Health and Welfare Provision

HL Deb 13 February 1985 vol 460 cc189-280

3.3 p.m.

Baroness Jeger rose to call attention to public and professional anxieties about the National Health Service and to changes in the social security system which affect the well-being of increasing numbers of people; and to move for Papers.

The noble Baroness said: My Lords, I beg to move the Motion standing in my name on the Order Paper. This is a very wide-ranging Motion, and deliberately so. Perhaps it would be of interest to your Lordships to know that, with all the respect and affection that we have for the noble Earl, Lord Caithness, we are sorry that the Minister, the noble Lord, Lord Glenarthur, is not with us today. I think I should inform the House that my noble friend Lord Ennals and myself agreed to alter the date of this debate to enable the noble Lord to be with us, and I do not know why this courteous gesture from this side was not accepted. However, I am sure that the noble Earl, Lord Caithness, will make the best of things, and we are very glad to have him here.

It is a wide-ranging Motion because we felt it necessary to bring together the many anxieties which are felt by increasing numbers, in all parties, in the caring professions, the voluntary societies, local authorities and the general public. Although many threads in the debate will come forward, they are in fact many threads in a seamless garment because all the problems arise from one cause: the Government's philosophy and policies. I anticipate two answers from the Government, because we have heard them before. First, we shall be told that there are four reviews of the social services which are under way. We welcome those reviews. Secondly, we shall be told that the public sector must be reduced. It is widely understood that as far as the reviews are concerned any proposed changes must be at nil cost, so any improvements which result from the reviews in one sphere will mean deprivation in another.

As regards public sector costs, I must remind your Lordships that it is clear from the White Paper on the Government's expenditure plans that while public expenditure this year—I refer to 1984–85—is 42.5 per cent. of the gross domestic product, the Government are asking that in 1987–88 that proportion should drop to 39.5 per cent. The Government's monetarist policies are typified by their attitude to the public sector. One feels that the Government wish that, like acne, it would go away. But in our complicated modern society it is bad economics to maintain this rigid differential between the public and private sectors, and that is what is at the heart of the problem we are debating today.

The public and the private sectors depend upon each other. When we see cuts in housing expenditure—because that is part of the programme of reducing public expenditure—I wonder how many noble Lords realise that that is a cut in private expenditure. It is a reduction in the work of architects, surveyors and people who make baths, lavatories, curtains, carpets and furniture. Therefore, there is a knock-on all the time between the public and the private sectors. It is totally unreal for the Government to put out their plans and to maintain that there is something evil about the public sector and that only the private sector is good. We are in a complicated modern society, and it is very bad economics to work that way because the two sectors depend on each other.

No rugged individual in our modern society can stand on his own. He might think he achieves this by, for example, using private medicine, but he will be looked after by doctors, nurses and others who have been trained at the public expense. The Prime Minister rejoices in private home ownership. So do we all. But the mortgage interest relief costs the public sector over £3 billion a year, with the biggest benefit going to the most well off; and that includes Members of Parliament, who were told last Friday in the other place that they can now claim mortgage relief on their second homes. I think that is an insult to the homeless and the people who are struggling to get a roof over their heads. I should like to think that the other place has enough dignity to throw out that suggestion.

Then there is the sale of council houses, which is a favourite of the Prime Minister and noble Lords opposite. When council houses are sold there is a discount which has to be met by the rest of the ratepayers, many of whom are too poor even to consider getting a mortgage. When the councils sell these houses and collect some money, they are now prevented by the Government from using that income for building more houses. So this distinction between what is good for the public sector and what is good for the private sector needs a good deal more concern. In fact, my Lords, I find that there is a very cosy little welfare state going on quietly within the private sector: tax reliefs and allowances and reductions in investment surcharges. However wealthy a man is, and however rich is his wife, he can claim a married man's tax allowance. These are the fundamental problems which we ought to be considering. In looking at how much we are spending on dental charges, or on prescription charges or on child benefits, and so on, we must realise that unless we mesh these things together, we do not get a full picture of the economy of this country. Unless the reviews take account of facts like these, there can be no radical reform of health and welfare finance. I am very disappointed because I cannot find in any of the many leaks which have come from the Government any information that there is to be any Treasury involvement in these reviews.

Many of the costs arise because of the Government's policies in other departments, not in the DHSS. They arise because of other policies. The main objective ought to be—and I am sure all parties ought to agree on this—to remove the causes of illness and penury wherever possible.

May I take, for example, unemployment. This Government deliberately creates unemployment by its policies. Its sacred cow is to reduce inflation. But as inflation has gone down, so unemployment has gone up to the disastrous figure of about 4 million. Therefore, in logic if it keeps on its one track, and if inflation is to be further reduced, then unemployment must increase. That is the track record of this Government. As night follows day this must happen. It is strange that a Government, who want to reduce spending in the public sector, do not seem to mind how much they spend on unemployment. This time it is we on this side who are saying that the country cannot afford unemployment—not only in money terms but because of the damage and disaster for millions of people, and the damage it does to the delicate fabric of our society.

I do not have a lot of time for the EEC. I think it costs too much and it pays too little; but, broad-minded as ever, I recently read the December issue of the Official Journal of the European Communities. It included a summary of a report from the Economic and Social Committee on social security problems in member countries.

May I read a few lines of this report which refers to the United Kingdom. The United Kingdom report explains that the financial imbalance is almost entirely due to the problem of unemployment impacting through the lower yield of national insurance contributions and taxes as well as the cost of benefits. If you add these two together … it can be calculated that, if we had higher levels of employment, which we were used to in the 1960s, the extra gain to the Exchequer of having full employment would enable, without any increase in contribution, a whole second National Health Service to be funded without any extra expense. That is the cost of unemployment to this country. Other noble Lords better qualified than I am will speak more specially on the National Health Service.

I want to refer to a particular case which was reported in the Sunday Times on 10th February, because it is a matter of public interest and concern. Police Constable Hammond was viciously stabbed while trying to arrest a burglar in a shop. He was taken to King's College Hospital. The only operating theatre available was a gynaecology theatre, and patients had received their pre-medication prior to operation. If their operations had begun, there would had been no theatre available and no hope for Police Constable Hammond. Dr. Robert Ware of King's College Hospital is reported in the Sunday Times as saying: It takes a lot of extra resources to provide for these cases if the flow of routine work is not to be interrupted. The hospital would be more efficient if we had more intensive-care beds and an emergency operating theatre, but acute medicine is being starved of funds. I leave your Lordships with that one case. I am sure our good wishes go to Police Constable Hammond, to his family and to those who are caring for him.

I turn briefly to supplementary benefit problems—briefly only because of lack of time and not because of lack of importance. The fact that we have over 7 million people on supplementary benefit, and an unknown number who should be on supplementary benefit but do not claim it, is a measure of the inadequacy of present benefits and of the failure of the Government's economic strategy. Beveridge never envisaged this. It is a nightmare for applicants and for staff alike. I must say that I have a great deal of sympathy with the staff, having visited many of the local offices.

I again will only give one example. It is topical because it is so very cold outside. I hope the noble Earl will give us some information about this extraordinary muddle concerning severe weather benefit. There is some extraordinary arrangement under which people on supplementary benefit are supposed to receive special payment during exceptionally severe weather. I must say that I feel exceptionally severe weather is upon me at the present time! Perhaps the noble Earl will tell us how much has been paid out in this bitter weather, and to how many people it has been paid. To begin with, the shivering old lady has to be on supplementary benefit, anyhow. Then he or she—I must not be sexist—has to go through another hoop of not having more than £500 in capital.

Now, my Lords, if you have worked all your life and saved for your funeral, then £500 is not a great deal of money. I cannot understand why £500 has been set as the disregard when for other supplementary benefits the capital disregard is £3,000. It seems as if there is a tax on being cold. Moreover, I cannot understand—and I only hope someone in your Lordships' House can do so—the fearful meteorological complexities under which this calculation is worked out. And nor could the Minister of State in another place, for he said (and I quote from Hansard of January 15th, at col 168): Frankly, the exceptionallly severe weather payments regulation is a pretty weird and wonderful construction.

If the Minister says that, how is an old lady, shivering in the Cairngorms, supposed to understand it? How is she supposed to know anything about it? I therefore asked the Minister about this. He said that there were leaflets in the offices, but the last thing that an old lady with hypothermia can do is to find her way through the snow to the office to get the leaflet which tells her that she should have 2p more deducted from her electricity bills.

The system is so weird that recently when Kent was frozen stiff its meteorological readings had to come from Heathrow, and it did not qualify because it was warmer at Heathrow than it was in Kent. The following week Kent qualified although it was warmer, but Heathrow was colder. I hope that the noble Earl can tell us whether anybody told the good citizens of Kent that they could get the extra help one week but they could not the next.

I do not go to Scotland more often than I can help, but from the newspapers I understand that at Braemar the temperature was the lowest recorded this century. I still cannot understand this business of Centigrade, Fahrenheit and all that, but I am told that it was minus 23°1/2C—I hope that that is right—

Noble Lords

Fahrenheit!

Baroness Jeger

Whatever it is, my Lords, I am cold. Anyhow, it was very cold. It was the lowest temperature recorded this century. Caring as I do about my friends in Scotland, I put down a Question to ask what the Minister was doing for cold people in cold Scotland, having read that the temperature was the lowest this century. The noble Lord, Lord Glenarthur, in a Written Answer on 7th February, replied: I understand that on the basis of these criteria the Chief Adjudication Officer has not so far this winter advised local adjudication officers that the 'exceptionally severe weather' condition has been satisfied in any part of Scotland".

Lord Ross of Marnock

Where was he?

Baroness Jeger

My Lords, he is in the Middle East, so perhaps that is why he does not know how cold it is in Scotland. One of my noble Scottish friends told me that the problem is that in Scotland they take the temperature at Dyce. If Dyce is warmer than Braemar, Braemar has to freeze.

I know that it is easy to make fun of this muddle, but it is no fun for the very many people who during these severely cold times do not know how to get help or how to keep warm. I have heard leaks—if I may use that word today of all days—that because the Government are in such a muddle about this they are proposing to abolish extra heating allowances altogether, as that will save them doing their homework and finding out what the temperature is at Dyce or at Braemar. I very much hope that that is not the case.

I am sorry that there are so many aspects to deal with on the Motion, but I must quickly refer to the widespread anxiety about the new regulations regarding the right of people, especially young people, to move around the country looking for work. We understand that it is the Government's intention to reduce the time during which young people can go away from home and look for work. No one on this side of the House wants to condone cheating over supplementary benefits, but if the Government are to deal with such problems, they must do so constructively. They should ask why these young people are going away from home. We know that it is because there are no jobs where they live.

I am reminded of the Combination Act of 1664, I think it was, passed by the Cavalier Parliament of Charles II, which forbade people to move around and gave parishes the right to send people back whence they came. Many years later, Adam Smith wrote that that had not worked at all because during that period the population of the towns had increased and the countryside had become depopulated. I leave that thought with the noble Earl, and shall not quote any more examples.

Then we have the two-way racket. There is the Government's manic cutting of public expenditure in order to increase private expenditure—to put more and more old and sick people into nursing homes which are run for profit. Some are run very well but certainly not all of them are. I quote the case, because it has been in the press, where in Blackpool the Government, who are supposed to be cutting down and making people do without this and that, have been paying £50,000 a year for a private home to look after 17 old people. The conditions have been found to be so deplorable that the nursing home is to be deregistered. At the same time local authority homes for the elderly and disabled are looking forward to a cut next year of £44 million. We have to ask what the Government's priorities are. Is their priority to give money to the private business of running nursing homes or is it to enable non-profit making local authority homes to make their contribution and to do the work of community care?

I do not know whether any of your Lordships wants to go on a cold walk tonight around Waterloo Station or Charing Cross to see how many homeless people are sleeping in boxes, while local authority housing starts are being disastrously cut. I read in The Times that the Ministry is closing 23 units for the homeless. When I put down a Question recently to ask the noble Earl, Lord Avon, how many people were sleeping rough and what was going to be done about it, he said that he did not have any figures—so, without any figures, he closes 23 homes. I think that that ought to lie heavily on the social conscience of everybody here. Anybody who does not feel that should sleep in the street tonight to find out what it is like.

I shall close now because I know that many of my noble friends will talk much more intelligently about many of these problems. I do not want to go down as the Mrs Thatcher of the Labour party, but I want to say to your Lordships, without going into kitchen sink financial politics, that I am not bad as a housewife. I think that when a good housewife is looking after her old mother-in-law, she does not sneak into the bedroom to switch off the electric fire and keep the old lady cold. But this Government have reduced by thousands of pounds the heating allowance to old people under 85. When a good housewife sees that two tiles have been blown off the roof, she gets it mended before the rain comes in and the roof deteriorates; but not the Prime Minister. The Government cuts in improvement grants and resources for housing are only postponing many urgently needed infrastructure improvements. I shall not list them all, but I love sewers, bridges and roads. By postponing such things, we are leaving to the future a legacy of increasing expenditure, debt, decay and yet further expense, while the only item that the Government are prepared to provide increases for is unemployment.

There are many aspects of the problems which I have tried briefly to put before your Lordships. I am very glad that so many noble Lords have put down their names to speak today, because that shows the interest and concern that there is. I look forward to listening to as many of the speeches as possible. My Lords, I beg to move for Papers.

3.30 p.m.

The Earl of Caithness

My Lords, the Government very much welcome today's debate and I am grateful to the noble Baroness for introducing it and for her reference to my noble friend Lord Glenarthur. He is in the Middle East. He is not on holiday; he is working for the department. The debate provides an opportunity to set out clearly and unequivocally the Government's record and their policy on two priceless national assets: the National Health Service and the social security system. It is always pleasant to be able to tell a good story—and the story is good, despite much erroneous and, occasionally, wilfully misleading talk of cuts and attacks on the welfare state.

The Motion in the name of the noble Baroness speaks of public anxiety about our social services. The noble Baroness also referred to this in her speech and I shall return to some of the detailed points she made when, with the leave of the House, I reply to the debate. In my opening remarks I want to try to demonstrate that any such anxiety, if it does exist, is not founded. That is not to say that we do not face difficulties and challenges—of course we do; and it is the Government's approach to face up to them with realism and tackle them firmly without excluding possible solutions for purely dogmatic reasons. But our approach starts from a deep-seated commitment to maintenance and improvement of the social services. This is demonstrated by the record; and it is to the National Health Service's record that I now turn.

One sometimes hears quite misleading allegations in Parliament and the media that the health service has been somehow undermined since the present Government came into office. Nothing could, in fact, be further from the truth. On the contrary, the number of patients treated has risen; there has been a real growth in resources; hospital waiting lists have come down; and there have been major improvements in management and efficiency which have released resources for the care of patients. That is not the record of a service that has been undermined.

Let me, without wearying your Lordships with statistics, just add a little detail. Comparing 1978 with 1983—the last year for which figures are so far available—the number of in-patient cases treated per year in English hospitals rose by 650,000—a threefold increase on the previous five years; the number of out-patient attendances by 2½ million; and the number of day cases by a quarter of a million. New forms of diagnosis and treatment have been introduced or made more widely available. For example, over the same period, the number of coronary artery by-pass graft operations has more than doubled and treatment by laser has been introduced for certain eye conditions that were previously untreatable. Still in the hospital service, by March 1984 waiting lists had come down by 60,000 from the March 1979 total; and they would have fallen by much more had it not been for the industrial dispute in 1982, which pushed them up again.

Improvements in the level of service have not been limited to acute hospitals. In long-stay hospitals for the mentally ill and the elderly there were, over the same period, improvements in medical staffing levels; district nurse staffing increased; and the number of attendances by children under five at health clinics rose substantially. In the family practitioner services the numbers of family doctors and dentists rose by 12 per cent. and the average family doctor's list size fell by 9 per cent.

I could go on much longer with the list, but I think that I have said enough to make my point. I should add that the Government would not claim that the increased levels of service which I have indicated are the full story. We have also to be concerned with the quality of service. That, of course, is often more difficult to measure, but we have some indications. The improved staffing levels which I have mentioned imply a qualitative improvement, particularly where staff-patient ratios have improved; and the rate of perinatal mortality is dramatically down—by about a third between 1978 and 1983.

The improvements which I have outlined in the provision of services are, first and foremost, a tribute to the skill, dedication and hard work of the staff of the National Health Service. The numbers of health authority staff in England grew between 1978 and 1983 by 8.9 per cent. overall, with those directly involved in patient care increasing by 14 per cent. as compared with only 2 per cent. for staff providing support services. Again, this is hardly indicative of a service under attack; nor are the figures on expenditure. The efforts of staff have been backed by a real increase in spending on the service under this Government.

I totally agree with the noble Baroness, Lady Jeger—and she will be pleased to hear that on public expenditure the total NHS spending in England and Wales has more than doubled, from £6½ billion in 1978–79 to approaching £14 billion planned spending in this financial year. That represents an increase over and above inflation of 20 per cent. Moreover, the Government have just announced, in their recently published White Paper on public expenditure, that they will be spending over £600 million more on the NHS next year. These plans allow for health authority spending to increase by 1 per cent. above forecast inflation in each of the next three years.

The increases in spending to which I have referred have not been limited to current expenditure. The trend of falling capital investment which this Government inherited has been reversed. This year capital investment in the National Health Service is 23 per cent. higher in real terms than it was in 1978–79. The noble Baroness will again be pleased to hear this because it is reflected in the fact that in the five years from 1980 to 1985, 35 major new hospital developments were completed. There are about 140 hospital schemes of more than £2 million each, together costing over £1 billion and they are at present being planned, designed or constructed.

These figures demonstrate the Government's determination to maintain a health service capable of meeting the needs of the people of this country. But our determination does not stop there; nor can it. The health service faces some very stiff challenges ahead. The Government are quite open and realistic about this. In their public expenditure White Paper they described the main challenges as being: to meet the greater demands for services which will be related to the growing number of elderly people; to take full advantage of advances in medical technology; to combat social problems of alcohol and drug misuse; and to continue to improve community support for those who do not require continuing hospital care by strengthening primary care and community health and social services. We must renew our efforts to get, and to give, full value for money. People have the right to be assured that the money they pay in taxes and contributions is used to the best advantage". A good sentiment, my Lords, and one that I am sure we would all agree with. I am happy to use those words as they were used by the noble Lord, Lord Ennals, in 1976 in the department's annual report for that year. If the NHS is to rise to these challenges, as it must, it and the Government will have to be determined, resourceful and imaginative. We have not only to maintain present levels of funding, but also to ensure that the best possible value is obtained from the resources voted to the service by Parliament.

The concept of value for money, so well formulated by the noble Lord, applies to all areas of the health service. The Government have a duty to see that all areas of expenditure are examined to ensure that, while respecting the fundamental aims and character of the health service, maximum value for money is obtained. Those who do not accept this put dogma and vested interests above service to patients.

The Government's recent proposal to limit the range of drugs prescribable under the NHS for certain conditions is a case in point. The two groups of drugs concerned are, first, those prescribed for minor conditions such as coughs and colds and, secondly, tranquillisers and sedatives. In both cases many different brand name products with essentially similar properties exist. What the Government propose is that in these two groups only a limited range of drugs—having the same properties and meeting all clinical needs, but costing less—should be available on the NHS. If a patient still prefers a particular brand name, he will be able either to buy it over the counter from his chemist or, if it requires a prescription, to ask his doctor to prescribe it privately.

We have consulted widely on the detail of the proposal, in order to ensure that patients' needs are indeed properly provided for. There has been, I understand, much helpful and supportive comment from members of the medical profession, which makes the British Medical Association's refusal to take part in the consultation all the more regrettable. I hope that I have shown that there really is no cause for professional anxiety or justification for some of the irresponsibly alarmist comments that have been made. This proposal should achieve substantial savings without—and this is the essential point—affecting the treatment of NHS patients, as all clinical needs will be met.

That is just one example of action taken in pursuit of maximum value for money in the health service. More generally, of course, the Government have initiated a wide-ranging programme of action to improve the structure and management of the health service and ensure that it is run as effectively and efficiently as possible in the interests of patients. We have abolished an unnecessary health authority tier. We have introduced improved accountability procedures and tighter manpower planning and control. Better budgeting procedures are being developed, involving doctors more fully in decisions about the resources they use. Now, general managers are being appointed at each management level to have a clear personal responsibility for management performance without—and I stress this—impinging on doctors' clinical freedom or altering the need for a multi-disciplinary approach to management in the health service.

