising doctor, I would welcome this simplification, and our group practice is in fact in the process of drawing up such a list for our own use.

If patients wanted a particular drug outside the list, they could always pay for it themselves. Clearly the nationalisation of the pharmaceutical companies will not occur in the next few months, but this could provide yet further savings. But even if some of the present profits of the drug companies were trimmed, it would at least save the need for half a cleaner in our health centre who has to cart black plastic sacks full of unwanted promotional literature away every day.

Further savings would occur if doctors were made much more aware of the costs of the procedures they order. This was alluded to by the noble Lords, Lord Hunter and Lord Prys-Davies, in the debate on the Public/Private Mix in the last parliamentary Session. Much more information is given to doctors about the details of their work in Scotland, with excellent results. In the United States doctors are also very much more cost conscious, particularly in such non-profit making, pre-paid health maintenance organisations as the Kaiser Permanente. I am indebted to Katherine Whitehorn in her excellent Observer article on Sunday for reminding me of this example.

There are other potential rationalisations and improvements within the National Health Service which are known to the Department of Health and Social Security but which are not being pursued vigorously—some, paradoxically, because of the cuts. For instance, early discharge of suitable patients from hospital could be greatly increased. But this would need, at least initially, some extra home nursing provision. Similarly, we read of delays in introducing the domino scheme for midwifery (that is delivery in hospital with early discharge and the name actually comes from "domiciliary in/out"). This is a popular system which has not been implemented as widely as it should because a few extra midwives are needed to get it started.

I do not think that the Secretary of State for Social Services, or the noble Minister here, should be criticised personally for the cuts. In fact, the Secretary of State has been quite successful in defending his department. But he has been aided by the immensely strong public opposition to cuts in the National Health Service. I am sure he will be delighted to know that we on these Benches will be right behind him, like the rest of the country, when he puts the case for the National Health Service in the Cabinet. This case might be even better received in the Cabinet if some of the improvements I have suggested, which are also money savers, could be introduced.

10.7 p.m.

Lord Colwyn

My Lords, I must also make an apology for not being present for the earlier speeches, as I was detained in my surgery.

As many of your Lordships will know I used to be the only dental surgeon in this House, and I intend to say a few brief words about dental charges without repeating too much of what my noble friend the Baroness Gardner of Parkes, the other dentist, has already said. I did not realise this debate would be quite so late and I must apologise again if I am not in my place for the closing speeches as I have some research to do for an early appointment tomorrow morning.

The importance of regular dental care is now becoming more widely recognised and in this country we have an independent dental profession that has given successive Governments a way of apparently rationalising charges for National Health Service dental treatment while not charging for other types of health care. This method of charging has not changed very much since the mid-1970s and treatment is still free for many patients, but other patients are asked to pay the full cost of routine treatment up to a certain level and there are additional charges for more expensive treatment.

In January 1976, the maximum charge for routine treatment was £3.50, with an overall maximum charge of £12. By April 1983 the routine maximum charge has quadrupled to £13.50 and the overall maximum charge has increased by eight times to 95 per cent. Allowing for the changing value of money the rises were 72 per cent. and 252 per cent. in real terms.

The overall effect of increases in dental charges since the mid-1970s has been to increase the amount paid by patients in England and Wales from £33.4 million in 1975–76 to £149.2 million in 1982–3. This represents an increase of 300 per cent. as against an all-items retail price index rise of 135 per cent. During these years, successive Governments have had a habit of not implementing the independent review bodies' reports as to recommended incomes so that charges to patients were being pushed up while, at the same time, payments to dentists were being held down. This resulted in a substantial reduction in the Government's financial commitment to the general dental services. In 1975–76 in England and Wales, patients' charges paid 17 per cent. of treatment cost, with the Exchequer paying 83 per cent., while in 1982–83 the share of cost paid by patients had risen to 27 per cent., with the Exchequer's share down to 73 per cent.

When priority groups are excluded and the cost of the actual dental examination, which is free, is removed, an examination of the figures shows that, of the patients who are actually bringing in that 27 per cent. of the total cost of general dental services, most are paying half the cost of their own treatment. In view of the Minister's comment on 30th March 1982 in a debate in the other place on dental and optical charges, where he said: We are following the practice of raising some modest charges from the proportion of the population that can pay for its treatment", I feel that "modest" is an unreasonable description when we are referring to the cost of half the treatment.

My objection to the charge is not because it is an illogical or discriminatory tax on a particular sort of health care, but because it can act as a deterrent to treatment at the right time. The British Dental Association has evidence from Gallup polls that about one adult in seven is delaying or putting off dental treatment because of these charges. There is also evidence that patients who may be entitled to automatic exemptions are not using the procedures either because of ignorance of the system or because the form, F l D, which is used is badly put together and far too long. There is no doubt that a simple extension of the range of exemptions would cut down on administrative costs and add very little to the overall total cost.

Another major problem is that general dental practitioners now see themselves acting as tax collectors for the NHS, with the added problem that the dentist has to carry any bad debts arising from failure to collect the appropriate charge. We feel that dental charges have now gone too far, that dental health is suffering and that the DHSS has lost touch with the ideals on which the NHS was founded.

Dental charges have developed as an expedient way of appearing to increase health provision while cutting public spending. Higher dental charges do not bring more money into the dental services; they merely cut the Government's share of the costs.

To turn from dentistry for a brief moment, may I remind the Government that the present difficulties of finance within the NHS can only become worse? I have warned before of the vast numbers of our population aged between 35 and 45 who in 10 or 20 years' time will come within the period in their lives which often gives rise to the development of chronic illnesses. The NHS will simply be unable to cope. The answer is that the NHS must now place far more emphasis on prevention and education. We are well aware of the dangers of smoking and the campaigns to discourage the use of tobacco. But it is very rare to see any advice at all on an aspect of health which is far more important—that is, the use of a correct diet. A very high proportion of diseases are caused or aggravated by the seemingly unlimited ingestion of sugars and refined carbohydrates through the continual drinking of coffee, sweetened drinks and alcohol.