Within the Department of Health and Social Security the Government have appointed a leading industrialist to bring his experience and skills in management outside the NHS to bear on the task of improving the management performance of health authorities and of the department itself.

Each of these developments—and there are others—deserves a more detailed description, for which I do not have time today. Underlying all these developments, however, is the Government's determination to create a health service which is capable of achieving the best possible service to patients and of facing up, as I have said, to the major challenges which lie ahead.

An important aspect is improving quality of care in the community of, in particular, old people and people with mental illness or handicap. Of course, there will always be those for whom residential care is the right answer. But there is now general acceptance of the policy that, wherever possible and desirable, these groups of people should be supported, according to their individual needs, in their own homes or in small units in their own local community.

In recognition of this, domiciliary and day care services have grown, lengths of stay for acute treatment in hospital have shortened, and alternatives to long-stay hospital care have been developed. The Government have encouraged these trends through a variety of means. We have, for example, increased the amount of money which health authorities may use for joint schemes with local authorities; and we have broadened the scope of those schemes to housing and education. We are funding pilot projects to demonstrate alternatives to long-stay hospital care. We also need to "care for the carers" and recognise the effort which community care requires of families, neighbours and volunteers. To help such people, the Government last year set aside £10.5 million over three years in an initiative which they have called "Helping the Community to Care".

I should like now to turn to the part of the Motion which refers to social security. The noble Baroness raised a number of points about the social security review. Before I say anything about that review, I should like to make a few points about this Government's record in the field of social security. As my right honourable friend the Prime Minister wrote in her foreword to the manifesto at the last election: We have a duty to protect the most vulnerable members of our society". The facts show that we have honoured this commitment. Social security expenditure now amounts to nearly £40 billion a year—almost one-third of all public expenditure. Expenditure is about 28 per cent. higher in real terms than when we came to office.

Though much of this increase is due to increased numbers of pensioners, of unemployed, of one-parent families and of long-term sick and disabled, the Government have found an extra £2½ billion which has gone to increase the real value of benefits. The basic rate of retirement pension for a single person has been increased from £19.50 a week when we came to office to £35.80 a week from last November. This is an increase of 84 per cent. compared with an increase in prices of only 77 per cent. over the same period. Supplementary benefit rates have been increased by about 6 per cent. in real terms over the same period. We have extended the help for heating allowance from 70 per cent. to 90 per cent. of all supplementary pensioners and increased the amount paid by £140 million in real terms over 1978–79.

These facts show what the Government have done to protect those most in need in our society. But it is also the responsibility of the Government to see that public money is spent as wisely as possible. This means that it is necessary to look initially at how the huge resources devoted to social security are used and to consider alternatives. The system we have now has grown up piecemeal and the time is ripe for a major review.

That is why we have set up the biggest review of social security for 40 years. The review has been set up with the full involvement of people from outside Government. Individual members, chosen for their personal qualities and for the knowledge and experience that they could bring to this examination of social security, have been advising Ministers on aspects of the review. Nearly 4,500 pieces of written evidence have been received. Many of the organisations which gave evidence published it, and this has generated further public debate. Ministers have also held 19 public sessions at which outside organisations and individuals, representing all shades of opinion, have presented that evidence. This has given Ministers the opportunity to hear at first hand their views and to explore and develop ideas arising out of evidence. The independent housing benefit review has held a further 16 oral hearings. Finally, Ministers have visited a total of eight other countries to see what problems they are experiencing and what responses they are considering.

Taken together, these steps represent an unprecedented degree of seeking out and listening to outside views. That process is now complete and the Government will be publishing conclusions and proposals for change as soon as possible. I cannot anticipate what those conclusions will be, but I can tell the House something about the principles on which our strategy will be based.

The review of social security is not, as some noble Lords may seek to imply, an attempt to cut expenditure on social security. It is an attempt to ensure that the huge resources devoted to social security are directed at those most in need. Our record shows that we have protected the living standards of the poorest members of society and we will continue to do so. At the same time, we will be seeking to ensure that the social security system is as simple as possible—both for claimants to understand and for staff to operate. I am sure that noble Lords will agree that the current system is immensely complicated and that action to reduce that complexity is highly desirable. Finally, the Government's proposals will take full account of problems of incentives and the importance of encouraging individuals to help themselves wherever possible.

As well as reviewing the social security system, positive steps have been taken to improve the way it is administered. For example, for the past three years, DHSS local offices have given priority to improving service to the public and have made real improvements. A recently introduced Freefone service makes information more readily accessible. And the gradual introduction of payment automatically to banks has made payment more certain and has reduced costs.

The transfer of the responsibility for paying money for sickness absence from the state to employers has been so successful that the Government have now decided to consolidate the advantages of it by extending its cover from eight to 28 weeks. The ability of people now to claim supplementary benefit by post has improved service and has saved staff as well. Already, an extensive programme is under way to computerise the social security system. This will help staff to achieve their basic objective of paying the right money to the right people at the right time.

At this point, perhaps I may say a quick word to the noble Baroness about the heating allowance question that she raised. I shall deal with this matter in more detail when I sum up at the end of the debate. However, the noble Baroness mentioned Braemar, which has a special significance for me as I spent a happy childhood eight miles from there. I know that it is cold. I fully appreciate the problems of the people who live there.

The National Health Service and the social security system are vast and complex enterprises catering for vital aspects of the lives of the people of this country. There will always be points which are open to criticism; and this debate gives your Lordships the opportunity to raise points which concern you. But I hope that I have demonstrated that the Government are determined to ensure that the NHS and the social security system fulfil their roles as effectively and efficiently as possible and that there should continue to be no general cause for the sort of anxiety to which the Motion before us refers.

3.50 p.m.

Lord Winstanley

My Lords, it is a great pleasure to be able once again to support the noble Baroness, Lady Jeger. I have worked closely and harmoniously with her on matters such as this over very many years, and I am sure she knows that I fully support everything she has said in this debate. I shall concentrate my remarks on the first part of this Motion; namely, that which refers to: public and professional anxieties about the National Health Service". I share those anxieties, both as a member of the public and also as a member of one of the professions which, along with others, provides the National Health Service. My noble friend Lord Banks, who is an acknowledged expert on social security matters, will deal with the social security aspect of the Motion. In regard to the National Health Service, I shall deal in the main with domiciliary care, which means the general practitioner services, in which I had first-hand experience working as a general practitioner for some 30 or 40 years; and I am quite sure that my noble friend Lady Robson will deal more specifically with hospital matters, of which, as noble Lords know, she has had very great experience.

May I say at the outset that it is a pleasure, speaking from these Benches, to be able to agree wholeheartedly with the implication of a Motion emerging from the Official Opposition. Noble Lords on these Benches, with me, are committed to the abolition of so-called adversarial politics. That being so—I hope I can say this carefully, without causing offence to any of my noble friends—I sometimes regret the enthusiasm with which some of my noble friends search for points of disagreement with the Labour Party. I am bound to say at the same time that I sometimes regret there are at the moment in the Labour Party certain elements who perhaps make it rather difficult for us to work entirely co-operatively with them. But I am bound to say also that we do indeed agree on many matters. The National Health Service and social security is one of them, and when we agree on matters I do not think we should be afraid to say so.

This is not a plea for another Lib-Lab pact. I had an opportunity to play a very minor role in the Lib-Lab Government. I happen to believe it was remarkably successful. I know that noble Lords opposite will say it was successful only because the IMF said it had to be successful, but I nevertheless believe that it in fact worked. That is not on offer at the moment; that is not what we are discussing. But I think that in the present situation and in present circumstances it does no harm occasionally if those who are opposed to the present Government, wherever they may happen to sit, and in whichever House they may happen to sit, make it clear that they could in fact work closely together in the nation's interest should the need happen to arise, as possibly it might. We can perhaps start working together on this particular Motion in relation to the health service and social security.

There is no clearer sign, in my view, of public and professional anxiety about the National Health Service than the explosive growth of the private sector of medicine. On these Benches we have never believed that it was either possible or indeed desirable to try to abolish private medicine by statute. Indeed, we have always felt that the existence of a small private sector was very valuable as a monitor, as an indicator of the adequacy of the public provision. We felt that if there was a small private sector and the private sector started to grow, then of course that would be a sharp warning to us that we should start to look at what was wrong with the public provision. I think we take that lesson now, when we no longer have a small private sector; we have a very large private sector.

While I have said that the existence of a small private sector could be helpful as a monitor as to what was going on, I am bound to say that the growth of private medicine now seems to me to be reaching a stage at which it could in fact prove to be very damaging to the National Health Service, not solely because it takes away resources that ought to be in the National Health Service or that it it using doctors who were trained at public expense, as the noble Baroness said, but for another reason. If it takes away the most articulate and influential of patients then that in itself causes a decline in National Health Service provisions. It is precisely the same situation as we have had with education. When the most articulate and influential parents take their children away to private schools the standard of the state schools declines because of their doing so. We are in the same kind of situation now in relation to the National Health Service.

As I have said, I do not believe anything could be done about private medicine by statute or that any attempt ought to be made to do anything about it by statute. What we have to do is improve the state provision; that is, the National Health Service. If we do that then I do not think we need to worry too much about private medicine. In looking for an improvement in the National Health Service I do not really think that at this stage we can look to the Government. We have heard the speech of the noble Earl. I should not say the speech of the noble Earl, but rather the speech which was written for the noble Earl and which he read to us, admirably. It seemed to me to be complacent and emollient to an extreme extent. If we want the National Health Service to improve, one thing we must stop doing—I say this to all those, in all parties, who support the National Health Service—is denigrating it. I accept that the National Health Service has its difficulties: prescription charges; waiting lists for in-patient and out-patient treatment getting longer; certain elements of the service disappearing altogether, so that virtually we no longer have a free dental service. Under present systems the average person now pays the full cost of his dental treatment.

All right; the National Health Service does have its problems: but the fact is that what remains is certainly worth preserving, worth cherishing, and I do not think we do that by denigrating it. Nor do I think we do that by failing to use it. One of the things I regret is the extent to which general practitioners—I have been one in the National Health Service for more than 30 years—are now opting for private care for themselves and, indeed, for their families. Who can blame the patient who sees his GP going for private treatment, through this insurance scheme or the other, if he begins to feel, "Well, perhaps it is a better service"? I think that general practitioners who do not themselves use the National Health Service are in a sense conniving at the decline in the standards of the National Health Service. We should not denigrate the whole thing too much. Indeed, we should make a point of using it.

If we allow natural forces to operate—and we do—and we are not going to legislate to do away with private medicine, we really must stop telling people that the health service is a mess, that it is unsafe and that people cannot use it. By all means let us point to faults, as the noble Baroness, Lady Jeger, has done; indeed, we in your Lordships' House have a duty occasionally to draw attention to matters which need attention. But we have to be a little careful about the words we use when we are undertaking efforts of that kind because I think there is a general tendency nowadays for too many people, in the health service and outside it, actually to decry the National Health Service. By so doing, in a way they are conniving at its decline and perhaps accelerating its decline.

I have skipped over all the deficiencies. I do not think we need here and now to say too much about them in any detail, because it has been said so often (very often, perhaps even too often, by me) on other occasions. Let me go straight to another matter which I think could perhaps accelerate the growth in the private sector. That is a matter which we discussed in an interesting debate last week on an Unstarred Question put down by my noble friend Lord Kilmarnock: the so-called restricted list. I know we discussed this last week, and I know that the noble Earl who is to reply today sat throughout the whole of that debate. Indeed, he was the only noble Lord on that side who did so apart from the Minister, and he heard all that debate.

I raise it again for this reason. In the course of that debate I put a question, which I thought was an important question, to the noble Lord, Lord Glenarthur. I asked what kind of legislative procedure is going to be necessary to give effect to the department's present proposals. We were told that what we would have would be an order subject to the negative procedure. In other words, we are not going to get a second bite at the cherry, save perhaps a Prayer against an order. We know that we have a convention in your Lordships' House that we will not vote against a Prayer, so virtually we have lost control of a matter, a very unfortunate matter, which I think was condemned by every noble Lord who spoke. The most moving speech was from the noble Lord, Lord Porritt, who said he hoped he would not live long enough to see the day when the Government started to treat patients. They did not actually treat patients when the Minister of Health was a doctor; that is, in the old days of Dr. Elliot, the noble Baroness's husband. It is true, of course, that if the Government are going to say which patient should have what, and for what, that amounts to the Government treating patients.

We still do not know precisely where we are. Earlier today the noble Earl, in an Answer, hinted that agreement had been reached with regard to the lists. But where are we now? Are we to have two lists—a black list and a white list? Are we going to have other lists for special categories? The noble Baroness, Lady Darcy (de Knayth), made it completely clear that we need an extra list for paraplegic patients. We need all manner of lists if we are to cover every possible eventuality. But the point I am making now—and it is one which I think is very important—is that if there is a general impression throughout the community that certain things which patients feel they need and which their doctors have always said they need are no longer going to be available through the National Health Service, then that in a sense will be an inducement to more people to bypass the National Health Service and to have private medical treatment. That is why the proposal of the restricted list needs to be looked at with the greatest possible care.

At the risk of wearying your Lordships' House, let me say that ever since the health service began there has been a procedure by which to deal with wasteful and extravagant prescribing; namely, through the medical services sub-committees, and later if necessary through the Secretary of State. It is largely in the hands of the doctors. It is utterly clear that the doctors have failed to use that procedure effectively and they are, to that extent, to be blamed for what has now happened. Had they operated that machinery effectively throughout those years we could have saved millions and millions of pounds on drugs, and that money could have been saved without detriment to the patient and without doctors having to forfeit their clinical freedom in any objectionable manner.

Therefore, the machinery to control drugs really already exists. Why have we not used it in the past? I hope that the noble Earl will be able to tell us that at long last the department has reached agreement with the profession—agreement whereby cuts can be made in the drugs bill and certainly we can get rid of some unnecessary and obsolete drugs which are wasteful and which should not be prescribed by anyone, but agreement whereby we have a system which allows a doctor, at the end of the day, to prescribe what he genuinely believes is absolutely necessary for the medical care of an individual patient. We cannot have a separate restricted list for every patient; but the list has to be sufficiently widely drawn to cover every eventuality.

The noble Earl in his speech referred to two groups of drugs: those prescribed for minor maladies, and tranquillisers. Are we to understand that the restricted list—if we are to have a restricted list—will merely apply to those two groups of drugs, or will it apply to all? Will it affect antibiotics and other fields? Shall we only have the two groups? It really is a muddle, and surely the sooner it is cleared up the better for the National Health Service.

If there is widespread apprehension about the effects of this list, and if patients believe that somehow it will deny them what they feel they need under the National Health Service, then more and more patients will opt out of the National Health Service and will go for private treatment. I repeat that I think it would be entirely wrong—and indeed impossible—to try to outlaw private medical treatment by statute. But I believe that we should look at the spectacular growth of the private sector in recent years and see it as a symptom of some type of inadequacies in the health service and view that as a reason not for outlawing private medicine, but for rapidly improving the state provision.

I am most grateful to the noble Baroness for bringing forward this Motion, and I hope that perhaps the Government will do a little more to fund effectively the services which are so very valuable. But I hope above all that we in your Lordships' House can somehow tell people—patients, those who work in the service, those in politics, people with influence in any direction—"For goodness sake, stop denigrating the National Health Service! That is no way in which to preserve it". If we want to preserve the National Health Service, we should tell people that although it has had difficulties, what remains is very valuable indeed, and it is in fact the best publicly provided health service anywhere in the world.

4.5 p.m.

Lord Wells-Pestell

My Lords, I am glad that the noble Viscount the Leader of the House is present because I want to make—I hope nicely—a minor complaint. Before doing so I want to assure the noble Earl, Lord Caithness, that we are, and have been ever since he came to the House, very good friends and nothing that I am about to say is any reflection upon him at all.

However, I think that when we have a matter of this calibre for debate in this House and upon this particular subject, the Government Front Bench should ensure that the Minister responsible for that department in this House is present. I know that the Minister is abroad on service for the Government. But I also know that when we were first told that he would be away, we readily agreed to change the date of our debate and that was accepted by the other side. Having done that, it was suddenly discovered—presumably suddenly discovered—by the Government that television cameras would be in the House on that particular Wednesday—namely, last Wednesday. Therefore, we were told that we could not have our debate on that day. Had we been able to do so, then I assume that the noble Lord the Minister would have been able to attend.

As I have said, this has no reflection upon either the competence or the ability of the noble Earl who is dealing with the matter on behalf of the Government. However, a Minister knows from his long experience in the House as a Minister that he can sense what the House feels, and that he can get some personal impression of the importance of the matters raised. When a department has a Minister in this House then care should be taken to ensure that he is present when matters relating to his department come before the House.

I wish this afternoon to speak about what I think is the Government's attitude towards the National Health Service. I do not want to argue with the noble Earl who is acting for the Government in this matter by trying to answer a whole variety of points which he has raised. However, what is passing through my mind is this. It is not just a question of increasing the amount of money expended per year by 1 per cent., 2 per cent., or 3 per cent., in real terms; it is a question of whether the Government have any real idea of what is happening in the field of medicine as it affects people who need the services of the National Health Service.

I have felt for a good many years, and so have some of my friends, that the Government have not really understood the problem. I believe that good government means looking after the needs of the individual, particularly those individuals who are handicapped or disadvantaged in some way. If we look at what is happening in the community, we find that a vast number of people are now in need of help which they cannot get. There are still over 6 million people waiting to go into hospital for operations. That was disclosed in a report which was issued fairly recently. I believe that it is the responsibility of the Government to see that the needs of the people are met as soon as possible.

I think that history will record that the greatest achievement in the past 100 or so years has been the coming into being of the National Health Service. As noble Lords on both sides of the House will know, it is admired all over the world. I believe it to be the most magnificent achievement that has happened in our history. A Government which do not do all in their power to help the sick, the elderly and the disadvantaged are not really doing their job. We are told that we must have some regard for Victorian virtues, and I would not disagree with that. But, if I may say so, we have too many examples of Victorian misery and poverty in our midst today about which we are doing nothing whatever.

Reference has been made to benefit cuts. An article published in The Times on 8th February 1985 reported that social security savings from changes since 1979 amounted to £8,200 million. In addition, since 1982 another £3 billion has been saved by taxing some benefits. If that is true, about £11,000 million has been saved by reducing certain benefits and by the taxation of certain benefits. Why cannot a substantial amount of that money be used for the National Health Service? We have only to think of the oil revenues that this country has received, of the vast sums of money that we have received from privatisation and of the money that has come in over the last five years to realise that if a Government were really concerned with the welfare and wellbeing of the less privileged and those in need they would be able to take some of that money—and should be prepared to do so—to ensure that the National Health Service is improved not just by 1, 2 or 3 per cent. every year but by a substantial amount of money, which would allow a very quick reduction in the list of those waiting for medical help, and particularly in the list of those waiting to go into hospital.

About 25 benefits are worth less in real terms today than they were in 1979. That is a matter which, again, contributes to people finding themselves in such a low state of health, either physical or mental, which means that they require medical services.

Reference has also been made to the change in the drug situation. I wonder whether noble Lords really know what is happening as regards drugs in this country. In this House there are probably a number of noble Lords who, in one form or another, suffer from arthritis. There is a whole range of drugs on the market today to deal with arthritis. However, a drug that suits some people does not necessarily suit others. One person could take a drug and it would make not the slightest difference, but another person could take the same drug and receive considerable help from it.

It is not a question of saying that generically they are all the same. The fact remains that even generic drugs will improve some situations in some people and have no effect on others. The result is that we cannot simply say that we shall put certain drugs on one side because they are generic and keep other drugs on the other side, and that if people want them they can pay for them. If I may say so, there would be some of us in your Lordships' House who would be very hard-pressed financially if we had to pay for the drugs which we are at present receiving.

I really want to speak—and it will not be for more than a few more minutes—on the question of equipment for the disabled. I declare an interest because I am wearing a considerable amount of equipment which enables me to stand on both legs and which, at the moment, enables me to walk. But I am not the only Member in your Lordships' Chamber in that position. The Chronically Sick and Disabled Persons Act was designed to help support the disabled members of the community. In a survey published some time ago the Office of Population Censuses and Surveys estimated that there were over 3 million impaired people of the age of 16 and over living in private households in Great Britain. It estimated that 37 per cent. of them were so disabled that they had difficulty in using a lavatory, feeding themselves or getting in and out of bed; were certainly unable to have a bath or, for that matter, a good wash down; could not even dress themselves, and were in need of various aids to enable them to perform those functions.