We must recognise and use our osteopaths, our chiropractors, acupuncturists, reflexologists, specialists in allergy diagnosis, homeopathic practitioners, dieticians and other members of the alternative medical professions, for it is they who are going to have the answer to many of our health problems in the late '80s and '90s. It is essential that their contribution is fully understood and utilised. The human organism is well designed to cope with the rigours and stresses of life and to avoid being a burden on our health system, provided that it is given the correct fuel. Without any doubt, the recognition and utilisation of this group of practitioners and their integration within our health system is going to be a vital factor in the ability of the NHS to survive in the future. I urge the Government to ensure that this integration and education takes place.

10. 15 p.m.

Lord Winstanley

My Lords, it is necessarily a hazard of speaking below the line, as it were, in a debate of this kind that it is inevitable that in the many speeches one will have listened to with great pleasure points will have been raised which one will be tempted to follow. Were I tempted to follow them all, we should be here for a very long time. I will try to resist that temptation, but I must take up one or two points. I greatly agreed with the speech of the noble Baroness, Lady Macleod, and in particular with her plea for a very special hospital in London which is providing for a very special need in a special way. That hospital needs special treatment, and I hope that it will receive it.

I also agree with the noble Baroness, and indeed with others who made this point, that we could save a great deal of money on the nation's drug bill; but, frankly, I cannot go the whole way with the noble Baroness on the question of prescription charges. If I went into that matter we really would be here for a long time. However, I must say this: it seems to me a little illogical that we should levy a charge purely on the random question of the need for a prescription. A patient may have taken an hour of my time, have no prescription at all and pay nothing, whereas another patient might take two minutes and need a prescription with four items on it, and would pay £6. In addition, the prescription charge encourages poly-pharmacy, over-prescribing and a number of other wasteful practices. So I would agree wholeheartedly with the noble Baroness that we could save money on the drugs bill, and should do so; but I would warn your Lordships not to go too far down the road of prescription charges being the main means of raising more money for the National Health Service.

Surely by now it should be utterly clear that there really is grave disquiet and deep anxiety among the people of this country about the plight of the National Health Service. The number and quality—I almost said the length—of the speeches made in this debate are very ample evidence of that anxiety. In addition, there are the debates in your Lordships' House and in another place, and Questions in this House and in another place, added to the constant references in the press, on TV and on radio to the whole question of the plight of the health service. Not a day goes by when we do not hear about this or that hospital being in danger of closure and when we do not hear of campaigns by people in order to preserve this or that hospital.

All these things combine to show that throughout our country there really is a very clear indication that people of all kinds and from all social groups and of all political parties—very many people—believe very strongly that they wish to see the National Health Service preserved, and preserved in the form in which it was originally introduced on the 5th July, 1948; in other words a fully comprehensive service free to the patient at the time of need. Of course, the service is not free. It has to be paid for; but many of us believe that it should he paid for not at the time of need but that the cost should be spread throughout life by means of taxation.

Here I have to acknowledge that medicine, if allowed to do so, could in fact spend all the resources that there are—and it could spend all those resources without any waste at all in a technical medical sense. If I followed the noble Baroness, Lady Lockwood, she said that once a new procedure is devised which is found to be helpful and advantageous it should be immediately available to any man, woman or child who could possibly benefit. I agree with the principle, but if we did that in all fields we should quickly find that medicine would soon spend all the resources that there were.

I accept that business methods are necessary, as the Griffiths Report indicated, in the deployment of resources once those resources have been fixed, but the fixing of those resources as between one Government function and another seems to me a very different matter. That is a matter of choice—choice by those who provide the resources. Like the right reverend Prelate the Lord Bishop of Southwark, I believe that the overwhelming mass of people, if given an opportunity, would in fact choose to spend more on health even if that meant spending less on some other Government function, and even if it meant increasing taxation.

All that having been said, I think we must all accept that there is now, and probably will continue to be, a gap between the resources for health, which are finite, and the ever-increasing workload, and that that gap will be there whatever the present Government now do. I listened with great care to the noble Lord, Lord Glenarthur, and heard his explanation of what is happening at the moment. I am hound to say to him, frankly, that I have heard it all before, not only from this Government, but from other Governments, too.

I recall that years ago there were the so-called July measures in July, 1966, when savage cuts were made by another Government, the Government of which the noble Lord, Lord Molloy, was such an enthusiasticsupporter—I thank him for introducing this debate. It was the Government of which my noble friend Lord Diamond was a very distinguished member. There were then cuts in the health service and in education and we were told by Ministers that they were not really cuts; they were a phased reduction in the rate of growth. It is the same old story.

I tell the noble Lord, Lord Glenarthur, that I accept the figures he has given. I do not dispute for a moment that we are spending more. I do not dispute for a moment that we are treating more patients. But in the end these really are cuts, and the sum total of these cuts is 2 ½ per cent., made up of an initial reduction of 1 per cent. in the target of health spending this year; secondly, a further 1 per cent. reduction imposed in the July mini-Budget; and, thirdly, a requirement to make 0 . 5 per cent. of efficiency savings.

Far more menacing than the expenditure cuts are the manpower cuts. With regard to those, I accept what the noble Lord has said. He said that with a cut of half of 1 per cent. we will surely manage. If we look at it, and remember that the cuts are to be based on the numbers of staff in post on 31st March, 1983, at a time when, as we all know, many posts had for reasons of prudence been kept empty and many new posts had not been created, we will see that the impact of those manpower cuts will be greater than has been envisaged. I am bound to say that when they are made they will have other consequences.

I greatly welcomed the Government's statement that they planned to end the disgraceful hours of overtime done by junior hospital doctors. I must ask the noble Baroness: is that decision now to be rescinded? If those hours are to be cut, then they can he cut only by making further impacts on other services elsewhere. The noble Lord, Lord Glenarthur, said that with a cut as small as half of 1 per cent. of staff in this huge organisation we will surely manage. We will manage. We will manage by cutting corners. But what is the base mark? Where do we start from?