In England there are more than 100 firms manufacturing over 3,000 items of equipment. Health authorities spend a great deal of money on equipment for the disabled, and it has been estimated that between them local authorities in Britain spend something like £70 million a year, of which over £11 million is spent on aids. Inquiries have been made into the usefulness of this expenditure, and, as my friends who are disabled know only too well, it has been found that many of these aids are not used, or are not fully used, because in point of fact they are not as helpful as they were made out to be. I simply want to say that a good deal of money is wasted on these aids.

This afternoon I want to raise one matter in relation to these aids, and here I must declare an interest. For a good many years the Nuffield Orthopaedic Hospital, of which I am a patient, has published a set of books bi-monthly. It costs something like £50,000 a year to publish these books, which are well known to disabled people and which are called Equipment for the Disabled. They are known throughout the length and breadth of England, and some of them find their way abroad.

These books are written by competent orthopaedic experts who can say what is needed in a certain situation when it comes to the use of aids. These books, which are published bi-monthly, are regularly brought up to date, so it is a continuous publication with a different book coming out every other month. As I say, the cost works out at about £50,000 a year, but I believe the amount that the books save in the course of a year to be phenomenal. I understand that this money is likely to be stopped in the not too distant future. I believe that the DHSS is at this present moment considering the matter.

I say to the Minister that I hope he will look into this matter. It may well be that he does not know of the discussion that is going on—and I do not say that at all unkindly. The books are of supreme importance not only to disabled people but also to those who are prescribing aids for the disabled; and what is more important, they are aids which have been tried and tested and which can be used with utmost satisfaction. I think that the books have already gone a long way towards saving a great deal of money in terms of useless expenditure on aids which are only partially effective or not effective at all. As I say, the books come from the Nuffield Orthopaedic Hospital.

When you think of the vast amount of money which is being spent every year by local authorities and others on aids and the number which turn out to be quite useless, the expenditure of £50,000, if I may say so, is infinitesimal. These books are of supreme importance to anybody who is trying to prescribe for disabled people. They cover the whole range of disability aids. I ask the Minister to look into this matter because it is important not only to disabled people but also to the community who, in the last analysis, have to pay for aids which can turn out to be useless.

4.22 p.m.

Baroness Masham of Ilton

My Lords, I should like to add my thanks to the noble Baroness, Lady Jeger. I agree with her about the effect of the cold on elderly and disabled people. I myself, being disabled, found your Lordships' Chamber rather cold and had to resort to my coat.

Our National Health Service is still the envy of many countries throughout the world, and there is now great sorrow that some countries cannot afford to send their medical students for training in this country; Mauritius being one such country. They now send their students to France or Egypt.

All is not gloom and doom. We have some splendid hospitals and some excellent, hardworking staff working in the National Health Service. Many new hospitals have been opened, as my noble kinsman said, but I must add that there have been some difficult decisions when useful, good hospitals have been closed because of lack of funds.

The need for physiotherapy as near to the community as possible is vital for the elderly and infirm, and this is one of the greatest worries when small, community-based hospitals have to close. These patients get totally confused and disorientated in large, impersonal hospitals. There are far greater waiting lists in some districts than there are in others. I should like to ask the Minister whether he thinks that the cross-boundary flow of patients is as good as it could be. Is one of the reasons for keeping waiting lists long in some districts to try to put pressure on patients so that they are encouraged to go privately?

Some patients do not mind travelling out of their district so long as they receive first-class treatment, especially the younger people who need to get back to work quickly. In some districts the problem has been a lack of surgeons to fill vacancies. In the North of England there has been, and still is, a lack of ear, nose and throat surgeons. If there were a few more senior registrar posts, would this not help?

What, my Lords, is wrong with the North? It is a very pleasant place to live in. Maybe there is not the scope for a lucrative private practice; but maybe it is something else. In one new unit for handicapped people in a new general hospital the unit has not been able to open because of lack of nursing staff—not for lack of money. Sometimes people do not want to move to where the jobs are.

There is continued anxiety by the public and professionals about the number of salmonella poisoning cases in some of our hospitals. Are we as hygienically conscious as we should be, and are our hospitals as clean as they might be? Having visited some hospitals in different countries, I should not think that we rated very highly in the top of the cleanliness stakes. I think that health and hygiene is a subject which should be taught in all our schools. Could it not, at least, be introduced in some of the youth training schemes? Have we given enough thought to this in years past?

I also feel that in many of the older hospitals throughout the country technicians who are having to carry out careful and detailed investigations are working behind the scenes in some very inadequate pathology departments. This work is a vitally important part of the National Health Service.

I have had a worry and if I mention it today, it will help to get it off my chest. I have been told—and I have read recently in the Nursing Times—that some staff working with severely physically disabled patients have not always been as kind as they could have been. If you are totally paralysed from the neck down and are dependent for everything until you start using aids, you can be very vulnerable.

I quote what was written about a spinal unit, and I shall send the article to the Minister: With a shortage of nurses, orderlies often worked under insufficient supervision, where they could pass on incorrect information or mishandle a patient. Several times I suffered from both"— writes an ex-patient— even from cruelty. Complaining took courage, mild retribution could follow—difficult to take when you are so helpless". Had I had not heard that from other sources, I should not be so worried.

Staff working with very disabled patients need to have an extra amount of support from seniors, and all staff themselves need support and counselling. There should be more time available and there should be more skills in a counselling service for both patients and staff in units which involve such a high pressure of work and emotion. Staff need to know how to talk to patients.

There is concern from many people about adequate care in the community for those who are very elderly or very disabled. The Crossroads Care Attendant Scheme and similar schemes do a great deal to support severely disabled people who have various disabilities and illnesses, and they help them to continue living in their own homes, which everybody wants to do as long as possible.

There are committees in many places, such as Bradford, trying to get the schemes going. The only problem is getting funds to run these schemes. They must be cost-effective as much of the administration is done by volunteers, and the attendants who get people up and put them to bed are not paid as much as nurses. If care in the community for many groups of people is going to work, then it must be well organised and the help must be forthcoming. Trained nurses are better used for tending the sick and the patients who need injections and dressings and nursing procedures.

Good primary care is as important now as it has ever been, and with such need for good community care, which involves family doctors, I ask the Government to look very closely at the great anxieties caused in rural GP practices by the discrimination against doctors' wives working in the practice and not being reimbursed as are other members of staff. A doctor can employ his mistress and be reimbursed if she works as a practice receptionist, but not his wife. In 1980 I moved an amendment in your Lordships' House over this matter to which your Lordships agreed and it is now waiting to be implemented in Section 7 of the Health Services Act 1980. I have received many letters from general practitioners in various parts of rural Britain over this matter. In fact, I am still awaiting an answer from the DHSS over it as I wrote to the Minister, the noble Lord, Lord Glenarthur, some time ago. The doctors' wives have now formed an association called, "The Campaign for Parity with Unrelated Ancillary Staff". The noble Lord, Lord Winstanley, has a Question down on the Order Paper for the 19th February and I hear that this problem is due for another review this March. The noble Lord and myself were planning an Unstarred Question debate on this matter but perhaps this will not be necessary if the Government will realise the problem. We are asking for this fairness to wives for the rural practices only, and the Government should allow this only if the wives are qualified to do the ancillary work.

When your Lordships recently had a short debate on the problems of controlled drug misuse there was not enough time in five minutes (which was the restricted time allowed) to bring to the notice of your Lordships a few of the anxieties of the current drug problem in respect to the National Health Service. There is, and has been for the past two years, as most people know, an alarming increase in heroin and cocaine. Last week, the World Health Organisation announced that the cocaine epidemic in America is creating a serious public health problem, as are the mixture of drugs and alcohol, amphetamines, barbiturates, sedatives and tranquillisers. The World Health Organisation recommends, as the problem has spread to many countries including Britain, that all countries should be training health workers in prevention, treatment and management of drug dependence and that there should be increased international monitoring of the drug problem.

I also feel that AIDS (Acquired Immune Deficiency Syndrome) should be monitored both internationally and nationally in the countries which have cases. There should be a clear policy of procedure so that all people who come into contact with a case know what to do. This is a world problem and the development of the disease should be kept under strict scrutiny; and the changes of the virus, if it happens, should be passed on to all who need to know.

A few years ago I had to stay at my home one of the most delightful young men I have had the pleasure of meeting. He was a very helpful and polite person. He was a haemophiliac and with him he bought little bottles (which, I suppose, contained Factor VIII) which resided in our fridge. This is their lifeline. The Haemophiliac Society have just brought out a book called, AIDS and the Blood, a Practical Guide. This seems a useful and helpful book. The Society are worried over some aspects of the increased workload associated with AIDS as they are a high-risk group and they need to know that there will be adequate staffing at haemophilia treatment centres during the present crisis to deal with the treatment and counselling.

The National Blood Transfusion Service has estimated that the United Kingdom will be self-sufficient in heat-treated Factor VIII by 1986. Since this requires a rise in excess of 200 per cent. in the amount of plasma supplied to BPL at Elstree, could the Government explain how this will be achieved? There is concern over some aspects of the varying product licences in respect of imported heat-treated Factor VIII. I hope that the Government will be able to give some assurances tonight over this important matter.

Another at-risk group concerning AIDS and Hepatitis B are the drug addicts. The parents of young drug addicts can be desperate. The first people they may try to get help from are their general practitioners. All GPs ought to know what advice to give and where to send the patients for treatment. These can be very sick young people, suffering many side effects. To get no sympathetic help from the doctor can make the family feel like outcasts. As your Lordships can imagine, these can be very unpopular patients. In an article in last week's Nursing Mirror, a community psychiatric nurse from the Wirral, Merseyside, writes: It is essential for health workers dealing with heroin abuse to be aware of what is happening at street level in their communities". I hope that the Government will put out guidelines to all health authorities throughout the country so that there are adequate training facilities and so that all regions and districts have a centre point for advice and monitoring of activities. It is vital that correct information is passed on to all those who need it.

As this debate includes the changes in the social security system, I should like to bring up what I consider to be an important matter. If my noble kinsman the Minister cannot answer it tonight, I should be grateful for a letter. It has been announced that young people between the ages of 16 and 17 will not get supplementary benefit but will have the choice of working, if they can find a job, continuing in education or joining a Government training scheme. I agree with this so far, but will the Government include one more choice? This is that if some of this age group are addicted to drugs and need treatment and rehabilitation, they can go to a treatment centre with special funds allocated for this purpose—otherwise, what is going to happen to them? At the moment local authorities and the social security system pay for some to get treatment if they do not go privately. If they are taken out of the social security system, what is going to happen?

This could be a very serious problem. Their families are sometimes so desperate that, for many reasons, they turn them out of home. The only solution will be to turn to crime to survive or die in the streets. As one who has had her car broken into by a drug addict, I have sympathy with the victims of these crimes. I also know how important treatment centres are for these desperate, sick addicts. I hope that this problem will not be covered up under a mound of bureaucratic paper. Sadly, I know that this problem is not going to go away in the immediate future.

There are many changing needs facing the National Health Service. A balance has to be kept and the problems have to be dealt with. The Eczema Association is worried over the fact that some skin products containing 1 per cent. hydro-cortisone will be sold over the counter this year. This, used unnecessarily, can cause skin problems. Will the Government see that warnings and correct instructions are given, remembering that many people will not be able to read English? If these products are used by the very young and by those with no previous history of skin disease, they can be extremely dangerous.

I end by saying that there is a worry about young people who are at risk from cervical cancer. Maybe this is one more problem of a promiscuous society, because there is an age limit, limiting the payment for cervical smearing to those above 35. Preventive medicine is an important part of the National Health Service, as it helps to avoid long-term disaster.

4.41 p.m.

Baroness Cox

My Lords, I join other Members of your Lordships' House in congratulating the noble Baroness, Lady Jeger, on initiating this debate, which raises so many issues of human concern and professional responsibility. I must at the outset reluctantly offer my sincere apologies because I have to leave your Lordships' House shortly before seven o'clock for a very long-standing commitment. I deeply regret that I will probably be unable to hear the latter stages of the debate, and I apologise especially to the noble Baroness, Lady Jeger, and my noble friend Lord Caithness; but I shall naturally read Hansard with special interest in the morning to familiarise myself with the contributions that I shall have missed.

The Motion before us encompasses a vast array of questions of consideration but I will limit myself to a contribution on only one issue: the policy of community care and its implications for those who are discharged from institutions into the community and for those who have the responsibility for their care. As your Lordships are aware, the policy of discharging as many patients as possible from institutions into the community affects people with a wide range of conditions, including the elderly, the mentally and physically handicapped and those suffering from psychiatric illness.

There were two major influences in the development of the policy of community care. One was the cost of maintaining large institutions; the other was research by many social scientists, who highlighted the problems of institutionalisation for long-stay patients. Many studies portray disturbing features of long-stay patients suffering from psychological dependency, diminished personal initiative and a loss of contact with the outside world, resulting in an impoverished quality of life.

Those problems have been generally acknowledged and reflected in the attempt to ameliorate them by returning as many patients as possible to the community. However, there is an obvious risk that such patients, who are inevitably vulnerable, may suffer social isolation or physical neglect unless adequate care can be provided in the community. It is therefore surprising and disturbing that there seems to be a lack of comparable research to ascertain the results of this policy of community care and to find out in a systematic way what is happening to those who are discharged from the protective environment of an institution into the relative independence of the outside world.

In my brief contribution to this debate, I wish to speak wearing my nursing hat (or perhaps I should say my starched cap) and to raise the question of community care with particular reference to the elderly. It is well known that the numbers of people surviving to old age have increased dramatically over recent decades as a result of general improvements in the standard of living, together with advances in medical science and health care. The proportion of the population over retirement age has increased from 6 per cent. at the turn of the century to over 17 per cent. now, and the proportion of those aged 75 and over has increased four-fold. This latter group—the elderly elderly—are the source of the greatest concern to the social services as they are more likely to be frail and infirm, and the numbers of these elderly elderly are likely to increase by about 20 per cent. between now and the end of the century. And within this group a high proportion are likely to be widowed or single.

Such trends pose three kinds of potential problem: for the elderly themselves, for their families and neighbours and for the professionals in the health and welfare services. Research undertaken in the 1960s and 1970s showed that most elderly people who had families were likely to receive some help and support. However, those without spouses or children were very vulnerable to social isolation and to neglect in times of illness. Moreover, the availability of help and support by families may bring its own problems. For example, one study found that two-thirds of patients admitted to a geriatric unit had to come into hospital because of a lack of basic care at home or because of excessive strain on relatives. That strain was often caused by tensions arising from having living in the same house an elderly person who was suffering from problems such as incontinence, immobility or confusion. The stress was frequently so severe that it threatened the physical or mental wellbeing of the families.

This raises an important point. Great care needs to be taken to ensure that the policy of community care, however admirable its intentions, does not result in intolerable pressure on relatives or in the inadvertent exploitation of neighbours. Many families and neighbours are able to accept this responsibility willingly and, indeed, they would not wish anything different. However, for others it may cause serious problems, both personal and financial; and it is most likely to be women who suffer, as the expectation to care generally falls on them.

It is therefore important to ensure that the hidden expenses of community care, both financial and psychological, are not carried by female relatives and neighbours at too great a personal cost. This is particularly likely to happen where the provision of back-up health and social services is inadequate or patchy. What happens, for example, to an elderly person who relies on Meals on Wheels for his or her main hot meal of the day when Meals on Wheels are not provided at weekends? In some cases, where school kitchens are used for the preparation of Meals on Wheels, the meals may not be provided throughout the entire school holidays.

Recently, I visited an elderly person in our neighbourhood. His first words, when he saw me, were: "You are the first person I have spoken to for five days." There was an elderly lady living nearby who was confined to her home, where she lived alone. When asked how she spent her time, she replied: "I just lie here on my own all day until it is time to go to bed."

Reference to those two brief personal encounters just serves to emphasise the urgency of the need for a very careful appraisal of the results of the policy of community care. My colleagues in the nursing profession appreciate that the Government have acknowledged the resource implications of their policy but the question must still be asked: are adequate resources available and are they being used effectively to ensure an appropriate quality of life for those who are discharged from institutions which do at least provide some warmth, shelter and companionship? It is crucial to examine the extent to which such personal and professional resources are co-ordinated to ensure a comprehensive and fail-safe network of care. In this context, the nursing profession is particularly concerned to promote greater co-operation between the health care and the social service professionals and to ensure the rationalisation of resources and a more systematic provision of health and welfare care.

A final point, my Lords: to the extent that the social services must bear a growing responsibility for the care of those discharged from institutions, it is essential that the training of social workers equips them for these responsibilities. I was concerned when, some time ago, I was sent the proposals for a course which would give both a social science degree (awarded by the Council for National Academic Awards) and a qualification to practise as a social worker. The content of the proposed course seemed to me to be grossly deficient in the coverage of precisely those subjects most needed for those who are going to be looking after people affected by the policy of community care. Most of that course was academically oriented, but the topic of mental illness was covered in a single paragraph, half of which represented a critique of the medical model of mental illness. There was very little on the care of the mentally handicapped or the care of the dying. It may be that these proposals were subsequently changed—I sincerely hope so—but it is worrying that they should even have been conceived in that way, given the fact that the social services are to carry such a large burden of responsibility for the implementation of community care.

So, in conclusion, may I ask my noble friend Lord Caithness what the Government are doing to monitor the results of this policy of community care which they have embraced so wholeheartedly? Can he offer some reassurance that research is under way to ensure that this policy—albeit humane in intention—is not proving disastrous in its effects on those who are inevitably vulnerable: the frail and infirm, the disabled, and those suffering from mental illness or handicap?

It has been said that a society is judged by the care which it takes of its weakest members. The inception of the National Health Service marked a breakthrough in the provision of such care. I am therefore looking forward to hearing from my noble friend what steps the Government are taking to monitor this policy of community care, to ensure that it is resulting in appropriate provision for those who are dependent, vulnerable and at such risk of loneliness and neglect. Their well-being is the yardstick by which the policy, and indeed the Government, must be judged.

4.52 p.m.

Baroness Vickers

My Lords, I am very grateful to the noble Baroness, Lady Jeger, for two reasons: first, for having initiated this debate—we have learned a great deal more about the services concerned—and, secondly, for the work that she did for the Elizabeth Garrett Anderson hospital. That was a very great gem in her crown. It was going to be closed and I remember the work that she did, the money which the Government kindly gave, and also the work of the voluntary workers, which was immense. We now have a serviceable and charming hospital, which is giving great pleasure and doing splendid work.

I can remember the days when there was no National Health Service, as can many people in this Chamber. I recall taking my children's training in the Macmillan Hospital, which was a very small hospital for children under five. In those days, we had to go to an old public house when the children had their tonsils out. Mattresses were laid along the floor, the doctor came along and did his job and went away, and if any children were not fit to go home I had to push them back to the hospital in a large pram, sometimes five at a time. I shall never forget those days, but the Macmillan Hospital was a wonderful hospital for that area of Notting Hill. Then I went to the London County Council and for eight years was on the hospital committee, so I know how marvellous the hospitals proved over the years.

I should now like to come to the present time and to discuss something really modern. I should like to say something about a subject which is of great importance; that is, organs for transplantation. My noble friend Lord Caithness referred in his very eloquent speech to the need for the health service to face up to the challenges of the future. One of the challenges we have to face up to is making available to those in need the new techniques of treatment as they are developed. This is more easily said than done, because it requires specially trained staff and facilities to be made available, and there are of course many other urgent areas for action, too. However, I think that making available new techniques as they are developed is of particular importance. It is very hard for patients and their families to hear of medical advances through the media and then to find that they are not easily available.

Organ transplantation is, of course, a new technique. The progress made in recent years in this field is generally heartening. Of course, there are difficulties. The availability of organs for transplantation has been one of these. The situation has eased considerably in the last year. Since the Government launched their campaign in February last year to increase public awareness of the benefits of organ transplantation and to promote the donor card scheme, I believe that more than 11 million additional donor cards have been distributed, together with many hundreds of thousands of leaflets, posters and car stickers.

I understand that, as a result, during the first nine months of the campaign about 35 per cent. more kidney transplants were performed in the United Kingdom than in the equivalent period in the previous year. This is a very encouraging result. There are still many patients waiting for a kidney transplant and I hope that the Government do not need urging to ensure that the momentum of the organ donation campaign is maintained and to consider, if necessary, what new initiatives will be called for.

Organ transplantation is not limited to kidneys. Heart transplantation has long been the very epitome of modern high technology medical care. It is encouraging that this country has been able to play an important part in developing this technique, and I welcome the additional funds which the Government have made available this year to the two centres in this country which carry out heart transplants; that is, Papworth Hospital in Cambridge and Harefield Hospital in Uxbridge.

Also, there are liver transplants. It is, I think, now generally agreed that liver transplantation is a lifesaving procedure and the success of last year's organ donor campaign has meant that the availability of donor livers is much less of a problem than it has been in the past. Of course, there are difficulties when you get a patient who is very young; and unfortunately we recently had the death of a very young baby. But the Government have acted with commendable commitment to the development of this important new service, and I welcome the sum of almost £900,000 of additional central funding which has been provided to help finance services at Cambridge, in London at King's College Hospital, and at the Royal Free Hospital in Birmingham.

I should like to support what the noble Baroness, Lady Cox, has said about community care. I went back to my old constituency the other day and found that many old houses had been turned into what they call community care houses. Unfortunately, these multiply in many areas, but they are not being supervised as they should be. In fact, a lot of them are not even registered. I should like to suggest that the Minister might consider asking the Women's Royal Voluntary Service whether they could casually call in from time to time, cast their eyes around and see whether they think that all is well. After all, they are going around these areas with Meals on Wheels and for other reasons, and I should have thought they could make a friendly call and report to the medical officer, or whoever is in charge, and see whether we can get a better guardianship for these homes.

My other point is on the question of blood transfusion. I took over from the noble Lord, Lord Amulree, the chairmanship of the Greater London Red Cross blood transfusion service and I do not think that we are being adequately used. We are always hearing appeals on the radio and so on about blood transfusions, but we do not get enough calls, although we have an office which is kept open night and day. I should like to suggest to my noble friend that there might be a change in the way that this is funded. At the present time hospitals have to get the patients through us. They then have to deal with the charges, which means several letters, and we have to get the payments and so on. I think that a lot of them do not want to be bothered, when they can get untested blood donors from off the streets after a call is put out.

A change could be a way of saving money. In other words, if the Minister would give a grant—not more than we can show has been paid in past years—this would stop any need for the hospital doing the accounts. I am sure that we would then get many more people in because I think fear of having to deal with these regulations stops hospitals from calling on our services which are available.

I understand that the Minister has sent out a letter to all hospitals with regard to AIDS. I was very grateful that he let me have copies of this. We have sent it to all our donors. We hope that we shall get replies and we hope that they will again, if necessary, be tested. I should very much like to see AIDS made a notifiable disease as that would really bring it to the attention of everybody in this country. I hope very much that we can get rid of this disease more quickly than we appear to be doing at the moment.

I should like to raise one point which was mentioned by the noble Baroness. It concerns the people under Charing Cross Bridge and others. I have time and again spoken to those people and have sometimes found them somewhere to go, especially before the old Charing Cross Hospital was taken over by the police. I have been most unsuccessful in getting them to go. I have seen one woman I do not know how many times. She says, "I am quite happy here, dear. It's nice seeing the public". I say, "What, on a rainy day or on a cold day?" We have to leave some of them there whether we like it or not. I think it is so bad for the general public and for foreigners to see people lying there. But it is to no avail so far as I am concerned, and I have tried many times during the war and since the war. But I am glad that the noble Baroness brought the question up again, because it is a matter on which we could perhaps have a general drive to get these people into a better state.

I should like now to return to transplant organs. When the right honourable Enoch Powell brought in the Bill dealing with eye transplants—cornea transplants—I immediately signed up. Now I have put in my will that I wish my body to go to a hospital. I think it might be rather interesting, considering the number of falls I have had, to see how well I am joined up! The hospitals are short of organs for students to practise on. I would far rather they were used in that way. My body has fortunately been very useful to me in life, and I should like to be very useful when I am dead.

5.2 p.m.

Lord Stallard

My Lords, I too would like to join in the congratulations to my noble friend Lady Jeger for giving us this opportunity to discuss these important health, welfare and social services questions, and to congratulate her on her opening remarks. The Motion before us refers to, changes in the social security system which affect the well-being of increasing numbers of people", and it refers to "anxieties". I want to talk about two such changes and to express some anxieties. The first relates to the housing benefits scheme; and the second relates to the proposed changes in board and lodging charges.

First, I should like to mention the housing benefits scheme. This scheme was introduced about two and a half years ago because the existing separate schemes were failing to provide the assistance necessary to those who really needed it. There were two main schemes. One was operated by the DHSS for people on supplementary benefit; and the other scheme, for low income households, was operated by the local authorities—the rent and rates rebates scheme.

Both schemes were means tested and these tests were different for both schemes. They also had different eligibility criteria. In the words of the chairman of the Supplementary Benefits Commission at the time, in 1979, they were varied, complex and confusing". That was a gross understatement in the view of many people. They were so confusing in fact that households with similar incomes, similar requirements and similar housing costs were getting different benefits. Different amounts of housing benefits were given to people in those circumstances. This was clearly unjust.

In addition, there were people not in full-time employment, including many pensioners, who were eligible to claim either benefit although not both. They could claim either but only if they could work out the very complicated calculations that would enable them to make such a choice. This aspect became known as the "better off" problem.

It is not surprising that thousands of poor people were unable to sort out which benefit to claim; so much so that in 1979, according to the Supplementary Benefits Commission, there were 400,000 claimants who had made the wrong choice. They were getting the wrong benefit because they could not do the calculations. The whole confusing scene has been researched and published in an excellent research report by Peter Kemp, produced by SHAC, and called The Cost of Chaos. I commend it to noble Lords as extremely interesting reading.

Demands for reform of that confusing system grew. There was a great clamour for change; evidence was produced by all and sundry until it could no longer be ignored. The Government proposed a new scheme outlined in a consultative document in March 1981. That is the housing benefits scheme which I have already mentioned.

The Government also decided that, in line with all reforms in benefits that have taken place since the Social Security Acts of 1980 and onwards, any reform should be introduced at no extra cost to the Exchequer—a nil cost constraint was imposed on all of those reforms. As Age Concern pointed out in their submission to the review body: Change took place because the need for limited reform had become inescapable, and this was seen as presenting an opportunity to effect savings in benefits and to reduce the numbers of administrators in government departments". It has always been my experience that changes introduced for the wrong reasons—those were the wrong reasons—are doomed from the start. When the housing benefits scheme was introduced it soon became obvious that it would not solve the problems with which the original idea of a unified housing benefit was meant to deal—in other words, the problems of complexity, the "better off" problem, and the take-up problem would not be solved.

The scheme was even more complicated than those it had replaced. It was difficult for administrators to operate and incomprehensible to tenants. The DHSS itself issued circular after circular. In fact, it issued 11 circulars in the first year of operation, and numerous amending regulations were issued which only made matters worse. Local authorities were unable to cope with the backlog of cases that soon mounted up. Errors in assessments became the norm and meant that tenants who had never owed a penny rent throughout their whole lives were suddenly plunged into arrears, with threats of eviction, and actual eviction in many cases, and great distress of course to all involved.

Advice bureaux, Members of Parliament, councillors and other advisers were inundated—and have been inundated ever since—with requests for assistance from worried tenants and residents. Voluntary organisations working in the field—the list is long; I shall not weary the House with the full list—reported an outline of the problems as they saw them and called again for further review. The Times had called the scheme, "a bungled reform", and later it called it, the biggest administrative fiasco in the history of the welfare state". So there is almost universal agreement that the housing benefits scheme is a disastrous failure.

Since its introduction the Government have cut benefits on a massive scale. SHAC, the organisation I mentioned a few moments ago, has calculated that more than 2.5 million households lost financially when the scheme was introduced in April 1983. A further 2 million households lost benefit in April 1984 as a result of cuts imposed in the Chancellor's 1983 Autumn Statement. In November 1984 a further 1 million households suffered losses again. In many cases, the same household has lost benefit on all three occasions. Cumulatively it is not uncommon for households to have lost as much as £10 a week or more.

The Government's cheeseparing has resulted in a scheme which fails to meet its objectives, and ironically has led to a massive increase in expenditure on administration but not on benefits. The latest Government White Paper on expenditure shows that the cost of administration of housing benefits by local authorities has risen from £45 million in 1981–82, immediately before the introduction of the scheme, to an estimated £177 million now—260 per cent. in three years.

I am indebted again to another booklet produced by the Housing Centre Trust with a foreword by David Donnison. It brings together all the evidence submitted to the reviews. I quote a couple of sentences only from one which is fairly typical. Speaking about housing benefit the submission from the Policy Studies Institute states: But a reform which appeared to have been motivated almost entirely by administrative considerations, quite independent of the major policy issues in the field, hardly deserved to succeed. This was not a comprehensive housing benefit, it was two old and incompatible benefits tied together with red tape. There is much irony in the outcome, since the most noticeable failure of the new benefit lies precisely in its administration. This will fail to amuse those claimants who got caught up in the tangle. For them, housing benefit is one more fetter in their bondage to bureaucracy". Those few sentences are typical of a great many submissions made to the current review.

I ask the Minister who is to reply, in view of all that evidence and all those submissions—and I assume he has read them—whether he can assure the House that there will be no more cuts in benefits until Parliament has debated the outcome of the current review. Can he assure us that there will be no more short-term changes and amendments to the scheme until after the outcome of the review has been accepted? I ask this because I have had a Motion on the Order Paper for many months now asking for a debate on the housing benefits scheme alone. No doubt the House will probably debate the outcome of the review in due course. I hope that I will be able to participate and develop my arguments for an end to the short-term cost-cutting exercises and the introduction of a long-term solution to the problems of housing support for low income families whether or not they are working and in whatever accommodation they reside.

That brings me to my second point: the proposed changes to the regulations governing supplementary payments to people living in board and lodging accommodation, such as hostels, lodging houses and bed-and-breakfast hotels. This is another change introduced in haste, almost in panic, the major element of which is the now familiar cost-cutting exercise. Far from curing the problems which undoubtedly exist the proposal could even worsen an already grim situation. Again, I need only one quote, from many, to illustrate what is being felt in the organisations most closely involved with the problem: The Birmingham Standing Conference is very worried by the proposals for changes in supplementary benefit board and lodging payments. It feels that these changes would lead to a great increase in the number of people in Birmingham forced to sleep rough and would lead to the rapid collapse of hostel provision in Birmingham". That is being repeated by Glasgow, Edinburgh, Newcastle, Manchester, Warwick and Portsmouth. The list is almost nationwide. Again, I hope that the noble Earl will be able to make some comment on that.

The proposals have already provoked a storm of protest from an extremely wide range of statutory, professional and voluntary organisations. The Social Security Advisory Committee has received an unprecedented volume of 500 protests on this issue—500 submissions—which is more than four times as many as on any previous issue. The proposals were announced in both Houses of Parliament and time prevents me from going into the details of those proposals; I would rather spend my few remaining minutes examining the Government's reasons for the proposals and to suggest, I hope, some constructive alternatives.

The Government said, first, "We must halt the growth of expenditure in this area". Nobody quarrels with that. However, between 1979 and 1984 government spending on supplementary benefits to claimants for board and lodging rose from £52 million to £380 million. But they did not give the reasons and those reasons are clear to all those people working in the field. First, there is the normal inflationary increases, which take a fair chunk. Secondly, there was a one-off exercise in 1982–83 where the Government had to concede that the existing payments were so abysmally low that they had to have a fairly substantial increase to bring them up to anything like the current rate. As I say, that accounted for a big chunk of this increased expenditure.

The third reason, of course, is the huge increase in claimants. They have increased from 50,000 in 1979 to 184,000 in 1984. The Government must accept some responsibility for that increase due to higher unemployment, the restrictions on furniture grants and increases in non-dependant deductions for housing benefits, the lack of any alternative low rented accommodation (mentioned by my noble friend in opening the debate), the restrictions on local authorities to provide such accommodation, the shortage of what we called "digs" or "lodgings", which have virtually disappeared because of redevelopment and the lack of purpose-built accommodation to replace them, and the closure of large hostels and the refurbishment of others resulting in a loss of beds. This is happening all over London at a time when we can ill afford it. There is a loss of hundreds of beds which are urgently needed at the moment. All these factors have contributed to that increase in the population demanding that service. Therefore, we must look at those factors if we are to understand this rise in expenditure and not simply shout in horror that too much is being spent and that it must be cut. We must find the reasons and we will then find that in fact not enough is being spent.

I contend that more investment in publicly-owned rented accommodation would be a far better use of resources than payments for board and lodging. The Government's own report a few years ago on the single homeless pointed out that the majority of people in that category would far rather be in their own homes, in a flat or a flatlet or in shared accommodation, than in the kind of hovels to which they have been subjected.

The Government then said, "We must prevent people from taking holidays by the seaside on benefits", as if that was a huge scandal and they had to have this big change. None of us condone the fraudulent practices that Ministers have mentioned, but we ought to be clear that there are already regulations to prevent this. Requirement Regulation No. 9, paragraph 14(b), provides that a person, who is in the opinion of the benefit officer on holiday and during a period which has not yet continued for more than 13 weeks is absent from the home … shall not be paid benefit at the boarder rates". If that regulation is not functioning then it should be amended. We do not need these huge cuts and alternatives in order to take care of simple administrative amendments like that. That could have been amended to take care of that alleged scandal.

The Government then said, "We must encourage young people to stay in their parents' homes". Again, all the evidence from the agencies working with young people points to the fact that most young homeless people do not have the option of returning home. Again I quote from a couple of examples because it is helpful to have some standards. The Short Stay Young Homeless Project, which made a submission to the review, stated: The basic premise of the Consultative Document would appear to be that the vast majority of young people living at present as boarders in hostels or hotels could, if they only so desired, pack their bags and return to the welcoming fireside of a family home … It is precisely because our residents' family support networks (if they ever existed) have completely broken down that they come to our hostel in the first place … A recent survey of the present hostel residents bears this out: 50 per cent. were 19 or under. Sixty-eight per cent. have been told by parent or step-parent that they couldn't go back home, 8 per cent. had left home after the death of a single parent, and 8 per cent. had come from overcrowded homes or had been in care". These comments are repeated one after the other by the Coventry Young Homeless Project.

As regards the single homeless on Tyneside, for instance, it is said about 16 and 17 year-old homeless people, who Newcastle accept as in priority need, that over 90 per cent. of applicants are made homeless from a parental home and all of these as a result of eviction or and/or violence, and/or sexual abuse, according to the City's Housing Department. These statistics have been accepted by the Newcastle City Council to show the gravity of the situation and to explode this myth, this premise that youngsters take a great delight and that there is a huge increase in kids running away from home just for fun, just to be put into these awful circumstances.

Again, the Kipper Young Homelessness Project from Merseyside—and this is the last quotation I make—says, The major problem with the mooted legislation, we believe, is the misguided assumptions at its root. We find that young people who turn to us have exhausted all other alternatives beforehand. For example, reconcilliation with their parents, staying with friends or relatives, attempting to obtain local authority housing … The decision to leave home is not taken lightly. Many, in fact, have been compelled to leave upon parental orders. Others have been subject to overcrowding, home violence, incest, or, less tangible, mental stress … Between May 1983 and October 1984 we placed 227 homeless young people with families. If the proposed legislation had been operative over that period, then our placements would be drastically diminished. This could only mean that more young people would have been forced to sleep rough.". Again, that comment is reported in report after report by voluntary organisations and agencies working at the grass roots; working on the receiving end of all these bits of expenditure cutting and saving legislation.

So, my Lords, I could go on for a long time yet but I think I have said enough. I hope I have said enough, anyway, to convince the noble Earl who is to reply that this is a serious problem; that there are indeed professional and public anxieties about this. We are also anxious about the complacency and, in fact, the approach of the Government that every problem can be solved by cutting resources when, in fact, we can prove that they are cutting them at the wrong end. I have just proved that they have cut the benefits that grossly inflated and exaggerated the administration, so we save nothing in the end.

I would say that these board and lodging proposals should be withdrawn and a comprehensive long-term solution—because there is no metrit at all in short-term solutions to these problems—should be sought, otherwise I feel that the problems will worsen, with who knows what consequences.

5.23 p.m.

The Countess of Mar

My Lords, I too should like to thank the noble Baroness, Lady Jeger, for introducing this subject. The frequency with which our anxieties about the National Health Service, and our social security system are expressed in your Lordships' House, in the other place, in the media and by individuals, must surely be a clear indication to the Government that, despite their optimism, their policies are not meeting the needs of large sections of our population. It is all very well to preach the doctrine of hard work and thrift to those who have well-paid jobs, but what of the 4 million unemployed, their families, the elderly, for whom simple survival is a daily battle?

I worked for the National Health Service for five years in the 1960s. Prior to that, I was in the Ministry of Pensions and National Insurance. Even in those "Never-had-it-so-good" days many of the cases with which I dealt were distressing. The hardships suffered were rarely self-induced. So often, it was ignorance and a simple inability to cope which caused the problems. The main difference now is one of scale, with the drain on funds for health and social security benefits caused by the appalling level of unemployment and our poor economic performance which inevitably hits the socially disadvantaged hardest.

The improvement in the health of our population, particularly since the inception of the National Health Service, is partially responsible for the large increase in those aged over 75, as the noble Baroness, Lady Cox, said so aptly. Reliable forecasts indicate that there will be over a million more over-75s in the next decade. They need nine times as much medical care and between 30 and 50 per cent. more hospital treatment than the rest of the population. I ask the Minister what capital is being put aside for this increased requirement? What is being done to encourage and assist local authorities to provide sheltered accommodation for the elderly, who really deserve to look forward to peace and security in their last years?

Last week, I listened to the distressing account of a man whose mother was in a local authority home. She suffers from senile dementia and is now too difficult for the staff of the home to manage. Her doctor telephoned the son and said his mother needed full-time nursing care; that there was no room in any of the local geriatric wards—she would have to go into a private institution—and that unless she had any property the DHSS would pay the fees. The old lady had a house, which her son has been buying from her on a privately arranged mortgage since the onset of her illness. Despite his interest in the house, it would have to be sold in order to pay the nursing home fees.

This is not an isolated occurance: I have heard of it often. What alternatives has this man? There are two. He can sell up? make himself homeless, and put his mother in a nursing home. As a single man, he has no hope of obtaining any local authority accommodation. The alternative he has chosen is to give up his job in a local factory and to have his mother at home, where he has neither the facilities nor the training to cope with her needs. He is at present having medical treatment for acute depression and will be totally reliant upon the state not only for his mother's financial needs but also his own. Is this really the way we should be treating people?

On a similar theme, the Government have very laudably redirected funds within the National Health Service to the psychiatric services, and to the care of the mentally and physically handicapped. Legislators in the 1960s safeguarded the interests of the mentally ill and handicapped and ensured that no one would be unnecessarily incarcerated for life in a mental institution. Sadly, with the Government's drive for economy, there are those who have fallen by the wayside. The closure of psychiatric hospitals and wards may have made some savings, but at what cost?

Many of those discharged have been totally institutionalised after long years in hospital, although on paper their disability may have been minor. The lucky few have found places in charity homes where they have been gradually taught to fend for themselves and to assimilate themselves into society. Tragically—and many have already said this—too many fall prey to the ruthless landlords and so-called hoteliers who trade upon their naivety and exploit them, and the social security system, to the hilt. The lack of social service workers to guide, advise and protect further exacerbates the problems. Does Her Majesty's Government really mean to treat this group of bewildered, helpless people in this callous way? What is being done to protect them?

Much money is being spent on psychiatry and yet few psychiatrists will deal with psychopaths. Many show symptoms of their illness before they commit the heinous crimes which we are so quick to condemn. Indeed, some even ask for help, and receive none. The Government must grasp the nettle, unpleasant as it is. They must ensure that these people receive the right treatment; that there are secure establishments for them outside prison and that innocent members of society, so often women and children, are as far as humanely possible, protected. What is Her Majesty's Government doing to solve this problem?