We have been cutting corners in the National Health Service ever since it began on 5th July, 1948. Indeed, the health service survived in its early days only because doctors, nurses and other people doing the work cut corners on a continuing basis. They did that in order to make the service survive and to make it work. We shall have to continue to cut corners; but I hope that at long last we shall start learning how to cut corners safely on a calculated and trained basis, rather than cutting them in a random and enforced way as we have done hitherto.

That really means that, perhaps at long last, we might have to start doing cost-effective studies in medicine—something which has never been regarded as very proper. We are not dealing with the raw materials of industry; we are dealing with people's lives. But we have to think at the moment when resources are in short supply: where do we apply those resources so that we get the maximum benefit in terms of the relief of human suffering? That is a new exercise.

But what else can we do to bridge this gap which will clearly exist far into the future? There are many things. Cut the drugs bill. Certainly encourage people to follow a much healthier life style. Certainly do a great deal more with regard to preventive medicine. These are all points which have been made by noble Lords and Baronesses in this debate. We shall have to look again at health education and perhaps give it a new course and a new direction.

When I first began to study medicine nearly 50 years ago, all the emphasis in health education was on early diagnosis—and rightly so. People were invariably told that at the first appearance of a symptom, they must go along and see the doctor for expert advice. That was right at that time. But is it still right now?

The general practitioner now is a very different animal from what he was when I first qualified. He is now a highly trained technologist in many ways. It is a fact that much of his time now is taken up with dealing with matters which do not, frankly, from a strictly medical point of view, need the use of these very scarce resources. This is not to say that patients are wasting doctors' time. I used to get very irritated with the chap who came into my surgery and said that he was so sorry that all the other people were wasting my time. It was always the other people; it was never he. I merely say that everybody who goes to see the doctor has a genuine need to see him. Very often it is merely a need for reassurance; but sometimes they need that reassurance because health education has not been properly directed.

We should teach people that many things—indeed, most things—get better with the expenditure of nothing more expensive than time. But if we are to teach people that abdominal pain in a child, unaccompanied by any other symptom, does not become an emergency until some hours have passed, we must also teach them other things. We must teach them how to recognise the danger signals which should indicate a visit to the doctor and therefore the use of these expensive resources. This would be a new exercise. It is one upon which we shall have to embark.

Much has been said in the course of this debate about morale. Morale is low for understandable reasons. But I wonder—this is a new point—whether the decline in morale in the National Health Service can be dated from the time when we ceased to have a single Minister of Cabinet rank responsible for the National Health Service and for nothing else. When this huge conglomerate, the Department of Health and Social Security, and everything else that involves all sorts of matters like pensions and social security, which are very much Treasury rather than health matters, first came into being, I think Mr Richard Crossman greatly enjoyed it, as did his successors: Mrs Castle, Sir Keith Joseph and the noble Lord, Lord Ennals, who has made such a distinguished maiden speech tonight. They all enjoyed it. But I wonder whether it would be better to break up this conglomerate and go back to an individual Minister, as we had when the noble Baroness's late husband was such a distinguished Minister, who was responsible for health and nothing else—and was known to be. In those days morale was much higher.

Let me move on, because my particular anxiety with regard to the future of the National Health Service is what I see as a threat to general practice as I and indeed many of us know it here in Britain. Some of us are not sufficiently aware that general practice—the family doctor in the ordinary sense—is becoming a well-nigh uniquely British institution. There are more and more countries where everything is specialised. In the case of the two countries on the opposite sides of the political coin, the Soviet Union and the United States of America, the Soviet Union has no general practitioners, although it has clinics, while the United States of America (the other extreme of capitalism) has no general practitioner in the ordinary sense. In the Soviet Union, the clinic based practices use many ancillaries, which I favour; but the patients are merely weeded out by lowly trained ancillaries and gradually passed from one specialist to another. One hopes that in the end they come under the eye of someone who actually understands their complaint.

I believe it is absolutely vital that we retain in our National Health Service the system under which one person is responsible for one patient—the whole patient, not a lot of little bits of a patient—in a family, in a job, in an environment. That is almost uniquely British. I know it was said when we were going into group practice that it was all going to be different. When the noble Lord, Lord Hill of Luton, encouraged us to go into groups he said it would all be very different: once in a group you can all specialise; you do not all have to be universal geniuses; Dr. A can specialise in skin diseases; Dr. B can specialise in children's diseases, and so on. In practice, the reality is somewhat different, as I found while working in a group for many years. In practice, Dr. A specialised not in skin diseases but in having Mondays off and Dr. B specialised not in children's diseases but in having Tuesdays off. These admirable administrative rearrangements were of great advantage to the doctor, but I think that a little of the personal element has perhaps gone out of medical practice in this country. I believe that if it were to go altogether, that would be a shame.

I believe the well-equipped, well-staffed group can give an immeasurably better service than the old, single-handed general practitioner in the technical, professional sense—a far better service. But I believe also that if we move to a wholly clinic-based system, we should see the disappearance of any personal element.

The present difficulties have arisen, in my view, in part at least because of overspending by family practitioner committee services. This was a point made very well in an admirable speech by my noble friend Lord Diamond. It was a speech which I hope the Government will study again and again—an important speech about the reduction of £1 billion in the contingency fund.

These difficulties have arisen, in part, because of overspending by the family practitioner committee services which are, as noble Lords have said, open-ended—and properly so at the moment, because no Minister and no Treasury official, however perspicacious, can accurately predict how many cases of pneumonia there will be next year, how ill we are going to be, and how much all this treatment will cost. So in a sense they have to be open-ended—and it is not a great surprise when they exceed their budget. This year, they did exceed their budget. The consequence of the overspending by family practitioner committee services was that the Government then were forced to make a 1 per cent. cut in their cash limited services —which are the hospitals. If one makes that 1 per cent. cut then, as sure as night follows day, the burden on the family practitioner committee services this year will be that much greater. Then there will be a further overspend and another 1 per cent. cut in the cash limited services will follow, and so on, until there is nothing left to cut by 1 per cent.