Unemployment is not the only drain on funds of the DHSS in terms of benefits. The toll on the emotional and physical health of the unemployed goes largely unrecorded. Cases of marital breakdown and family alienation associated with lack of money are daily occurrences. Many of the people involved are, unfortunately, destined for doctors' surgeries. The cost to the National Health Service is enormous. The Government are proposing to reduce some social security benefits, particularly to young people, and to abolish wages councils, which protect many low-paid workers. It seems unreasonable that the wife of a man who has struggled to keep his home and family together on a low income is better off away from the matrimonial home, living with her children in a council house on social security benefit. The answer is not to reduce social security benefits, which are already at subsistence level, but to ensure that wages and statutory deductions are equitable. No quantity of pills and potions will solve the problem.

I am sorry, my Lords, but I am infuriated by the pompous statements made by Ministers and their spokesmen who say that the unemployed should be prepared to accept low wages and that young people should work for £30 a week or less. They have been told to get on their bikes. Where are they to cycle to? Many come to London, where they find that even the meanest accommodation costs £20 or more a week. How on earth are they to pay for food, clothing and transport at that? Do let us have some realism?

Has the Secretary of State any idea of the additional hardship that he will cause in families if he deprives young people of lodging allowances? Does he realise how many parents of the young unemployed are unemployed themselves; or how much friction is generated in those families because of their situation? I cannot believe that the Secretary of State has never been north of Watford. To promise tax reductions for those in employment offers no solace to the unemployed and very little to the low paid.

This is a very wide subject. There is a lot more that I could say about my concern for our wonderful hospital service, particularly as I have recently spent two weeks on one of the wards in my local general hospital. My admiration for the dedication of the qualified and ancillary staff who cared for me is beyond expression. I was deeply shocked by the effects of financial strictures, especially upon the staff. For example, there was one nursing auxiliary looking after a ward of 14 post-operative patients on her own, with a sister taking care of five wards. That cannot be right.

It is all very well for the DHSS to provide reams of statistics to show that more patients are being treated, that the cost-effectiveness of the National Health Service has improved, and virtually anything else that it wishes to demonstrate to its advantage. Fortunately, many have the wisdom to look beneath the figures to the people on whom they are based. Andrew Lang could have been describing the Minister of State and his department when he wrote at the turn of this century: He uses statistics as a drunken man uses a lamp-post—for support rather than illumination".

5.32 p.m.

Lord Rea

My Lords, I am grateful to my noble friend Lady Jeger for introducing this debate, not only because of the national importance of the subject but also, I have to confess, because it affects my livelihood, as I work as a full-time general practitioner in the National Health Service when I am not in your Lordships' House.

Public and professional anxieties about the National Health Service certainly persist, despite the fact that the Treasury allocation is more than keeping pace with inflation, as of course the Minister has predictably reminded us. The central funding of the NHS from taxation is a highly efficient way of regulating how much of the gross national product is to be spent on health. The whole organisation is highly cost-effective when compared with the health care systems of other developed countries. I think that the Government know that, although perhaps it flies in the face of a philosophy which would really like every individual to pay their own way.

Expenditure on the NHS needs to rise more than inflation because of the new developments which prolong and improve life. That has been pointed out by almost every speaker so far. Kidney transplants, coronary artery by-pass surgery (as the noble Earl mentioned) and hip replacements are just three well-known examples. The problem is that those developments do not save money. They cause more to be spent in so far as they prolong life. Older people need more care, as has been graphically described by the noble Baroness, Lady Cox, and the noble Countess, Lady Mar. Any Government are really in a dilemma about promoting policies which save life.

If an employed person were quietly to "snuff it" at the age of 65, no money has to be paid out, but if he has a happy and active retirement until 75, and this is then followed by a period of ill-health and dependency until he finally dies at 80, it will cost, at a very low estimate, some £50,000, taking into account 15 years of old age pension, say, two hospital admissions for two weeks each, and increasing community care for the last five years, including home helps and possibly Part III accommodation in an old people's home at the end.

It is true that many fewer people die before retirement than used to and an economic gain has been the result, some people will say because of effective health services; but the noble Baroness, Lady Cox, has pointed out that the lives saved are more likely to be due to the improved standard of living that we have achieved over the last century, and that is what has protected us from the major killing diseases of the past, such as tuberculosis. However, there are still—and this is perhaps an aside—some 30,000 people dying before retirement age from coronary heart disease alone, in which our high standard of living, if you like, has played a part, although the high standard of living may have been misapplied by smoking too many cigarettes, eating the wrong food and not taking enough exercise.

However, it could be held that somebody who dies before retirement today is even benefiting the economy, because someone else takes his place who might have been drawing unemployment benefit or social security. Such is the state of the economy that we are in the awful position of seeing an economic benefit from the early death of some of our working citizens, and that is of course even more so if one of those who dies is unemployed or receiving social security.

Thus for these and other reasons the very success of the NHS creates the need for an increasing allocation of resources. It is in this context that we have to view the proud claims of increasing numbers of patients seen, operations done and money spent. It is a fact that in health expenditure we have to run to stay in the same place. The NHS is run as a tight ship, and so it should be, but true economy will come only with the willing co-operation of both the public and the professionals in the health service. We need to feel that we are willing passengers on this tight ship, being consulted about where it is going.

As my noble friend Lord Beswick said in opening his debate on the economy on 23rd January (at column 230 of Hansard): Proper economy, yes; a campaign for efficiency because we are proud of the service, yes. That is one thing. But cuts because we are told public expenditure is, by definition, a burden, are demoralising". Many of us who work in the NHS are, to use his words, proud of the service. We are pleased to be working in the NHS. If we felt confident that it really was in safe hands, many of us would feel less anxious. We should perhaps be content to let certain hospitals be closed, for example, as representing the end of an era if we could clearly see a positive programme of community care taking their place. I seem to be one of many talking about community care, and I shall concentrate particularly on primary care.

This Government have on many occasions stated that they are in favour of expanding care in the community and in favour of the closure of many Victorian mental institutions and other old hospitals, and they are proceeding apace with that policy. But it is being done before the community services have been built up sufficiently. The noble Baroness, Lady Cox, has spelt that out admirably. When one looks at primary care, apart from a small injection of cash for the inner cities, one sees that it has had little encouragement to develop. Health centre building, for example, has virtually dried up. Many of us fear that the main reason for making the family practitioner committees independent and directly answerable to the DHSS is that their cash can be more closely controlled.

Binder Hamlyn, the accountants, made a report on general practice which the Government have seen fit to keep as a closely guarded secret. I must say that the DHSS seems to be rather better at that than the Ministry of Defence. The much promised Green Paper on primary care has been so long in gestation that I suspect that the original conception may have been aborted or stillborn. We are now having to wait a further nine months for a new version. Let us hope that it is a forward-looking and happy child—not like "Baby", the monster in the cartoon series in the Guardian, who terrorises his parents.

What is unnerving in this process is the lack of consultation with the BMA or the Royal College of General Practitioners about what it is going to recommend. Both these organisations are enthusiastic about how general practice (primary care, if you like) should develop. I am sure that the Government will have seen the BMA's own Binder Hamlyn—the report on the cost-effectiveness of primary care by Coopers and Lybrand. The BMA has been waiting to publish this simultaneously with the Binder Hamlyn Report, but, having waited over a year, they decided to go ahead and publish it about a month ago. A copy has been sent to the Department of Health and Social Security. It will be very interesting to have a full Government response to this paper.

The report shows how only a modest investment in primary care may well save money in the end. They analysed only three examples in detail: minor surgery, child development clinics, and hypertension screening. In each case general practice is shown to be highly cost-effective compared with hospitals or district health authority clinics. The Royal College of General Practitioners (which now has two-fifths of general practitioners in its ranks) has been promoting a campaign of "self-audit" among its members to improve efficiency. It has published a series of occasional papers on preventive medicine in general practice, as well as the occasional paper Prescribing: a suitable case for treatment, which I have already mentioned in a previous debate. It has also published other monographs, such as those by Professor Peter Parish, looking critically at doctors' prescribing habits. Economy has been one aim of these papers, but efficacy and safety have been the main themes.

Why has the DHSS not welcomed these initiatives? Why does it persist in giving out edicts without consultation? The limited list of drugs, which has been described by the noble Lord, Lord Winstanley, has been handled in such a clumsy way that its acceptance by the profession will be grudging at best. With fuller consultations, using the Greenfield Report as a basis, an agreed and wider ranging solution could have been arrived at.

But primary care, including GPs and nurses, can do little to keep people out of hospital or allow them to be discharged early without the care given at a more basic level by home helps, the meals service, and suitable accommodation such as sheltered housing for the elderly or staffed hospitals for the mentally ill. I should not like to forget to mention the voluntary services, which have been mentioned by the noble Baroness, Lady Masham. But they cost money to administer; their own expenses need to be met. All these things are paid for by the social service departments of local authorities whose finances are in jeopardy because of rate-capping threats—or maybe realities by now.

I should like to ask the noble Earl, to whom I have given notice of this question, whether the Government would consider exempting from rate capping that part of rate support grant which goes to social service departments of local authorities, for home helps, meals service and other provisions which help keep patients in the community or allow early discharge from hospital. I am aware that there are specific joint funding, pump-priming agreements for social services when they take over hospital patients. But my suggestion would be for a more long-term agreement. Local authorities would in this way be encouraged to recruit community support teams up to an agreed level, varying according to the assessed needs of each locality. There is a precedent for this in that local authority activities which are carried out to further government policy—for instance, civil defence—are not only exempt from rate capping but also are largely funded centrally. Could it not be said that care in the community is Government policy?

Finally, I should like to mention the plight of the Medical Research Council. This is strictly outside the National Health Service but it should be mentioned because its activities are vital to the efficiency of the National Health Service. The noble Earl may have seen the leader in The Lancet of January 5th, entitled "The Distress of the Medical Research Council". This explains that although the cut in this year's finances is less than 3 per cent., the effect has been disastrous on the funding of new, promising projects. Existing ongoing projects have had to be funded and their costs have escalated beyond the inflation rate. For instance, take the additional cost, with the exchange rate disaster, of buying scientific equipment from the United States.

I should like to quote some passages from the leader: The Medical Research Council has never received so many first-class applications for research grants, yet in 1983–84 the MRC was unable to fund 199 approved applications for project grants, usually of three years' duration, and 22 approved applications for longer-term support for research programmes … The Secretary of the Council, Sir James Gowan, has informed university vice-chancellors that the Council must reduce provision for new 'out of house' programme grants by 25 per cent. and for new project grants by 7.5 per cent., and for studentships for research and for advanced courses by 30 per cent. It seems likely that the Council will reduce by 10 per cent. the number of intercalated awards to medical students—a serious blow to medical schools who seek to nurture the future generation of medical scientists". The leader concludes: The unexploited talent and the dismay of young research workers are painful to witness … The evidence is compelling that the MRC's predicament threatens some of the best research being carried out in the country today. What makes this seem even worse is that at the same time medical research budgets in the United States have been substantially increased. It seems to me that these cuts in research are in the long term more harmful than many of the other cuts which may seem to hurt more at the time. I am sorry to have to say this, but cuts in research grants seem to me to indicate that this Government are determined to reduce this country to second-rate status in the scientific as well as the economic arena.

5.47 p.m.

Baroness Lane-Fox

My Lords, in many ways it was a sad and doleful tale told to this House by the noble Baronesses, Lady Jeger and Lady Masham of Ilton, and by the noble Lord, Lord Stallard. All that has been reported in human suffering and distress goes to the hearts of everyone who cares, for we know the real, genuine quality of the noble Baronesses and the noble Lord. Indeed, I should be the very first to agree that of course the standard of well-being of numbers of people is much lower than we would wish. I say so knowing that, however high is the standard reached, we should still try for more improvements.

This is not intended to belittle the individual cases that were explained, for people in need always deserve the fullest attention from their fellow citizens. Nevertheless, it does seem fair that these cases should be viewed in the context of the undoubtedly increased expenditure and service in the NHS and expenditure on pensions since 1978–79.

The Motion speaks of "public and professional anxieties about the National Health Service". I really must jog back here. The truth is that despite repeated attempts to suggest that the NHS is creaking and breaking-up, there has been, as we have heard from my noble friend the Minister, a vast increase in the number of in-patients and out-patients during the last five years. It may be asked, "How is that? Why is there this sudden escalation?" It is partly, no doubt, because of the reduction in waiting lists—those lists which have been the bane of the National Health Service since its inception—and also through the skill and progress of modern surgery and medicine, and the huge additional types of treatment now given.

Although all of us connected with hospitals are amazed by the wonders performed, we know that provision does not always keep pace with need. Therefore, assistance by many voluntary organisations really is an essential adjunct to the NHS. These are organisations such as the National Association of Leagues of Hospital Friends, of which the national chairman is of course my noble friend Lady Macleod; the National Association of Welfare of Children in Hospital; and a number of other organizations, including those run by religious bodies. As chairman of a patients' association, I find the hospital service temporarily outstripped by the fruits of success in medical treatment. Because our particular requirements of new accommodation and equipment on a new site in St. Thomas's Hospital—although it is acceptable—cannot be met through existing budgets, the patients' association has embarked on an urgent appeal for £1 million. This is daunting work for both us and our friends whom we badger. But there was no doubt in the minds of patients that the unit was vital to us and that, as we had been treated in hospital so magnificently, we should help to achieve this goal.

It seems a little ironic to us, with NHS spending in the United Kingdom running at £14 billion, that in 1984–85 the unit with which I am connected is still driven to take these drastic steps. However, the timing for us is essential for a variety of reasons; and as we cannot, this year, be slotted into the financial programme, we hope very much that we shall do better next year. Be that as it may, we have heard of the great acceleration in hospital building over the last year. It is a great increase. With the National Health Service running at a cost of £300 a year for every man, woman and child, of course we need to make certain that the best value for money is obtained.

Despite all the anxieties, I am convinced that the Government are right to take what they consider are the measures to ensure this. The new management personnel and budgets may initially give cause to the anxieties referred to by the noble Baroness. Leaving aside the limited drugs list so well debated a week ago, a war on waste must be pursued—but pursued with very great sensitivity in these surroundings of trust. Official findings suggest that massive savings could be, and should be, made. So these, in my opinion, should be embarked upon. One saving, for example, is seen to come from NHS transport outside the ambulance service. This is estimated to show room for reductions of over £30 million a year.

I support the remarks of my noble friends Lady Cox and Lady Vickers. Care in the community is a most important element of the National Health Service. Here I speak as one with first-hand current knowledge of the excellence of community nurses. Four years ago, when my mother reached the age of 90, she, albeit unwillingly, relinquished the task that she had undertaken so well for more than 50 years of getting me up each day. She had become expert in the use of hoists and gadgets and rightly regarded these as her territory. But, when the time came, the nurses took over tactfully, efficiently and with good humour. Now, they—there are several of them who come to call on us—are our friends. We know from them that they have very difficult individual circumstances and that they often have to make large sacrifices. I want to say that undoubtedly theirs is a valuable arm of the service that deserves searching consideration. Their work is of the highest standard. They and the health visitors deserve staunch support.

I should like to mention one aspect where disabled or elderly persons in the community have a worry at the moment. Patients in hospital or residential care most likely are the financial responsibility of the DHSS. They live independently, happily and much more economically if they are in the community, helped by back-up support services, when their costs are charged to the local authority. The temptation to the local authority to shrug off the cost of caring for such cases by having them admitted as in-patients must he very strong. Will my noble friend the Minister hear my plea that only when funding is made from one purse instead of two will it be possible to reach arrangements that are both happy and economic? It is good that joint funding now enables a district health authority to pay for someone discharged from hospital over 13 years instead of seven. But what worries me is the person who has not been in hospital and might be sent there by a hard-put local authority.

I am delighted to hear today's news of a £10,000 Government grant for the National Council for Carers and their Elderly Dependants. This grant really shows the intention to improve life for many elderly people.

Although the social security budget has increased in real terms enormously since 1978–79 and is huge at this time, there are still powerful arguments to be made out for increasing a number of pensions and allowances. This, obviously, is a very friendly and appealing line to take; of course it is—much more so than the reasoned logic which first asks, "Where is the money to come from?" If the reply to that question is that it could be got from cutting the defence estimates, I, for one, learnt my lesson in 1939 when earlier disarmament policies brought us to the brink of disaster. With that memory I could never support a policy to lower our defences. Survival is the name of both games here. So this would be a wholly illogical area to explore.

The suggestion for obtaining the money for higher pensions by increasing the money supply is, I would say, a one-way ticket to raising the rate of inflation; and inflation hits perhaps hardest of all at careful, thrifty pensioners who see it gobbling up their savings nest egg. Any policy that leads away from the thankful relief of lower inflation is a threat to pensioners. So that is not the course to take.

Disabled people and the elderly are two categories in which I claim an interest. It is still as clear as crystal in my memory that before 1970 there was no allowance or benefit whatever suitable for me and many disabled people like me unless we went sick or were unemployed, neither of which states, certainly, had much appeal for me. So, while things are very hard for people now and while expectations have been sadly raised, at least people need not feel completely ignored by the general plan. Before 1970 our category was completely left out. Now expectations have been raised so high that the sky is the limit; and when you feel ill and old and skint the Government are the handy target for your wrath.

Those retirement pensioners who have suffered the indignity of the earnings rule saw the limit of this raised to £70 a week last November, which suggests that the next stop on that train will be abolition of the rule. My hope is that the same will soon apply to conditions for those handicapped people drawing invalidity pension, penalised by the therapeutic earnings rule—that terrible thing, the rule that stops pension if they earn more than £23.50 a week. When I was working the limit used to be £4 a week. Now, at least, you are allowed to earn £23.50 before your pension is affected. To call this method the therapeutic earnings rule is the greatest misnomer. Far from rendering therapy, the mere mention of the rule sends blood pressure racing to dangerous levels. It is my hope and belief that the advantage of self-provision is becoming more widely understood; that ingenuity, enterprise and sustained effort will be valued more highly and given more support and a freer rein, underpinned by detailed care for those who are unable to have the fun of making their own way. They are the ones who deserve maximum support. I hope this will be revealed by the current surveys.

Finally, I would like to say to my noble friend the Minister that I rely on the Government to speed on these numerous reviews, to give where the shoe is shown to pinch, but otherwise to hold boldly to their course and policies, because I believe this to be the wisest and best way to allay these public and professional anxieties referred to in the Motion.

6 p.m.

Baroness Robson of Kiddington

My Lords, I, too, am deeply grateful to the noble Baroness, Lady Jeger, for having raised the subject of the National Health Service and social security and the anxieties which exist among both public and professional people. We are anxious—it is important to say this—because, as my noble friend Lord Winstanley said, we believe that the National Health Service is among the best of the services we have created in this country since the last war, and we want to preserve it. I ask the Government to listen most carefully to what is being said all round this Chamber, on the media and in the press, about the National Health Service. Although a lot of the things that are said sound like great complaints—and some of them are great complaints—they are said in the spirit of trying to make the health service as good as we can possibly afford to have it. They are not said in a political sense to try to prove that the Government are not doing their job. I believe the Government are doing what they are doing because they believe this is the right way. I think there is equally much right among people on the other side, who can see other ways of treating the problem.

Speaking at this point in the debate, it is very difficult to go over the large number of questions one should like to raise. Therefore I shall confine myself to the part of the health service which I know a little about and refer to one or two problems relating to health authorities in the South-East. I was chairman of one of them for a number of years. In the media in particular there has been reference to a matter which my noble friend Lord Winstanley has also spoken about: how waiting lists can be used to create an increase in private practice. It has been said quite often that consultants deliberately create waiting lists in order to be able to put pressure on their patients to become private patients. I do not believe that is true of any number of consultants. There may be one or two, but I believe that doctors on the whole would not behave in that way.

There was a programme on television on Tuesday, 5th February, dealing with waiting lists, particularly those for orthopaedics. I do not know how many noble Lords saw it. A woman was being interviewed by a consultant on the south coast. She was told that she could have her hip operation in three years' time. The consultant did not ask, "Would you like to have it done privately?", but she asked herself, which is a natural thing to do. She was told that the cost was such that she could not possibly afford it. What I regretted about that presentation was that nobody suggested to the patient that she should look in some other area or district to see whether the waiting lists were shorter.