No Government will put up with that situation indefinitely, so the Government will be forced in the end to think—as my noble friends Lord Kilmarnock and Lady Robson of Kiddington are beginning to think—that we shall have to introduce cash limited family practitioner committee services. I can deal with my friends in the Alliance but whether I can deal with the Government on this matter is another question.

If we take away the present open-endedness of family practitioner committee services, we might then be on the road towards the only way in which that can be done: by a clinic-based type of primary health care—and once one moves to that, then one is in danger of losing something very vital to our National Health Service.

All I will say in conclusion is that I am absolutely certain that our National Health Service has a future. I am certain that the people of this country will insist upon its being maintained, and certain that the Government will maintain it and that the next Government will maintain it. I hope that in maintaining it, they will make sure that they preserve that especially British role of the family doctor who is responsible for a whole patient, rather than having a whole lot of different doctors who are answerable for different bits of a patient.

10.33 p.m.

Baroness Jeger

My Lords, there may be some Members of this House who think that the hour is rather late, but I can assure them that, to those of us who started our parliamentary lives in another place, the night is young. I hope that the noble Baroness who is to reply, although she has not had the experience, will feel that she can take all the time in the world to answer this very important debate, because noble Lords have spoken very seriously and have asked questions which deserve answers. It would be a matter of regret if anybody felt it was time to catch the last tram home before the noble Baroness had finished.

I must join in the thanks to my noble friend Lord Molloy, who provided us with the opportunity for this important debate. I congratulate the noble Lord Ennals on his maiden speech. I am sure we shall learn a great deal from him, and perhaps he will even learn from us.

This debate has covered many subjects, but there are one or two points to which I should like the Government to reply, tonight if possible. I was very impressed by the speeches, which came from their professional experience, of the noble Baronesses, Lady Cox and Lady McFarlane. I hope the Government, even if they have not yet started the review of the structure of the nursing profession, will put it on the agenda. It seems to me—and I am not making a party point, because the Government I supported was responsible for a lot of the difficulties—absolutely stupid that the only way a highly trained nurse can go forward and get more money is to leave the ward or leave the operating theatre and go into an office. I should like to turn the whole thing upside down and dock her pay when she goes to sit behind a desk; I think it is much harder work to be a theatre sister or a ward sister than to be in an administrative job. But it seems that not only throughout the National Health Service but throughout our national life it is more important to administer than to do.

The other question to which I hope we can get an answer tonight is the question of the South London Hospital for Women. We had a debate in this House some time ago. We were given to understand that the Government were giving most careful consideration to all the representations put forward. What reply have we had to those representations? We had a sneaked out Written Answer in another place, and according to the noble Baroness, Lady Macleod, no communication to the staff of the hospital at all.

I know that one of the arguments against that hospital was that there are now so many women doctors that any woman patient who wants to be seen by a woman doctor can have her wishes met. But may I remind your Lordships that in the whole of this country there are only nine women consultant surgeons?—so the chances of a woman who needs to see a consultant surgeon who is a woman are not very great. Those nine posts are scattered throughout the country. I think it is very unfair to suggest that this problem is going away.

I do not really understand much about money, so I shall be rather shy about bringing this question into the debate, but when talking about the future of the health service we have to talk about money; even I have to think about money as best I can. I like to read John Maynard Keynes, not because I understand all the economics but because he writes very good English. He defined money as "a subtle device for linking the present to the future". I think that that should be engraved in the offices of every Minister concerned with the health service, because, if there is any place where money does link the present to the future, it is in the health service; it is the future of people's lives and people's health that is determined by the money that we spend on them at the present time.

I agree with those noble Lords who have said that of course we must do away with waste. I should like to be practical and point out a few areas of waste which worry me. One of the main areas of waste at present is the unemployment of doctors. It costs thousands of pounds to train a doctor. I read in the BMJ of 15th October a letter from the father of a young qualified doctor. He wrote: I am writing because he himself is too busy to write, being fully occupied as a plumber's mate I do not know what businessman on the Government Benches would consider that that was not a wasteful use of invested capital. We do not know how many unemployed doctors there are, for the simple reason that many of them do not register and those who do register do not now have to give their professional qualifications. There are many nurses in the same position who are out of work. I hope that when the Government are thinking of economies by reducing staff they will do the arithmetic properly, as even I understand it. The money saved on paying personnel in the National Health Service must be set against the amount of unemployment pay which must be met, the loss of national insurance contributions and the loss of income tax contributions by the unemployed, in addition to the write-off of the capital expense of their training.

We had a debate in the House on 16th February 1982 about the long hours which junior hospital doctors were working. I must ask the Minister how are the assurances given at that time that the Government care very much about the long hours that junior doctors have to work compatible with the fact that they are now cutting the number of doctors employed? It does not make any sense at all to ordinary people who only look at the facts.

We have had speeches from two dentists which we much appreciated. There is another sphere of waste, which is to put up dental charges so high that people stop going to the dentist for as long as possible and then end up having more expensive treatment.

There is, of course, the waste of life. I was glad that the Minister referred to the arrangements being made for more money to be available for hone marrow transplants. I understand that it costs about £7,000 for a successful hone marrow transplant and that the experience so far is good. If people are denied that capital expenditure of £7,000, I wonder how much money is used up in keeping them alive, probably in a moribund condition, in hospital for months and perhaps years, unable to work. How much of that should be set against the £7,000? Those are the sort of mathematics I find difficult to understand and the sort of economies which certainly seem to make no sense at all.

In the financing of the National Health Service there seems to be a confusion between capital and current expenditure which makes nonsense of practical economics. For instance, there is a very new modern expensive hospital—the Royal Free—in Camden. For 10 years that hospital, which was highly expensive to build, has had a special ward for bone marrow transplants which has been empty for 10 years. That is locked-up capital and there are wasted lives. Those are the real areas of waste. I read that the Government are to make a contribution to this work, and we welcome it. But I must tell the House that Professor John Hobbs at Westminster Hospital, who is very skilled in this work said—and I quote from The Times: It will not even sustain our existing programme and no way can it increase our chances of coping with the waiting lists. If the Westminster Hospital got £30,000 this year that would provide for four more transplants in a waiting list of 43. The lives of the other 39 would still be wasted. I hope that, when we are talking about economies in the health service, we shall make sure that they are real economies and set off other factors against them to have just a simple balance sheet so that we can see where we are going.