We had a debate last year on the National Health Service, and at that time the Minister promised to look into the possibility of providing general practitioners with the expected waiting lists round the country for various types of surgery. As far as I know, this has not yet happened, but the College of Health has issued a guide to hospital patients on waiting lists for various surgical procedures. It is no fault of the present Government that the balance between facilities existing in a certain district and the number of patients who require a particular operation is not equal. This is accounted for partly by the change in population and the moving down to the south coast of elderly people who go there for retirement, against the background, historically, of all the leading teaching hospitals being in London. They have enormous facilities which enable them to give a shorter waiting time than the hospitals down on the south coast.

There are many consultants and other people who feel that, if you live in a district, services should be available within a reasonable distance of your home. But I am certain that if they are not, due to historical development, the average patient would not mind coming up to North Kensington, for instance, or to Merton and Sutton if they want an orthopaedic operation. Having myself had an operation, and knowing the relief when you come out of the anaesthetic, I would go up to Aberdeen or Dundee—in fact, I would go anywhere—to have it done.

The resistance is not from patients. I believe it comes from a certain percentage of the medical profession who want to have the facilities in their own particular district. In the meantime, patients are finding it difficult and are suffering unnecessarily. We cannot expect to change this balance overnight, and so we have to work towards creating the facilities in the places where they are needed. In the meantime, I ask the Government to try, please, to see that general practitioners and doctors in hospitals have an up-to-date list of waiting lists for various surgical problems.

The noble Baroness, Lady Masham, asked whether there was enough cross-boundary flow. What also militates against using to the full the facilities we have in this country is the application of RAWP to the metropolitan regions. This has meant that, though the facilities exist in some of the large London hospitals, their revenue has been cut to such an extent that in many cases they cannot afford to take patients because they will overrun their financial allocation. I should like to ask the Minister whether he will please make it easier not only for cross-boundary flow but for cross-boundary payments between regions and districts; these are desperately important.

The noble Baroness, Lady Masham, referred also to drug addiction and the increasing problem that this is presenting in our society. It is more than a health problem—it is a whole social problem—but it has got to be dealt with through the health service.

I was delighted when last year the department issued Health Circular No. 44/14 which asked regional health authorities to make drug abuse a priority problem to be dealt with within their regions. They did that, of course, without adding any extra revenue—savings had to be made from other sources. However, I was even more delighted when I heard that the DHSS had set up a special fund of £7 million to be used for new projects by the voluntary services. In other words, I presume that the department will be giving pump-priming grants to voluntary bodies which are prepared to set up clinics.

That all sounds very good, and we welcome it. However, at the same time there is a tragic situation to be borne in mind. In the centre of London we have perhaps one of the best drug addiction clinics City Road's Crisis Intervention Clinic—which was started in 1980. It was supported by a grant from the DHSS for three years and that grant was then extended for another year. It is funded by voluntary contributions; by the department; by three of the regions in London; by the GLC and by the Boroughs Association. The clinic deals with the problem of drug addiction straight off the streets. The patients are allowed to stay there for three weeks and they are then sent out or placed. Indeed, it has been very successful in placing people in the right institutions, in the right surroundings, to enable them to "take of" after spending three weeks inside the clinic.

If that clinic did not exist, those patients would walk straight off the street into casualty departments in London; and we all know how disturbing and disruptive that type of patient can be in a casualty department. Moreover, that type of patient is unlikely to get the kind of counselling and treatment in a casualty department which will begin to persuade him or her to come off heroin, cocaine or whatever drug he or she may be taking. After spending 24 hours in casualty such a patient is likely to come out and go on to the streets again. However, the City Road's Crisis Intervention Clinic attempts to keep them at the clinic and frequently succeeds in counselling them to undergo longer-term treatment.

As I understand it, as from this year the DHSS is not going to fund that clinic, or it is very, very doubtful that it will do so. It could be said that the funding comes from so many sources that we ought to be able to make up what is missing. However, I point out that more funding is in the balance, and I refer in this connection to the GLC funding. What will happen to the GLC funding once the GLC has gone? It is true that the clinic could probably ride the DHSS withdrawal of funding, but it could not possibly ride the withdrawal of both sources of funding. This is a great difficulty in London at present. The clinic is a voluntary body. The Government have put aside £7 million for voluntary projects. Why should those projects have to be new projects? Why should not a project that has proved itself effective be supported? Incidentally, it can be of enormous educational value to regional health authorities and to district health authorities which want to set up clinics. We can learn a lot from what this particular clinic has done.

Originally I wanted to say something about the social security board and lodging allowances, but so much has already been said on that subject. I was going to mention only one point as regards London itself. I am a trustee of the charity of the noble Baroness, Lady Macleod—Crisis at Christmas. We have some knowledge of what makes young people come to London and I agree 100 per cent. that they do not come just because they decide that they want to leave home. Of course there is the odd young person who does that, but many come in search of a job because they feel that down here in the South-East there will be a job for them. There will be an enormous increase in the number of young people on the streets of London who have nowhere to sleep unless the position is changed.

Equally, I am concerned about the fact that an unemployed person can get board and lodging outside his own area for only two to four weeks. If someone who lives in Liverpool hears that there are jobs going in Southampton and he goes there, in the present economic climate it would be very optimistic of him to expect to get a job and somewhere to live within two to four weeks. The Government have told everybody, particularly the people up North, that if they want a job, they should get on their bicycle. Indeed, somebody has already mentioned this point. However, what is the good of getting on a bicycle if when you get there, you have nowhere to stay or live? This is an extremely important question. From personal experience I know that the majority of young people do not come to London because they think it will be fun; they come to look for something.

We all know that we have to save money. I do not know whether the noble Earl saw the article in the Financial Times today which said that the National Health Service could save £80 million a year on fuel costs. It could save that amount as an energy saving. I find that a most acceptable suggestion. Indeed, it has come out of the Report of the Comptroller and Auditor General on the National Health Service. It would be a pure saving, which could be diverted to patient care. It would not hurt anybody and it would not interfere with anybody's clinical judgment. If we are going to save £100 million on a drug prescription list, then in my view it would be better to get the money by energy saving.

6.17 p.m.

Lord Wallace of Coslany

My Lords, I willingly join in the alliance with the noble Lord, Lord Winstanley, and, to a great extent, with the noble Baroness, Lady Robson, as regards the health service. I support the appeal of the noble Lord, Lord Winstanley, that there should be fewer attacks on the service. I have good reason to say that, because it so happens that I am old enough—and heaven alone knows that I feel that I am getting older—to have been one of those who in early, younger days, fought for the establishment of a National Health Service: and I did so in a humble capacity. In 1937 I fought and won my first council election on the issue of a proper health service and the provision of a hospital for my district. I am proud of the health service and have no hesitation in saying so.

Time and time again we are told by the Government and, indeed, we have been told today by the noble Earl, that we have never had it so good as far as the National Health Service is concerned. Actually, there is hardly anywhere in Britain that is not facing a cash crisis in its hospital services. I want to quote one such area, and I can assure the House that what I am going to say has been checked and rechecked, so that the House will not have some vague idea of guesswork on my part, but will have actual facts. It is a very serious matter.

A shock shortfall in Bexley Health District of £5 million over the next 10 years has created a situation where health services in the area could fall below statutory requirements. The health authority members are absolutely convinced that they will not be able to survive, let alone develop their priority services as required, unless a major additional capital injection is received.

During the last few years, in my experience in this particular area, crisis has followed crisis. Attempts have been made to economise, particularly on maintenance work.

The new Queen Mary's Hospital at Sidcup, which replaced the old hutted hospital 10 years ago, was regarded as a showpiece, but now window frames are rotting and glass is falling out, and these will have to be replaced at a cost of at least £65,000. The flat roof of the maternity unit will have to be replaced for the second time in 18 years at a cost of £120,000. The pathology department is now completely inadequate and needs extending, as working conditions are becoming impossible. I can assure the House that I have seen this for myself. It is the result of bad planning originally. With the increasing workload of the hospital some positive action must be taken.

A scheme has been prepared which is estimated to cost £1.3 million. However, the problem is: where will the money come from—out of already inadequate capital resources? There are other urgent works of backlog maintenance required within the next three years, at an estimated cost of at least £200,000. The situation is critical to say the least. One of the hospital administrators is on record as saying: These are problems faced throughout the National Health Service at the present time". What an expression of despair and frustration which, let us face it, exists among those working in the health service today.

I have quoted one example from that particular health district, but there are many other problems of capital expenditure, including the upkeep and backlog maintenance of Bexley Psychiatric Hospital, an old building the future of which is likely to be uncertain for quite a number of years. The necessary redevelopment of Erith Hospital—all this and more—could lead to an over-commitment of £8 million; and that is being optimistic. I am told that there is no more money available. The regional authority says that it has no money, but it did suggest a bridging loan in one instance. But what on earth is the use of that?—the money has to be paid back.

Then we are told by the noble Earl the Minister that there has been a real growth of resources. If that is the case, may we have some to carry out the work that we are supposed to do?—because the situation in that district is so critical that I think the department should start an investigation at once.

On the matter of the privatisation of some hospital services, it is a well-known fact that health authorities have always had the option of seeking tenders from outside contractors. The Government's policy on this at present is far too rigid and far too dictatorial. There are problems arising from the enforced privatisation of domestic services in hospitals having long-stay units for the disabled and the elderly. Domestic staffs in hospitals have proved to be valuable ancillaries to nursing staff, and in long-stay units they tend to build up a personal relationship with the patients they serve.

At my local hospital there is a disabled unit for young people which many regard as their home and where they keep many of their own possessions. The domestic work will be going out to tender in March. Will this lead to strangers taking over the jobs of staff whom these patients have grown to love and trust, staff who are important because they have an intimate knowledge of the limitations and abilities of each patient?

There is no guarantee that, should an outside contractor be appointed, such staff would be retained, or may even wish to be retained should conditions of employment prove to be unfavourable. Of course, the health authorities can put in tenders involving their own staff, but the Government's lowest tender approach is rigid. One health authority in East Anglia—Norwich—whose tender was a little above the lowest and who in its wisdom opted for its own tender, was forced by the Department of Health to rescind its decision and to take the lowest tender. This is typical of the dictatorial approach that we face today in many fields of Government policy on the basis that Whitehall knows best.

There should be a degree of flexibility and discretion afforded to local health authorities, which has always been the case as regards local authorities. The constant pressure to reduce local expenditure and the introduction of rate capping hits, and will hit harder, the poorest sections of the community. Services such as home helps and welfare services for the elderly are easy and obvious targets. These services are vital to health care, and reductions, especially for those living alone, can only lead to greater pressure on already overloaded hospital and institutional facilities; and this is already taking place in some areas. Minor services, such as chiropody, are vital to the mobility of the elderly and reductions already taking place can make more elderly people housebound, place a greater burden on the state and, more important, affect their health.

I should like to say a few brief words on housing because basically housing provision is a social service. Bad housing contributes to physical illness and, to some extent, to mental illness. It can also lead to moral decline and antisocial behaviour. Government policy has led to an appalling decline in housing standards. I am not against home ownership as such; it is a good thing. But it is wrong to force people into ownership against their better judgment. The sale of council houses and the failure to increase publicly-owned stocks of homes to rent is leading to a critical situation. Thousands of properties, mainly in big cities, are empty; many are in a derelict state; many are capable of conversion to reasonable standards of accommodation. But nothing is done.

As we have already been told, homelessness is on the increase and this, with increasing unemployment, provides a growing risk to mental and physical health. I appeal to the Government to moderate their approach to some of the actions that they are taking, particularly in the case of tendering for contracts. It is a fact that the great majority of people working in the health service in, shall we say, the more humble, domestic ancillary field are dedicated people, helping and trying to serve those patients for whom they care. They are a valuable adjunct to nursing and I fear that there are many cases where a private contract will not result in the same attitude of care.

Reverting to the hospital situation that I have mentioned—and it is not the only one—this is a very serious matter. I ask the Government as a matter of urgency to sort out the situation, because I do not want that lovely hospital to fall into disuse—and that is what is happening. Where a service is being rendered under great pressure, I think that the people who work in it and those who fought for it certainly deserve better treatment.

6.30 p.m.

Lord Colwyn

My Lords, while thanking the noble Baroness opposite for again bringing this important subject to our attention, I must apologise to her for missing her introductory speech and, indeed, the speeches of my noble friend the Minister and some of the earlier speakers. When I put my name down to speak today I re-read the debate initiated by the noble Lord, Lord Molloy, on 9th November 1983. The list of speakers then was remarkably similar to our list today, and the content of some of the speeches I have heard even more so.

As in November 1983 I wish to confine my remarks to the anxieties within my own profession; namely, dentistry. Having declared this interest, I have to admit that, although largely unaffected now within my own sphere of private practice, I am very much aware of the major problems which confront many of my colleagues in practices within the National Health Service in all parts of the country. There are lots of things for human beings to have anxieties about—understandable things—and it is understandable that we are debating anxieties within the National Health Service. Everyone is concerned that efficient health services will be there when they are needed, and I am sure that we shall have this debate many more times. But we need to keep our anxieties in perspective, and not let them turn into neuroses.

I have seen the health service's annual report, and I am impressed. I am impressed, first, that the National Health Service is doing a proper PR job for itself and is explaining its work and its aims to its shareholders, all of us. I am impressed, too, at what is being done to improve patient care and to get as good value as possible for the money we spend. Therefore, I am not going to attack what is happening in the NHS. Generally, I think that Norman Fowler and his team are doing a good job, but there is one area in which I am critical. I am a dentist, and dentists chiefly look after teeth and mouths. We help patients to eat properly, to speak properly and to relate socially to other people without an appearance damaged by disease, or accident, or congenital abnormality.

Dental health is part of general physical health and also mental health, and it has wider implications than one might immediately realise. But regular dental care under the National Health Service is being priced out of the reach of many people. Last April the average manual worker had gross weekly pay of £153—say £120 after tax and other deductions for a married man. At the same time last April the maximum charge for National Health Service dental treatment was £110. That is getting on for a whole week's take-home pay. I do not know what the average take-home pay for Members of this House is, but I ask noble Lords to think of their own income and to consider whether they could afford easily to allocate a week's net pay for National Health Service dental treatment; because that is what we are asking a lot of our patients to do.

I accept that few patients will actually have to pay this amount. Average charges are much lower, and if only routine treatment is needed the charge will not be more than £14.50; but we have to think not just about facts and figures and averages but also about psychology and the deterrent effects of figures like £110, or £59 to have just one tooth crowned, or £92 for a set of metal dentures. I ask noble Lords to imagine themselves earning £153 a week and to think whether they would go to a dentist if threatened with the possibility of charges at this level.

Dentists have been worried about dental charges for many years. Some of the complaints and fears have been hysterical, I freely admit, but this time there really is a wolf. Over the past five years dental charges have risen by vastly more than the rate of inflation; and, as Nicholas Timmins reported in The Times on 23rd January, the latest public spending White Paper threatens another 25 per cent. increase this April. As a dentist I am convinced that a charge increase of this order would be a disaster for dental health and for the National Health Service.

I know that the Minister will say, "Show us the evidence. Show us that anyone has stopped having regular dental treatment because of the charge increases which have taken place so far". I have two answers. First, the burden of proof should be on Ministers to prove to us that the charge increases will not do damage. As it is, they seem to be trying to test National Health Service dental services to destruction. Secondly, there is evidence that charge increases reduce the growth of treatment take-up. I have with me a table showing trends in dental treatment provision over the last five years for adults in six age groups. I intend to make this table available to the Minister after I have spoken.

As one might expect, the type of dental treatment being provided tends to change over time, and treatment also differs from age group to age group. Also, different treatments are charged at different rates, so that the charges levied in the various age groups have changed over time. If we use the age groups to compare charge increases with the changes in treatment take-up, it is clear that the biggest improvements by far have been in the age groups experiencing the smallest increase in charges.

I suggest that this evidence needs to be examined by all in the Department of Health who have said repeatedly that charge increases have no long-term effect on the demand for treatment. It really does offend common sense to say that putting up the price of dental treatment will not reduce demand. Of all Governments, the present Administration ought to understand that economic laws cannot be suspended, that market forces will assert themselves.

Let me make one more point. I am not saying in any general sense that it is wrong to charge for dental health care or for health care in general. What I am saying is that it is wrong to charge so much for dentistry when most health care is free of charge at the time a service is used. My dentist colleagues call dental charges "a tax on teeth", and that is what they are. Generally, we in Britain try to avoid discriminatory taxes except on things like cigarettes and drink—and a good case might also be made for a tax on sugar. We dropped the highly specific purchase tax system in favour of VAT as a generally applicable tax which did not fall heavily on a narrow range of goods. My contention is that dental charges at present levels are wrong and discriminatory in the sense that purchase tax on cookers or on refrigerators was wrong and discriminatory before.

I have to admit that I have repeated much of what I said in November 1983. At the time I was complimented by my noble friend Lady Trumpington for my profound knowledge of dentistry, but she made no comment on the appalling statistics of increases in dental charges that I spoke about then. May I urge my noble friend the Minister who is to reply this evening to say that he will bring the real fears of the dental profession to the attention of his right honourable friend, and that he will give serious and urgent consideration to the matters I have raised.

6.39 p.m.

The Earl of Longford

My Lords, we have all listened with much attention to the noble Lord, Lord Colwyn. He said that the health service was working remarkably well except in one area. That, by a curious coincidence, proved to be the one area of which he has special knowledge. If he had special knowledge of—and if I may say so politely, a special interest in—other areas he might not have found the rest of it so satisfactory. He must allow me to point that out a little ironically.

I have long admired the noble Baroness who opened the debate, and never more than today when she spoke with such a delightful combination of the grave and the gay. And I admire, or at any rate I look up to, the noble Earl, Lord Caithness, or at least I did so until recently when I discovered that he is the 20th Earl. From that point of view, he is three times as good a man as I am, so that I speak with some diffidence in front of him. Even Lord Home might feel something of the same sort though he is twice as good a man on that criterion. I do admire the noble Earl for the gallantry with which he stuck to his brief. At times, it might have been a little disheartening but he stepped into the breach very nobly and no one could have blamed him if he had fainted at the Dispatch Box.

I hope that I am not being offensive but perhaps he will allow me to tell a story of my days when I was a Lord in Waiting and was handed documents at short notice to read to the House. I remember that Lord Addison, then the Leader of the House, used to kick me on the back of the calf fairly early in my speech and say, "I should stop now. You've got the House with you and you'll lose it if you go on any longer!" I do not know quite the moment to have suggested to the noble Earl that he should stop but quite a good moment would have been at the very beginning, when he announced encouragingly, "I have a good story to tell". I think that at that moment we were all encouraged but, as he proceeded, I am afraid that very few of us experienced the same measure of satisfaction as he did.

My Lords, I am, like other noble Lords, interested in various forms of social service, but I shall concentrate on mental health and will not even deal with mental offenders because I opened a debate on that subject on December 12th. Nearly four years ago, I opened a debate here on mental aftercare, following which a committee was set up which included a certain number of noble Lords of different parties, including the noble Baroness, Lady Trumpington, and some of the best psychiatrists in the country. We produced a report which was debated at about the same time as the debate—only it was a different debate—referred to by the noble Lord, Lord Colwyn. The debate on our report was initiated by my noble friend Lord Beswick.

One of the conclusions we reached in that report was that there was no cheap way, no (shall we say?) painless way of providing a better mental health service. Someone had the idea—it was not mine—that by switching things round one might find some way of providing better services; but it was clear to everybody, including these expert psychiatrists, that there must be considerably larger resources devoted to mental health if there was to be a real improvement. I am not saying that the noble Lord, Lord Glenarthur, when he replied accepted that particular proposition but he did refer (and we know he is very polite and that Ministers here are apt to be polite) to his very real appreciation of the enormous contribution made by, and the effort that had gone into the production of, the Richmond Fellowship Report. Here I should mention that that was organised and paid for by the much renowned Richmond Fellowship and we were sure that the Government would give the report their fullest consideration.

Rather more than a year later, all of us in the House, and particularly those concerned with that report, are entitled to ask how things are going. I do not think that anybody, despite the bouyant tone of the noble Earl, could think that in regard to mental health they were going at all well. I think that it would be impossible to find anybody who (unless they had a special reason for saving so) would think that things were going well on that front.

As we on these Benches have maintained many times, starting long before my report, we entirely approve of the aspiration to remove the mentally ill wherever suitable and wherever possible from the hospitals and to provide them with care in the community: on that principle—which is the Government's principle, I believe—we are at one. The question is, how do we do that? I am afraid that I do not think that the Government have begun to do it at all effectively.

Today, we face a clear conflict between the Government's policy—and, as I say, we share it—of expanding community care on the one hand and, on the other hand, their policy, which we certainly do not share, of rate capping. There is a total conflict between those two ideas.

We all may carry out these little local investigations as best we can, and I spent some time with the people at Islington. If you take Islington, you have the closure of the mental hospital at Friern, and that means that several hundred patients will gradually come on to the shoulders of the community. And this has come at a time when, for other reasons such as the recession, the demand on social welfare is increasing and so are the family and individual breakdowns. If you take just Islington, and it is only a microcosm of the whole, the move towards community care represents yet a further demand on local services. That is non-controversial and I am sure that the Minister will accept that point. You do not reduce the number of people who need help by removing them from hospitals. The question is whether we in this country are providing the necessary alternative, and the answer to that must be no.

I am aware that the Minister has said this to some extent already but he will say it again, I am sure, when he replies: that the Government are assisting the process of the transfer to the provision of joint finance of various kinds. But these, as was said by the noble Lord, Lord Rea, in a speech which I should like respectfully to endorse, are temporary provisions. From the point of view of the local authorities, to be told that the Government are going to give you help initially with providing community care is very little consolation because very soon, unless some new step or the issue of some new affirmation of policy is taken, that money will run out and they will be subject to the extra charges.

Here I am putting forward a point that was made by Lord Rea and perhaps by other speakers, but I am putting it forward especially in connection with the mentally ill. It is a general point but I feel that in the case of the mentally ill there is a special reason why it is most urgent. I understand that the noble Lord, Lord Glenarthur, at a meeting with the North Thames Regional Health Authority in March last year which discussed the closure of Friern Hospital, indicated that expenditure on care in the community would be excluded from rate capping. I have given notice to the noble Earl that I would raise this point in connection with mental illness, and I hope that he received the notice and will be ready to answer. I am aware that the question goes wider than mental illness, but, as I think I have tried to indicate, the problem there is especially acute.

Before I close, I should like to say a few words about the voluntary bodies. There are a number of bodies doing wonderful work. The noble Lord, Lord Ennals, Director of Mind, will no doubt have something to say on Mind, which is of course in many ways quite unrivalled. Then again there are smaller bodies like the Matthew Trust, which has made extraordinary progress under many difficulties. But the body with which I have been closely in touch with for many years is the Richmond Fellowship (which I mentioned earlier) and, if there is any one person in the whole field to whom I should like to listen and do listen, it is Elly Jansen.

Your Lordships can guess but will not be surprised to hear that these bodies are utterly dissatisfied with the position in which the voluntary bodies find themselves in the field of mental health. No doubt it is the same in other fields too, but I am talking about mental health. The Government are expecting more and more effort and achievement from the voluntary bodies, yet making it harder and harder for them to bring that achievement about. I am aware that fundraising is getting harder, Government policy on the whole is making it harder and, to take the Richmond Fellowship as an example, the Government have steadfastly declined to help them with their development work.

There is one point which I know the Richmond Fellowship are very keen on, and I am very sympathetic towards it. I doubt that it has as yet become the policy of my party, but I hope it will. I must sympathise with the idea that community care should be given extra legal sanction. By that I mean if you are running hostels as the Richmond Fellowship and other organisations do—although the Richmond Fellowship provides more than others—you find again and again that local pressures are brought to bear which make it impossible for those hostels to be established. I think there is a great deal to be said for looking at the law of the land to see whether this could be made possible.

I will close now, although, like so many other speakers, no doubt, I could dwell everlastingly on this terrible affliction of mental health and the failure of the Government—all Governments if you like, but this Government in recent years—to do anything effective about it.

I do not know what it is fair to expect from the noble Earl. With the best will in the world—and I speak as an old Lord in Waiting who has attended many debates in that capacity—at the end of the day it is difficult for the Lord in Waiting to announce some new and startling aspect of Government policy. So I must not expect too much. I will ask him to give a personal pledge: to take an interest from now on in mental health. Perhaps he does so already, and in that case I would ask him to redouble his interest. I know that, having put his hand to the plough, he will not turn back. I am very grateful to the noble Baroness for starting our debate on this subject. I think that we ought to return to it again and again, because the present position is shocking and cannot be allowed to continue for ever.

6.52 p.m.

The Lord Bishop of Carlisle

My Lords, like others before me, I want to say how grateful I am to the noble Baroness, Lady Jeger, for initiating this debate, which is both valuable and timely. The Ministry is currently conducting a far-reaching survey of the social security system, and the vast majority of people welcome it and agree that it is needed, although there is not the same measure of agreement as to how or what should be done.

The social security system has been under very great pressure for at least the last 20 years or more and it has been showing signs of age and decrepitude. As one report puts it: The main pressure on the social security system derives from the inability of the national insurance benefits to carry out the role for which they were intended: that is, to guarantee an income without resort to means-testing". The writer of the article, Mr. Atkinson, goes on to say: That may not be a novel diagnosis but that does not make it any the less correct". That there is room for simplification of the system, there can be no doubt both for the sake of the claimants and for those who administer the system. Indeed, one report opens with a quotation from a letter from a single mother, who wrote, "I signed on the dole and, after receiving no money for three weeks, I was told they had filed me away by mistake".

This bewildering system is a minefield into which I do not really wish to stray this evening, beyond repeating again the Question which I tabled in your Lordships' House a few months ago on extending the higher rate of supplementary benefit to the long-term unemployed. I would remind the Minister that at a count in March last year there were 622,000 such claimants who between them are responsible for nearly half a million children.

This evening, however, I would like to concentrate on the process by which the review has taken place and to ask some questions about the overall philosophy which appears to inform the review and to touch on some of the major worries which some of those who are working directly with the poor feel about the method by which this review has been conducted so far—worries that raise questions about the eventual outcome and the degree of consensus that the reforms will carry in the country as a whole. I hope that what I am going to say may indeed help towards that consensus, which I believe is vital for the success of this report and the well-being of the country.

Perhaps your Lordships will not be too surprised if, speaking from these Benches, I group these anxieties under three headings: speed, secrecy and independence. As regards speed, for a review that sets out, in the words of the Secretary of State, to be the most substantial examination of the social security system since the Beveridge Report 40 years ago", the actual time allowed has been breathtakingly short. The review was announced on 2nd April, written submissions had to be handed in by 31st August and oral submissions were completed by the end of October. In other words, all the evidence-gathering was to be concluded in six months, and let it be noted that they were the summer months, including the high holiday period. Inevitably many people have been asking whether this time schedule has really allowed sufficient time for a review of such complexity and importance, especially as there is naturally a wide range of views.

I have also been given to understand that the Government plan to publish their findings and thereafter introduce legislation following the Queen's Speech in November. Can it be reasonably said that this gives the necessary time for criticism, amendment and—what I believe is of the greatest importance—the forming of a consensus of opinion which will be necessary? It would be a grave mistake, especially as there is great goodwill towards this review and widespread agreement that the time is ripe for it to take place, if the end of it all is a programme of reform, pressed through by the Government, which did not command widespread agreement. I would therefore urge the Government that the paper, which Dr. Rhodes Boyson announced that the Government would produce "of some colour"—I quote his words— may have more than a tinge of green about it rather than just being a penny plain white". My second point is the secrecy which seems to surround the whole matter. The Secretary of State, in another place on 2nd April 1984, at col. 654, promised an "open review" with "open discussion". But I understand that the Government do not plan to publish either the written or the oral evidence but will probably produce a paper outlining possible changes after the Budget. There has been great criticism of these reviews on this score, and little there appears to be "open" about them. Nor indeed is there that "open discussion" one would have hoped for and believed would be allowed following the Minister's speech.

Indeed, respected groups like the National Consumer Council and the National Council of Voluntary Organisations have pointed out that the prospects of genuine reform of the system are jeopardised by the way in which the reviews have been framed. First, the reforms are nil-cost and any alternatives must be within an existing or even a reduced budget. Secondly, they are not open, in the sense that they are too narrow. For example, mortgage tax relief, which is a powerful way in which central Government subsidises one section of the population, is not included. Reports in the press have also suggested that the matters under consideration are much wider and the proposals for reform much more sweeping than the consultative documents indicate. Such radical reforms might well be welcomed, but all this should not happen behind closed doors. Indeed, if these reforms include, as rumour suggests, the integration of income tax and national insurance contributions, the public should be given an opportunity to comment on them.

But there is a third matter which concerns me very greatly; namely, the lack of independence of these reviews. I understand that the Ministers of the departments concerned are in fact chairing the reviews themselves, and I suppose that in some cases they must be reporting to themselves. What is less likely to produce a fresh or independent point of view than that? In a field as important as this one, would not a more independent review procedure, conducted over a longer time period, with published findings, have given that sense of confidence to all concerned that the Government have come to this task with a genuinely open mind and were genuinely concerned to bring about reforms that would be in the best interests of the poor?

As the Association of British Chambers of Commerce has recently stated, a Royal Commission, consisting of well-known experts likely to command public respect, with the best brains, rather than representatives of all the vested interests, receiving and publishing written evidence and examining witnesses in public over a period of two or three years, and then publishing a report which would certainly advance understanding, even if it did not indicate clear or unanimous conclusions, might be the best way ahead.

Let me add one more point. If the Government are concerned about the maintenance of a genuine welfare state then they will be concerned, as I believe most of your Lordships are, not so much about the relief of poverty as about the building of new systems that prevent people from getting into poverty. Beveridge's vision was to provide "security against want without a means test". Clearly, in 1985 such an ideal would be both expensive and sacrificial, but not, I believe, impossible. Indeed, alternative programmes and reforms have been put forward which aim towards that ideal—yes, my Lords, a consensus of agreement which would help to build the nation into one nation, rather than aggravate bitterness or deepen the divisions which at present exist.

Your Lordships may remember that the Psalmist of old prayed that he might not be caught in the snare of the fowler. My own prayer and hope is that Mr. Fowler will set no snares at all, so that the poverty trap may not be found in our land.

7.1 p.m.

Lord Molloy

My Lords, it has been a very interesting debate and, as the noble Lord, Lord Colwyn, has said, many of the people who have participated in this debate also participated in the debate which I initiated some time ago. The remarkable fact is that we have become more depressed. What the noble Lord, Lord Colwyn, failed to notice is that things have got worse. He himself thought that it was correct to congratulate the Secretary of State and the Government on the way in which they have been handling the National Health Service except, as the noble Earl, Lord Longford, said, in the department about which he knows a great deal. He spent two minutes in congratulating the Government and the rest in giving them a right good drubbing, which they deserve, for the way that they are treating dentists and dental surgeons—and he belongs to that profession! There must be a lesson there for the Government.

The speeches which have been made were well-informed. The speech of the noble Lord, Lord Colwyn, was well informed, as were the speeches of everyone else, and we are all very grateful to my noble friend Lady Jeger for initiating this debate. The noble Earl, Lord Caithness, said that there have been so many increases in various aspects of the National Health Service—and he was quite right. But the reason why the National Health Service is costing more under Toryism is that everything else is costing more. People paying rents, people paying mortgages and housewives going to the shops all know that the price of everything has gone up since that disastrous day when VAT was increased to 15 per cent. The increases just have not stopped. In consequence thereof, you have to spend a lot of money on our National Health Service simply to stand still.

I do not think that the noble Earl has much of a case when he says how much more money is being spent. He could have said that there has been an increase in many other things which are indirectly related to our National Health Service. The noble Earl pointed out that there has been an increase in the incidence of heart attacks, but he did not say that there has been an increase in homelessness. There has also been the biggest increase in the history of our nation in bankruptcies; and how sad it is to have to relate that there has also been a massive increase in suicides and a tremendous increase in unemployment!

What I find difficult to understand is that we can talk about the amount of money which is being spent on the NHS while at the same time experts in defence unanimously condemn the multi-millions that are being spent on the Trident nuclear weapon. Therefore, I have to say that the Government should not endeavour to get the care of our people on the cheap, because what is happening is that all sectors are suffering. The Government are spending more, but the service is decreasing. At one time it was the mentally handicapped who suffered most. Now it is the specialist hospitals, the general hospitals and, what is terribly sad, the children's hospitals. Therefore, it is easy to understand, as the Motion states, the "public and professional anxieties".

Of course the general public have anxieties and are worried, but, to their credit, so are the great professions. For example, the Confederation of Health Service Employees, which look after the rights of our nurses, midwives, ambulance staff and so on, are particularly concerned about the dirtiness of hospitals. Privatisation has brought more danger to hospitals because of the inefficient manner in which hospitals are being, so-called, cleaned. COHSE is worried about staff reductions and the recruitment and training of nurses, midwives, ambulance crews and ancillary staff, and all these people know what is going on. I ask the Minister to understand that they are making serious complaints, not about another ha'penny on their pay but because of the terms under which they are now being asked to work, which can only result in damaging the profession's endeavour to cure the patients—and that ought to give us very real concern.

The British Dental Association was mentioned by the noble Lord, Lord Colwyn, and I support him in what he said. They have written to me because they are alarmed at the closure of community dental service clinics in various parts of the country, and they have given me as an example the Richmond, Twickenham and Roehampton health authority, which has decided to close four clinics. The British Dental Association have put in writing, beyond all peradventure, for everybody to read, that the district health authority blatantly states, "Yes, it is a terrible thing but we are doing it to save money". In this day and age that is something which ought to give even this Government some concern, because these clinics to which the British Dental Association refer provide state school inspection for 11,500 children and they consider that this health authority's attack to save money is an attack on children, the socially disadvantaged and the underprivileged. As the noble Lord, Lord Colwyn, has said, the consequence thereof is that the British Dental Association are totally opposed to what the Government and the health authorities intend to do, and it is their desire that Parliament and the people should know that.

Lord Colwyn

My Lords, in fact, it has now been decided that these clinics are not to be closed, so the noble Lord's anxieties are unfounded. The British Dental Association certainly put many questions to the DHSS, but these clinics are not now to be closed.

Lord Molloy

My Lords, that is very welcome news indeed, and a great deal of credit can go to the British Dental Association—the noble Lord nods his head—because in no way was that the Government's decision. They would have loved the clinics to be closed. The noble Lord and I will agree that it is his profession that ultimately forced the Government to change what they are pleased to call their mind.

As the noble Lord said, there is another aspect of patient charges. They are now too expensive and many people cannot afford to visit the dentist. As I understand it, on 25th April this year, there will be another rise of 25 per cent. Obviously that will mean that more people will not be able to afford to go to the dentist. As the noble Lord, Lord Colwyn, said, they want to go not merely because they have toothache or because they want a filling. Much of it is concerned with preventive medicine—the prevention of tooth and gum decay.

As was pointed out to me by my dentist, one of the things all dentists are looking for, just in case it is there, is an indication that will show swiftly and quickly whether there is an element of cancer of the gum. When the new charges are imposed and people do not go to the dentist, they will find later that it is too late to have something done. The dentists are alarmed by this because they feel, as I do, that it is a form of means test. We ought to stop this kind of practice.

I should like to ask the Secretary of State through the noble Earl, Lord Caithness, whether the review body for dentists' pay and conditions is alarmed. The review body has always been totally independent, but as I understand it, the Secretary of State, or one of his Ministers of State, is to have talks with the body before it makes its submissions. Such a thing is unheard of. I hope it is not true, but if it is, I trust that the Minister will quickly step in and stop it, because it would be a disgraceful thing to happen.

I should like to have dealt with very many other matters, but I shall mention only one or two. First, the noble Earl, Lord Caithness, to a degree criticised organisations such as the Association of the Pharmaceutical Industry and the British Medical Association. I admire his courage—and we all know where courage sometimes stems from. It really is a serious matter when Parliament is prepared to disregard the British Medical Association, which represents the majority of Britain's doctors, and the Association of the Pharmaceutical Industry.

In this connection, I should like to turn briefly to the proposition for a limited list of drugs. The BMA's strong case differs from the case of some industrial lobbyists. The BMA believes that we must get back to the principles on which the NHS was created; namely, that prescribing for patients should in no way be inhibited, and that there should be no fear of prescribing for a patient because of his inability to pay. That is a fundamental principle to which we should all stick.

The BMA has said that the Greenfield proposals were a basis for formal negotiations. The rejection of the working group's considered advice, the hasty publication of the proposals without consultation and the need to seek what The Times leader of 30th December described as "closet advice" long before the consultation period has expired, all pointed to a too-hastily conceived cost-cutting exercise. That must be answered.

The BMA goes on to deal in the Lancet with other aspects of the drug industry's campaign and its own campaign. I shall read just the end of the article, which I think is worth bringing to the attention of the House and the Minister: Ministers such as the Under-Secretary of Health, Mr. John Patten, insist that the drug industry's campaign is an attempt to frighten the poor and elderly into believing that they will have to pay for essential medicines". The doctors of this country say that that is just untrue.

We are left to seek one thing from the Government. Will they now start talking to the professional bodies? Will they not put in front of them anything which will compel them to have second thoughts on whether they wish to talk with the Government? Let there be no conditions whatsoever. Let our doctors and our dentists and the representatives of our nurses and ambulancemen get together and have a free, sensible and intelligent discussion with the Government.

I should like also to mention the position of the voluntary organisations. In short, the voluntary organisations connected with our health service and our social services are in despair. Age Concern, for example, and the National Old People's Welfare Council, with their 1,300 local groups—pioneers in voluntary service—are gravely concerned about the Government's financial cut-back policy. These are people with a history of devotion and sacrifice. On their behalf I ask the Government to consider their plea.

The principle of the National Health Service is that it gives consideration not to this or that sectional interest, but to all the British people. It seems to me that the cancer of privatisation in the NHS will slowly destroy that great principle and undermine a contract entered into by the British Parliament with the British people. Will the Government acknowledge that the NHS should have lifted from it this frightening shadow, which is also a frightening shadow over millions of people and millions of homes? The NHS has enabled people to live longer; it has reduced pain and suffering; it has produced a higher standard for our medical profession. The threat of its diminution and of these principles and standards and, perhaps, of its ultimate demise is a very serious matter. That is at the root of the very grave anxiety of both the professionals in the NHS and ordinary people.

In conclusion, all of us in this Chamber should show resolve to make every endeavour to allay that fear. The Government should join with us, with people in all political parties, with those in none, and with people in all the great professions to see that the anxiety that now exists in this nation about our great National Health Service is removed once and for all.

7.17 p.m.

Lord Prys-Davies

My Lords, I, too, should like to thank my noble friend Lady Jeger for having prompted this debate. The Motion is in two parts. It deals with the NHS in one part and with the social security system in the other. There have been many changes in social security since the two Acts of 1980, but we have been led to believe that radical changes in its role, and indeed in the role of the welfare state, may now be under consideration. We await with some apprehension—some people with mistrust—the recommendations which may well emerge from the four reviews of the whole range of social security. As we heard this evening, these have been described as the most wide-ranging reviews since the Beveridge report of 40 years ago. But they have also been described as being far removed from the Beveridge report.

I would agree with the right reverend Prelate the Bishop of Carlisle that there are a number of grounds for concern about the reviews. Indeed, I think I could adopt almost all of his comments on the reviews. One ground for concern is that the work has been undertaken by small teams of individuals, some of whom are associated with the Institute of Directors, and one of them at least with the Adam Smith Institute. They are people who have very strong views or prejudices as to the way they think things should go, whereas we wish to have the review undertaken by a Royal Commission, consisting of experts in the field, which would collect all the relevant evidence, test all the hypotheses and publish the evidence which had been submitted. Therefore, I go along entirely with the right reverend Prelate the Bishop of Carlisle when he, too, called for a Royal Commission.

We have read reports from witnesses who have given oral evidence to the review teams; witnesses who could not help feeling, in the light of the questions which had been addressed to them by some members of the teams, that the members of the teams were more concerned to confirm their own prejudices rather than to look objectively at the evidence. The National Health Service side of the DHSS knows to its cost how it was trapped in 1972–73 between a firm of management consultants which really did not understand the matter in hand and a Government who were in an awful hurry.

Another cause of concern is that the Government may be attracted by what appears to be simple or easy solutions which will deliver up savings to finance tax cuts. Here, I do not entirely go along with the right reverend Prelate the Bishop of Carlisle in his plea for a simple solution. Of course, we go along with a policy which aims at simplifying social security procedure, but on one condition: that is, that the simplified procedure does not lead to injustice.