As I say, we have had very many interesting speeches today. I enjoyed particularly the thoughtful remarks of the right reverend Prelate the Bishop of Southwark. He referred to the question of the reallocation of resources. We have discussed this before. I do not think that we have the answer to this problem at all. I happen to live in, and have represented, an area that is part of the Bloomsbury health authority. By accidents of history, we have many teaching and specialist hospitals in our area. People come from all over the country. When I visited these hospitals as a Member of Parliament I hardly ever found a constituent in them, so no one could accuse me of visiting the hospitals to get the sick votes.

The Bloomsbury Health Authority is beset with overwhelming financial problems because these hospitals happen to be in that area. I know that the teaching hospitals have special arrangements, but we were told in a previous debate when the noble Baroness, Lady Masham of Ilton, raised the subject that the Government were to look at the question of special financing for centres of expertise. Perhaps we could know how far that has got. There are hospitals which are dealing with very special problems and which should not have to be financed out of the resources of the area in which the building happens to be situated.

Another area of waste which is almost too obvious to mention is the under-achievement and the unnecessary sick leave especially of those who are chronically ill mentally or physically and who with a bit more attention and treatment could be working and contributing to the community. One thing annoys me very much, not only today but always when we talk about the National Health Service. I wish people, including Ministers, would stop talking about those of us who are over 65 as if we are a burden and a nuisance. Most of us have been paying taxes and national insurance since we left school. We have lived through two wars. We have worked hard. Some of us are still working hard and, I regret to say, still paying income tax. The idea that we are a burden which the nation cannot put up with and a waste and cause extravagance in the National Health Service is quite unacceptable.

I say this because I have great concern about it. I think that a much more serious problem is not we old chronics but the young chronically sick. I am talking only about preventable illness and the young people who, because of that, will not be working, paying taxes or contributing in other ways and who will have to be kept. Many of them have potential which could be released if we cared more about that.

I have to ask another particular question about prescription charges. I want the noble Baroness who is to reply to know how interested I am in Conservative politics. I even watch the Conservative party conference on television. I was very moved by a woman speaker who came to the rostrum to say that her husband had died of cancer. It must have been a great strain for her to do so. She said that she had to pay £20 a week in prescription charges during the months of his terminal illness. She had written to the Prime Minister and had received a letter back from her office saying that she should have applied for a season ticket. That is a phrase used to describe the yearly payment by which one gets drugs more cheaply. The poor woman said, "When you have just been told that your husband has only three months to live and he is dying of cancer, are you really expected to go round looking for a season ticket, even if you know what it means?" Mr. Fowler said, "The moment I get hack to London I am going to look into this". I wonder whether Mr. Fowler has found an answer to that dilemma. I would ask the noble Baroness perhaps not to reply to the detailed point but to let us know whether any reconsideration is being given to exemptions from prescription charges.

It seems to me totally unfair that where a woman—or it might be a man—undertakes the arduous nursing of her nearest and dearest at home and saves the enormous hospital costs of the patient, she is penalised by having to pay for the drugs as well, which if the patient were shipped off to hospital would be provided free. Although this matter came into my mind because of the Conservative party conference, I am not making a party point because I do not think we got it right, either. I hope that there are people who will look at this again. Having made the point that I think the National Health Service finances are at loggerheads between capital and current expenditure, I believe that there is another dichotomy in our thinking. I make no apology for stressing this point, since we are talking about the future of the health service. We seem to have a much more sensitive and alert attitude to injury than we do to illness. It is a fact that if a young man is involved in a motorcycle accident and sustains a fractured skull, he is taken into hospital. Nobody says, "There isn't a bed", or, "We have run out of money; he must go to the end of the queue". But if the young man's little brother needs a kidney transplant, the little brother has to go to the end of the queue. It seems tome that life is precious, whatever element has put it in danger.

It makes me feel fed up when the Minister says, "We are cutting only half of 1 per cent.". To the patient the cut is 100 per cent. One cannot tell a patient that he will get only half of 1 per cent. neglect of his case. If he is put at the end of the queue and dies before his turn is reached, he is 100 per cent. dead. We must face this fact and not talk about a half of 1 per cent. as though it is nothing at all.

Even I must exercise a little discipline. I shall say only that I hope, too, that there will be some debate on the Griffiths Report. It seems to me that even the noble Lord, Lord Sainsbury, would not allow Mr. Griffiths to do some of the things that the present Government are doing. There is, for instance, the alteration in the availability of finance half way through the year. No business would run like that. I understand that the Griffiths Report was supposed to make the National Health Service more businesslike. But what business, having budgeted, made its arrangements and taken on its staff, would change its mind half way through the year? Not even Mr. Griffiths would do that in any shop.

There is another, slightly clinical, question on which I hope the noble Baroness can help us. I understand that the present advice from the National Health Service to doctors is that cervical smears should be undertaken within the health service for women with no symptoms—I am talking about women who are well over the age of 35 and at five-yearly intervals. There have been two reports recently about the possible side-effects of oral contraception. Some of the doctors who signed those reports recommended that tests should be undertaken at three-yearly intevals. As so many women in this country are involved, I hope the Minister will be able to say that the Government are looking at changing the rules so that some of the anxieties can be allayed.

A country can afford that in which it believes. I remember in the House of Commons in July 1946 the Tories trooped into the Lobbies to vote against the National Health Service. I think that they had to come round slightly to believing in it because of the pressure of public opinion. They were forced to believe that the public wanted it. But it has never got into the gut-thinking of their ethos that it really matters. There was a Third Reading vote of 261 to 113 on 26th July 1946 —and do not let any Tory forget that.

I conclude on money. I cannot say that I remember, but I have read some of the debates on the Forster Education Act of 1870, when compulsory education was introduced. "We cannot afford it", was the cry. Every time that we have tried to raise the school-leaving age there has always been someone saying that we cannot afford it. But there are things in which the whole nation and the whole community believes. The National Health Service is first in the minds, the affections and the consideration of the majority of people in this country. I hope that the Government will try to look at the problems in the light of that, and in the light of the national concern.

10.57 p.m.

Baroness Trumpington

My Lords, I apologise for the fact, which must be obvious, that I have a heavy cold. I hope that the noble Lord, Lord Winstanley, is right when he says that time is a great healer. We have had a wide ranging debate in the best tradition of health service debates in your Lordships' House. There could be no question of the passionate, indeed, compassionate, commitment expressed by all who spoke. If that passion led some noble Lords in the cut and thrust of debate, to make some points with more ascerbity than was strictly called for, we must forgive them. We know that their hearts are always in the right place even if their facts and opinions are surely less well based.

Despite what has been said by the noble Lord, Lord Molloy, and my noble friend Lord Mottistone, many outside this House believe that the National Health Service is not a Socialist creation. William Beveridge, a Liberal, whose report provided the foundation of the National Health Service, was brought in by a coalition Government headed by Churchill. Had the general election of 1945 brought the Conservatives back to power, it would be truer to say that the National Health Service was a Conservative brainchild——

Lord Elwyn-Jones

They opposed it.

Baroness Trumpington

—and as things happened the Socialists took the credit. There were more Socialist MPs at the time. It is as simple as that.

Your Lordships' House is blessed with considerable expertise in these matters. I listened with great interest—although not always in agreement—to the maiden speech of the noble Lord, Lord Ennals. I am sure that his lively contribution and great experience promise a yet further raising of the standards and perhaps the temperature of health service debates. For a time, he was my MP. I did not actually vote for him, but I know how much people in and around Dover—he seems not to be listening to me, either—appreciated his excellence as a constituency MP. He may read it tomorrow in Hansard.

Not a few of the speeches we heard today, particularly from the party opposite, called for additional resources to be devoted to the National Health Service both in general and in particular areas of services. Few pointed to from where those resources should come. The noble Baroness, Lady Ewart-Biggs, the noble Lord, Lord Rea and others, talked about the drug companies and their profits. They should not forget that my right honourable friend the Secretary of State has already cut the drugs bill by £25 million in this year. Again, I noted that the promises of the Opposition by far outstripped their past performances. It is far from difficult to point to areas in which, in the best of all possible worlds, we could spend more money. Describing problems is easy; finding solutions causes rather more difficulty.

As my noble friend the Parliamentary Under-Secretary said in opening this debate, it is no good simply to call for more money; we cannot debate the future of the National Health Service at that simplistic level. That is why I welcome the emphasis given by some speakers to gaining proper value for the very large sums of money spent on the National Health Service out of taxpayers' money. The Griffiths Report has been mentioned several times and I will have more to say on that later. The recommendations in that report clearly point the way to more effective and efficient management systems. More effective management means better targeting of resources for patient care.

I listened to every word uttered by the noble Baroness, Lady Jeger. The answer to one of her questions is that it is estimated that less than 1 per cent. of the medical workforce is unemployed at any time. Most of this unemployment is short term and frictional. At the same time many medical posts remain unfilled for lack of suitable candidates. The present exemption on prescription rates will be maintained. I fear that I have no time to reply to the other points raised by the noble Baroness. With a debate of this length it is impossible for me to answer all the many questions put to me on this vast subject. I will of course be happy to write to any noble Lord or noble Baroness who feels that I have not replied to his or her particular point.

Lord Graham of Edmonton

My Lords, will the noble Baroness give way?

Baroness Trumpington

My Lords, I do not wish to give way at this time of night. I am going to carry on; I am very sorry.

I turn to the point raised by the noble Lord, Lord Diamond. The noble Lord stated that the Government mismanaged public expenditure plans in March. I know that the noble Lord has had to leave the Chamber but I will answer his point. The central fact is that public expenditure must be kept at a level the country can afford. It is not sound management, as the noble Lord appears to suggest, that increases in particular areas of expenditure have to be accommodated regardless of the total burden on the taxpayer. We had to review expenditure in July in the light of higher than budgeted spending in a number of demand-led services in order to keep overall expenditure under control. The alternatives of increasing taxation leading to higher interest rates and more unemployment would simply damage the economy; and that, with his experience, the noble Lord will, I hope, accept.

I know that the noble Lord, Lord Wallace, has also had to leave his place. I hate talking about people when they are not here but I shall carry on. I was surprised to hear the noble Lord, Lord Wallace, speak in the way in which he did about blood donors. My view is and has always been that people donate blood to help people—not the National Health Service or the private sector. Let me quickly put that red herring out of the way. I must also add that for once I thought the noble Lord, Lord Wallace, was less than his usual gracious self when referring to the really excellent opening speech of my noble friend the Minister. The noble Lord, Lord Wallace, alleged that in the first two years of Conservative Government there were cuts of £147 million and £20 million. The fact is that in Great Britain spending in the National Health Service increased by £4 billion in the first two years of this Government, allowing for real growth in services after allowing for national health inflation. Labour made spending pledges before the 1979 election, but we had to provide the cash to pay for them. In 1979–80 public expenditure on the National Health Service was over £400 million higher than Labour had actually provided for before the election. The noble Lord, Lord Diamond, may care to be reminded of that fact as distinct from Labour's promise.

I have welcomed the maiden speech of the noble Lord, Lord Ennals, and I shall take up two of his points. The first is the treatment of kidney failure. Kidney transplantation is the best and most cost-efficient treatment for kidney failure, and in recognition of this we carry out more such operations than any other European Community country. We are seeking to improve on this creditable record by vigorously promoting the kidney donor scheme. We also recognise the importance of dialysis and we are encouraging regional health authorities to see that proper priority is given to this area of provision.

With regard to manpower, the noble Lord, Lord Ennals, asked why there was manpower constraint after the expenditure cut. The reductions flow from an exercise first instituted in July 1982 to ensure that there was adequate manpower and control. It was the failure of health authorities to satisfy Ministers that adequate manpower planning and control systems had been established which led to overall reductions being set nationally. Manpower will increase in four regions.

The right reverend Prelate the Bishop of Southwark, the noble Lord, Lord Ennals, and the noble Lord, Lord Winstanley, spoke about people being willing to spend more money on the National Health Service. I am aware of the recent polls which suggest that people would be willing to pay more in taxation for the National Health Service; but I have not seen people dancing in the streets in the past when taxation has actually been raised. All Governments have to take a view on the total public expenditure the country can afford and set their taxation plans accordingly. A little more for each deserving case could lead to an unacceptable total burden.

My noble friend Lord Mottistone brought up the subject of local pay bargaining in the Griffiths Report. I welcome the support which my noble friend gave to the recommendations. I cannot go all the way with him in his suggestion that all centralised pay negotiations should cease, but I point to the recommendation in the Griffiths Report that the Whitley agreement should be reviewed so as to secure maximum flexibility in local management and freedom to demand or sanction staff.

I should very much like to support my noble friend Lady Cox in her praise for nurses, which I greatly share. I am sure that there is not one person in this House who would not wish to be associated with her remarks. The noble Baroness, Lady McFarlane of Llandaff, and others have commented on the nursing aspect of the Griffiths Report. The Griffiths inquiry team was not asked to provide guidance on specific management functions but to review the overall efficiency of the health service and to advise management action to secure value for money and the best service to patients.

During the course of its inquiries, the Griffiths team held discussions with representatives of the nursing profession, including the Royal College of Nursing. One of the recommendations in the report is that district chairmen should identify a general manager for every unit of management. We recognise the vital importance of the work of the nursing profession and value the skills and dedication that nurses bring to their work. Let there be no mistake about that. The purpose of the Griffiths recommendations is precisely to clarify management functions so that nurses, clinicians and all other groups involved in patient care are in no doubt about what is being asked of them, and to help them to bring the best possible service to patients.

At unit and district level the chosen general manager could well be a nurse. Even if that is not so, nurses will be managed by nurses. A further recommendation of the Griffiths team was the appointment to the proposed national health management board of a personnel director, one of whose tasks would be to improve career development appraisal for all groups of staff. I should stress that no decisions have yet been taken on the final composition of either the proposed management board or the health supervisory board. I have no doubt that the Secretary of State will take full account of the requests and representations put to him.

The noble Baroness, Lady Robson of Kiddington, brought up various points also regarding Griffiths and I fear I probably shall not be able to answer all the questions that she asked. If she will let me know I will gladly write to her. In the meantime I think the best I can do on one of the points she raised is to quote from my right honourable friend the Secretary of State, who said: First, the report does not propose any further structural reorganisation. All its recommendations are designed to take place within the existing statutory structure without affecting the constitutional position of Parliament, Ministers and the health authorities. Secondly, the recommendations will not add to existing costs or staff numbers. Indeed, inside the Department of Health they should lead to a reduction of activities and staff. Thirdly, the report emphasises that the National Health Service is about delivering services to people, it is not about organising systems for their own sake. The team said the driving force behind their advice is their concern to secure the best deal for patients and the community within available resources, the best value for the taxpayer and the best motivation for staff. The Secretary of State has accepted the broad thrust of the report. He is now proceeding with consulting the health and professional interests. Nevertheless he is anxious to make progress in this key area without undue delay.

My noble friend Lady Cox brought up the question of manpower targets and agency nurses. As the base line for the manpower target exercise includes only permanent paid staff, agency nurses are excluded. When considering the effect that any changes in agency nursing levels have this must be compared with the reasons behind these changes. What we are looking for is good manpower planning. We are well aware that converting agency nurses to permanent paid nurses saves money and improves efficiency, but increases staff numbers in this exercise. However, as this is obviously good manpower planning, we would not penalise a health authority for taking such steps. If the health authority were to say it could only meet its target by employing more agency nurses rather than permanent paid nurses, we would consider it had failed to scrutinise the efficient use of its manpower and had gone against the spirit of this exercise.

My noble friend Lord Auckland spoke about the Epsom cluster of hospitals and I was grateful for his kind remarks. But in answer to his questions he will find the information he seeks in the two Questions which were answered last week. In answer to the noble Baroness, Lady Lockwood, and other noble Lords who spoke about demography and medical advance, I think my noble friend the Minister included most of the details concerning these matters in his speech, but I will write to the noble Baroness, if she so wishes.

Hurrying through to the co-operation with the private sector, which my noble friend Lord Ferrier raised—and many other noble Lords referred to his speech—I would say that the main points about co-operation with the private sector are that the Government are committed to a full and constructive partnership with the private and the voluntary sectors. There is a long tradition of private facilities complementing statutory services, particularly through contractual arrangements, to use beds in private nursing homes. The private sector is comparatively small—33,000 beds, compared with 350,000 beds in the National Health Service—but offers choice, a measure of relief to hard-pressed National Health services and a means of comparing public and private sector performance. Incidentally, the noble Baroness, Lady Macleod, asked me about the use of equipment. It is quite usual for borrowing to go on of privately-owned equipment to the National Health and sometimes vice-versa. People want to have the option to take out private health insurance, as evidenced by the growth in subscriptions. In 1979, there were about 2½ million people insured; but that has now risen to over 4 million.

With regard to the matters concerning the Black Report raised by the noble Lords, Lord Rea, Lord Ennals and, certainly, by Lord Prys-Davies, this report was fully debated in the House of Commons on 6th December 1982. It had been raised twice previously during parliamentary debates and has also been the subject of frequent correspondence with MPs and others. Underlying objectives are in line with policies set out in Care in Action so, in many instances, we are pursuing the same end by different means. The special development programme could only be financed by taking money from other deprived areas. These recommendations, with extensive consequences cannot be afforded in the present economic climate and there is nothing in the report to show that they would be effective. We have invited the Social Science Research Council and the Medical Research Council to bear in mind the recommendations on further research.

I was extremely interested by the speech of the noble Lord. Lord Richardson. The views of a physician of his eminence must always command respect. I feel sure that my right honourable friend the Secretary of State will note what he has said. My noble friends Lady Gardner of Parkes and Lord Colwyn gave us the benefit of their profound knowledge of dentistry. We all listened with great interest to the noble Baroness. She described the problems of success and we rejoice in that success. We must take account of those problems. The pay of dentists is settled by an independent review body, the Doctors and Dentists Review Body, which reports directly to the Prime Minister. The Government are committed to accepting those recommendations unless there are clear and compelling reasons to the contrary. I am sure that the review body will take account of the points made. On dental charges, since 1951 it has been the policy of successive Governments to supplement the public funds available to the National Health Service for charging dental treatment to those able to pay. The alternative would not be free dental treatment. The money has to come from somewhere. It would be increased taxation or reductions in the National Health Service.

Now we come to the South London Hospital for Women. The first points made to me by my noble friend Lady Macleod will, I am sure, be of great interest. These points were not concerning the South London Hospital for Women but I am sure that they will be of great interest to my right honourable friend the Secretary of State. On her last point, on the South London Hospital for Women, I think I can do little better than quote from the announcement made by my honourable friend the Minister when he said: No one likes to close a much-loved local hospital such as the South London and I have not taken this decision lightly. I and other Ministers of the DHSS have had discussions with the local MPs, the Community Health Council and some of the staff at the hospital. We have considered very carefully the proposals put forward by the Wandsworth Health Authority and have examined all alternative options which have been put to us. We have decided that none of them would enable the same significant improvement of services to be made in the locality without an unjustifiably large increase in resources. We have also taken full account of the representations we have received from the many people who have been particularly concerned that women locally should continue to have the option of being seen and treated by women doctors. I understand this and I accept that there are many women who for religious, cultural or other reasons prefer to be seen by women doctors. It has never been possible for the National Health Service to provide an all-female service of this kind outside Wandsworth, however, and the advantages to the district that would flow from closure justify putting patients there on the same footing as patients elsewhere in the country. He went on to say: We recognise the important role that the South London Hospital has played in the past in training women doctors. Since its foundation, however, much has changed since training career opportunities for women in medicine have expanded. Indeed, St. George's Hospital, for example, currently employs 35 women doctors in training grades, compared with 18 at the South London Hospital. It is expected that most medical staff employed at the South London Hospital will transfer to hospitals elsewhere in Wandsworth and neighbouring districts. I fear that I can do no more than just quote those remarks. The night is getting later and there is other business for the House to consider after this: so I repeat that I will write to anybody whose views and particular points I have not dealt with.

Finally, I must say that what I really resent is the strategy of fear tactics adopted by the Labour Party—a kind of instant electioneering attitude. For pity's sake! let us be thankful for the treatment which you and I and all our fellow citizens receive. Nothing in this world is perfect but we in this country have a health service of which we can be proud. The most vulnerable, from babies to the mentally handicapped and elderly, are looked after in a way undreamed of 30 years ago. For Heaven's sake!—let us try to be constructive in our thoughts. Let us not alarm those who need help by throwing doubts and worries into their paths. Neither let us alarm those who care for the sick. This debate has had its helpful aspects, and for that we are grateful to the noble Lord, Lord Molloy, for his initiative. Where it has fallen into mere party political posturing, its results have been less than constructive.

11.23 p.m.

Lord Molloy

My Lords, may I just take advantage of this moment to join in the felicitations that have been given to my noble friend Lord Ennals? I should particularly like to thank the noble Lord, Lord Diamond, for his remarkably searching speech. I am very glad that there is nothing wrong with his hearing, or my voice. The noble Baroness, Lady Macleod, thought that I had not said very much about the future of the NHS. That is rather like the patient complaining about the doctor who was not interested in his health but only in curing him of a very serious disease.

What a hammering the Front Bench opposite have had tonight! From all over this House, they have been shattered and I am bound to say this: all Governments from time to time have surrendered something to the Treasury. It is always the Treasury that is the really baneful influence in destroying something that is perfect—because the National Health Service was perfect. It was destroyed by the Treasury under Labour Governments and it is being destroyed now by the Treasury under a Conservative Government. All Governments have surrendered something of the NHS to the Treasury.

What we really want—and here I agree absolutely with the noble Lord, Lord Winstanley—and what I should like to see is this edifice that has been created —I think it was a Labour Government that created it—with a Secretary of State and underneath him a Minister of Labour. We did so well to transform society with that first Labour Government, when Jim Griffiths was responsible for the social services and Aneurin Bevan was responsible for the health service, and both of them were in the Cabinet. The quicker we return to that, the better it will be.

I hope that this House, and particularly the Government, will take note of the very many speeches. I do not think that there was a single speech which was not critical, somehow, of the Secretary of State and the Front Bench opposite, and which was not somehow in support of what I said when I opened this debate. Therefore, I believe that it is very necessary for the Government to realise that what is really at stake is a great service.

I hope that we shall not have too much cognisance taken now of either Marks and Spencer or Sainsbury's, because—and I beg Ministers' representatives opposite to take this to the Prime Minister—what has been said tonight from all sides of this House demands more recognition, more acknowledgement from this Government's Cabinet than anything that Marks and Spencer or Sainsbury's have to say about the National Health Service. If that is not done, then democracy will have been dealt a very savage blow.

Therefore, I want to see whether we can have a Minister of Health, because I believe that it is the desire of the people of our country to see our health service improved, enhanced and defended, because it is a great service. It is not only the envy of the world. It is, indeed, a guide to civilised, sensible behaviour for all mankind. My Lords, I beg leave to withdraw my Motion.

Motion for Papers, by leave, withdrawn.