I remember one of the greatest, in my view, of our Secretaries of State for Health and Social Security telling a group of us one day that it is never easy to find a solution which is both simple and just in its application. That was Richard Crossman. It is awfully difficult to find such a solution when individual circumstances vary so much, as they do among applicants for social security. Conditions vary in terms of the additional diet or special diet that they require, the additional heating requirements, the additional laundry requirements and the additional clothing requirements. They all vary tremendously; so we must be cautious when we speak of easy, simple solutions.

I hope that the Minister can assure the House that the Financial Times had it right when it reported last week that the recommendations to emerge from the reviews will be published in a Green Paper, and that he can also assure the House that the Government will not make up their mind until there have been full consultations about the merits, the demerits and the implications of the recommendations; and there has been an opportunity—the right reverend Prelate was pressing for this—for a consensus agreement to emerge.

I turn to the NHS part of the Motion. We have been told by the Secretary of State that the NHS budget for 1985–86 for England will be 5.5 per cent. higher. I have not seen the NHS increase for Wales and Scotland and I shall be grateful if the Minister can give the House this information. I concede that compared with education and housing the NHS has been relatively protected by this Government. I also accept, for what it is worth, that expenditure on the NHS is at a record level. Any conclusion to be drawn from that fact should be treated with great care and great caution because the pressures on the NHS are not constant.

We have heard this afternoon and this evening how demands are growing every month and every week, yet we hear every month and every week that a ward in this hospital or that hospital has been closed, and we hear on the radio about charities appealing for funds in order to buy equipment. They tell us that the skill is there and that the equipment is there but they are short of funds, so the charities are collecting monies in order to buy the equipment. We read also—and I want to come back to this of the deterioration due to cost-cutting exercises in the community nursing service in particular.

We have many worries about client groups in the NHS and one of my main worries is that the demands that the elderly, the very elderly and the mentally ill are making on the service are not being adequately met. This worry has been expressed on every side of the House this evening—from the Government Benches, the Cross-Benches, the Alliance Benches and the Labour Benches. I shall not go into great detail but will be content to adopt the arguments developed by the noble Baroness, Lady Cox. The need here is not simply to keep up with or ahead of inflation, but to keep up with the increase in the number of very elderly people. This has been indicated by a number of noble Lords this evening. The increase in the number of the very elderly and their increased frailty, in combination, are making heavy demands on the service.

I should like to ask the Minister this: is the department satisfied that the regions and the districts, in combination with the local authorities, have by now formulated an adequate long-term strategy to meet the needs of the mentally ill and the growing demand by the very elderly? Health Ministers—and my noble friend Lord Ennals is here and I am sure he can support me—have been talking about this problem for the past 15 years. Can the Government now, in 1985, give us the assurance that they are satisfied that the regions and the districts have formulated adequate terms for the very elderly? Will he also assure the House that the strategy and the plans are protected from cuts demanded by short-term, and sometimes short-sighted, policies?

The quality of primary care outside hospitals is important. And that is why I am concerned to read that there is widespread deterioration in the community nursing service. One hears about district nurses having to call on elderly patients in their own homes at monthly instead of weekly intervals to give them a bath or a wash-down. Will the Minister tell the House whether the DHSS has made, or is making, inquiries into the extent of this problem? Is it monitoring the nursing services available in the community?

I should now like to make a reference to the waiting lists. There is considerable public anxiety about the length of waiting lists, and the waiting times between referral and seeing the consultant, and the waiting time after seeing the consultant and waiting for admission. When did the DHSS last call on the regions and the districts to review the problem in the hospitals and especially in the various hospitals and the various specialties where the problems are at their most acute? Is the DHSS monitoring the position in those hospitals and in those specialties? Is it pressing for a determined action to bring down the waiting list? Or, has it really disengaged itself from this duty?

We know that the position varies from hospital to hospital and varies from specialty to specialty, but why should that be so? Is that a reflection on poor local management? Or is there in those districts an underlying shortage of resources of one kind or another? Or does the noble Lord, Lord Winstanley, have a point in suggesting that some consultants may be manipulating the waiting lists in order to encourage their own private practice? Have consultants been reported to the Director of Public Prosecutions for manipulating waiting lists? Is there any evidence one way or the other?

Then, there is also another waiting time which is much criticised. It is the waiting time in the clinic, or the out-patient department, on the day of one's appointment. Many patients are given an appointment at nine in the morning. They have to hang around for hours before they are seen. I recently heard of a lady, aged 73, who had been given a 9.30 a.m. appointment, but was not seen until 12.30 p.m.; and I heard of a mother and a young child having a nine o'clock appointment and not being seen until after lunch. Surely there can be no reason why the department or the regional boards or the district authorities should not be insisting on staggered appointments in all specialties in all hospitals. That is a small reform and will cost no money at all.

I would accept that we in this country, in this century, will probably never, never reach the promised land of lower demand on the health services. For that reason, if for no other, it behoves us to ensure the most effective use of resources committed to health and care. The Secretary of State places his trust in his new general managers. The management consultants got it wrong in 1973, and I am not so sure that the new breed will fare any better, as indeed most of them were in key posts in the system before they were promoted managers.

I come to my last point. It will take me no more than a minute. Is it just possible that the structure is partly at fault because it fails to give a role to the patient? In terms of good management it is almost certain that those running the health service should be constantly aware of the experience, feeling, and beliefs of patients about the way they have been treated within the service. Should we not, therefore, see the patient not simply as a patient but as a partner in the doctor-patient relationship? Who knows better than the patient who is on the receiving end—to use the words of my noble friend Lord Stallard—how well the system is working? Therefore, should not the department be insisting that the districts should be building, within their own structure, a patient affairs department to conduct an on-going survey of patients' experience while patients, and to put this information to the positive advantage of the service? This again would be a very small reform, but I believe it would be a small reform that could lead to very beneficial results for the service.

7.36 p.m.

Baroness Macleod of Borve

My Lords, first of all I want to start by apologising to the noble Baroness, Lady Jeger, and also to my noble friend the Minister for not being here during most of the debate. I had to leave the Chamber because I was almost suffering from hypothermia at the beginning, and I also had a very important meeting which is really part of this debate this afternoon. I thank the noble Baroness for introducing this debate, which most of us would think could have taken two days as it is really in two separate parts.

The proposals that the Minister has let us see, through perhaps other sources, on the social services side of this debate, are, I hope, only proposals and, having said that, I hope that the Minister will take back everything that we say here tonight and discuss it. Indeed, I am sure he will before coming to a conclusion about anything that he has in mind for the future, certainly on the social services side.

I start, my Lords, with the health service. I am so glad to hear the figures that the Minister gave us this afternoon. I was not aware of them at all. The escalation in the numbers of people being treated both in and out of hospital, the way that the turnover has increased, I think certainly speaks very well of the the National Health Service: I do so agree with the noble Lord, Lord Winstanley, who is not in his place, when he says "Don't knock the health service". I do think that we do not pay sufficient tribute to the service. Those who are patients pay tribute, but there are those of us who cling on to some story or another that gets into some newspaper and who think that the health service is crumbling and is of no use to anybody. That is absolutely wrong and completely without foundation and I hope that even this debate may help to tell the public at large that the National Health Service is a very good and a going concern.

I should, however, like to make one plea. It is too late for one hospital, but I make a plea for some of the other hospitals that more notice should be taken before any hospitals are closed. The South London Hospital for Women is about to be closed, and that is a very great shame indeed for that part of the National Health Service.

I think we now all know that the large hospital is neither beautiful, nor wonderful, nor even viable, and that the smaller hospitals though they are not necessarily the ones where the better treatment is given are certainly happier hospitals than those great big barracks where everybody gets lost. I do hope that in the future the Minister will, before closing a small hospital, take far more into consideration the needs of the local people.

I want to speak primarily, and shortly, about the social security part of the debate this evening. This part of the debate is the most worrying to those who have some knowledge of the problems of the homeless of all ages, the unemployed and the law-breakers. In my view, they are all part of the same unhappy pattern. They all need help. The Government, I am sure, are quite right to try to get the best possible for the taxpayers' money, but all the proposals must be approached by the departments involved in a humane and caring way. Sometimes we feel that the departments are too far away from those who are in dire need.

It is suggested that the amounts allowed for sheltering the homeless should be uniform and centralised: one amount for London and another for outside London. That, I feel, is absolutely sensible. People in this field whom I have contacted agree that it does not seem to be right that there should be differentiation between borough and borough for the same people. But the allowances must be adequate. Otherwise, the, unfortunately, greedy landlords will cram more people into their accommodation to give them the same profit and the lodging houses will become even more sub-standard. In future, I should like to see that the value for money is ensured to protect people in all accommodation. There should be more rigorous inspection to see that health, hygiene, fire risk and other standards are upheld. CHAR, which is well known to all noble Lords, has been trying for years to bring forward its Bill on houses in multiple occupation. Perhaps in due course the ministry will look at that.

As a magistrate, I am worried about the vulnerable age group of the 16 to 17 year-olds. Such young people may want to get a job and there may be no job for them in the area in which they are living, so they leave home to seek fame and fortune where they think the grass may be greener, but they have no idea of the problems that they face without a home. They need protection, guidance and help. It is no good telling them that they must stay in their own area. Some young people have to leave home. They may be in a one-parent family or a growing family, and perhaps there is no room for them and they are told to get out directly they have left school. No matter how great is the carrot that they are offered of further education, if young people want to get away, perhaps from an unhappy home, they should be able to do so and to find accommodation and money to help them along the way.

I am hoping that the Minister will take particular note of this plea. I have read—and I hope that this is correct, because I have not had time to check it—that the Westminster City Council, which administers Bruce House, has been refused permission to make it habitable for 400 people. To those people sleeping out in this weather, that decision must seem rough justice. I hope that it will be reversed.

However, there is some good news which noble Lords may have seen. The London Boroughs Association has issued an interim schedule of 69 single-homeless and other housing organisations recommended so far by its association to receive grants under the London-wide arrangements following the abolition of the GLC. It says that that illustrates its concern that future grant arrangements must be preserved for the vital work of the voluntary organisations.

Here I come to the end of my few remarks. I hope that your Lordships will bear with me. From my knowledge, I want to pay tribute to the many thousands of people in our country who give of their time voluntarily to help in both the centres of activity about which we are talking tonight. I have the privilege of being chairman of all the Leagues of Hospital Friends, in which there are half a million workers. The local people raise for their hospitals about …14 million a year. They also give of their time, love and service to help within those hospitals. These are people of all ages, from 15 to 80-plus. They give of their devotion. I should like to pay tribute to them.

I should also like to pay tribute, as I gather did the noble Baroness, Lady Robson, to those who help the homeless throughout London and in some of our other cities. Last Christmas, at the Open Christmas which is organised by the charity Crisis at Christmas, which my late husband and I started in 1967, 957 people came to volunteer their services on a rota system to look after the single homeless who had no food, nowhere to go and nothing to do over Christmas. I think that it says a very great deal for the voluntary part of our society today that all those people came forward and for six days and six nights we were able to help about 800 people a day with three meals.

I should like to close on that. All is not black, or even gloomy. While we have people who help us in these two branches of our work, we should be very proud.

7.47 p.m.

Lord Pitt of Hampstead

My Lords, like other speakers I am grateful to my noble friend Lady Jeger for introducing this debate. I was a little shattered by the complacent speech of the Minister. It is all very well to say that one is spending a lot of money on a particular job. If you are not doing what is required, you are failing. I remember when I was in County Hall and there was the question of flooding. The banks were always being built up a few feet every year, but there was still the threat of flooding, so in the end we built the barrier. I want the Government to think of these issues in that light. The question is not whether they are spending more money on the health service but whether they are meeting the need; and we are not meeting the need.

The Minister says that the waiting lists are shorter, but I have a survey here which says that waiting times are longer, and they have been getting longer over the years. The waiting time between 1983 and 1984, not only for an out-patient appointment but, after the appointment, for admission to a hospital, has extended considerably. What is more, it is not evenly spread. In some specialties it is not too bad, but in others—and the noble Lord, Lord Prys-Davies, mentioned orthopaedics—it is terrible. This is one situation.

There is also another situation. It is the one that worries me most, for reasons which members of this House will not know. It is this question of kidney dialysis. It is a field in which we are deliberately forcing doctors to play God—which is wrong. In this country, for example, in 1983 we provided 33 dialyses per million of the population compared with 102 per million provided in America. In the profession it is generally felt that if we could meet 50 or 60 per million we would be doing well and that we should be trying to get there. I gather the Minister asked all regions to try to reach 40 per million. That is progress. But it is no use not trying to meet this particular need.

In this country we do quite well on renal transplants but not all patients are suitable for these. Renal transplants are limited by the amount of kidneys that become available from other people. Therefore, we must concern ourselves with renal dialysis. By a proper programme of renal dialysis we can keep most kidney patients alive and functioning. Therefore, what is required is a very much larger programme for this.

On a previous occasion in this House, when we were debating the health service, I mentioned that the Government ought to consider treating this question of the provision of resources for kidney patients on a national level. In other words, we should provide resources at a national level and make sure that we have the requisite resources available for meeting this need.

I believe that it is necessary for the health service to provide resources at different levels for different things. When I mentioned renal treatment as one of the national requirements I also mentioned haemophilia. They are the things that ought to be dealt with at national level. The resources should be provided from the centre. I believe it is done now for children's services. There is no particular reason why it cannot be done for something like renal services. I should like the Government to give serious thought to this because there is an area in which we have an effective treatment which we can carry out but we do not have enough resources with which to do so. This is ridiculous. We ought to see that we remedy this.

I heard only today of a regional authority that was attacking a particular hospital to try to curb its expansionist policies as regards kidney units. I found that staggering but it is a fact; a doctor told me that that is so. I hope the Government will look at this matter and take a sensible view on it.

There are other areas of worry. They have been touched on by others. For example, there is the case of the elderly. The noble Countess, Lady Mar, the noble Baroness, Lady Cox, and the noble Lord, Lord Prys-Davies, have touched on these issues; therefore, I will not delay the House by repeating them. I just hope the Minister will convey to his right honourable friend the worries of people who see that there is an increasing problem arising in relation to the elderly.

As regards the subject of drug abuse, we have had two debates on it. Again it has been raised. However, I hope the Government will continue to recognise that the victims of this drug abuse, the drug addicts, need the attention of the community and need adequate treatment, and that you cannot have adequate treatment without adequate resources.

I want to touch on this question of cervical cytology. The figures I have indicate that we are having an increase in cervical cancer and that we are having it in the very age group which the Government are suggesting we do not need to screen. I do hope the Government will take these matters on board.

Then, there is all the worry that now faces the Medical Research Council and the UGC. The combination of a cut in the grant to the Medical Research Council and, at the same time, reduction in the grants to the UGC, spells some difficulties for the profession not today but tomorrow. We ought not to be merely dealing with problems of today but we ought also to be ready to see the problems of tomorrow. Therefore, again I hope the Government will watch this point.

Take the Government expenditure plan. It has been touched on by the noble Lord, Lord PrysDavies—one of the advantages of speaking late is that you can then pass over matters because other people have touched on them. However, this matter is quite important. It seems to me, from the projected expenditure, that we may be able to get through this year but in the following couple of years we shall have problems.

I well understand why the Government are so adamant about the limited list: it is because their expenditure programme is predicated on it. All I want to say to the Minister tonight—because we have previously had a debate on a limited list—is for Christ's sake look at the issue in the way you ought to look at it. There is a marked difference between a compulsorily enforced limited list and a recommended list. If you have a recommended list, the chances are that most doctors will use it anyway; but they will not feel that their clinical judgment is being challenged; they will not feel that the Government are trying to treat patients themselves. On the other hand, a compulsory limited list is an anathema to the profession and there will be problems as a consequence of enforcing it. So I beg the Government just to think again on this issue.

One of the things that can be done to reduce expenditure on the service—oh no, I am using the wrong word; you cannot reduce expenditure on the service; but one of the things you can do to make the expenditure on the service more effective is to have more services carried out by the family practitioner service. The ratio of cost of the one to the other is so tremendous that if the family practitioner service can undertake many more services than they are undertaking at the moment much benefit would flow. I am thinking seriously of matters like a shorter stay in hospital for patients and then their being looked after by their GP. I am thinking also of day surgeries where patients are operated on and sent home on the same day and then looked after by their GPs.

Quite apart from the matters that were mentioned by my noble friend Lord Rea there are many ways in which the general practitioner services can do more than they are doing at the moment. They could carry out minor surgery. Where there is a good practice, an operating theatre could be established for this purpose. There are many things that could be done by the GP services. The Government should be thinking in these terms.

However, it cannot be achieved simply by employing GPs and telling them to do it. This is where the social services come in. There will be need for back-up services provided by social workers, health visitors and district nurses. That is the only way to proceed. We have to stop departmentalising our expenditure. There is a great need for the Department of the Environment and the DHSS to be working together. The steps that I advocate cannot be achieved if patients live in bad housing. The patient has to be adequately housed in order to benefit. Therefore, housing is just as important as any of the matters we have been discussing. We cannot continue to deal with matters separately; we have to examine the field as a whole. It would be nice to sit back, look at the situation and see what can be done to get things moving.

No matter to what extent the Government boast of increased expenditure, the fact remains that this country spends less per capita on its National Health Service than any of the countries in Europe, or the United States, Japan and Australia. All these countries spend more per capita. What is more, with the exception of Japan all these countries provide a higher percentage of gross national product for health services. We have to stop being complacent. Of course, the idea of a National Health Service is terrific. We spend less than most people because the National Health Service is a more efficient way of using resources. In the United States, spending per capita is three times higher. I am not suggesting that we should follow that example. Spending is higher in the United States because its method of providing services does not conserve resources; it wastes resources.

I am suggesting, however, that although resources are not infinite there is a level that we must try to attain. We have not attained that level. It is not that difficult to move up a little. I gather, for example, that the Chancellor of the Exchequer is talking about reducing income tax. Half of that, half of a penny, would provide a good sum to use on the health service. By adding another 50p to a bottle of spirits, another 3p to a pint of beer and another 20p or 30p to a packet of cigarettes—I do not think we could touch wine—we should obtain another £500 million. It is not the case that we cannot do it. If we have the political will, we can meet the needs.

The objective should be to meet the needs of the community. It is no use being complacent, throwing figures about and saying that one has done more than one's predecessors. It does not matter one way or the other. If you are not meeting needs, you are failing. I recognise that the Minister cannot give commitments tonight, but I hope that he will take up the matter with his right honourable friend and will tell him that it is not all that difficult to do what is required to preserve the National Health Service—something of which this country can be proud and which it must preserve.

8.5 p.m.

Baroness Fisher of Rednal

My Lords, I, too, should like to thank my noble friend Lady Jeger for introducing this debate and all noble Lords who have contributed to it. My noble friend Lord Stallard said he would speak about two specific issues. I wish to concentrate on one particular issue; that is, the mentally handicapped. I am in full support of the principles behind the policy of care in the community—that, wherever possible, mentally handicapped and mentally ill people should not be cared for in large institutions but should receive the care that they need within their own local communities. I recognise that this policy is not an easy pattern of care to implement. I also agree that some improvement in the provision of community-based care for the mentally handicapped has been accomplished over the past 10 years. However, it must be acknowledged that the progress has not been sufficient.

"Care in the community" are words that have been used by most noble Lords who have spoken. But those words are interpreted in many and various different ways to suit, perhaps, the various ways in which people intend to operate the policy. What we have to accept—this was a point made by the noble Baroness, Lady Cox—is that it is normally care by the community. The onus, as the noble Baroness said, must not simply be placed on the carers—normally the family and, particularly, the mother. A move out of hospital, whether for a child or for an adult, should not leave them worse off in respect of their care. That happens if there is not a clear-cut philosophy about community care.

I am involved to a certain extent with the mentally handicapped. I am aware of the very good practice inside many large mental hospitals. We have no need to decry them as places that have not seen progress or change. They have been the Cinderella of the National Health Service for a long time. Those working in these hospitals, especially the progressive ones, recognise that there is now a different attitude towards care of the mentally handicapped. While agreeing that people should be brought out of hospitals, it is important that those who work within them and who have provided care for so long should know that they have performed a yeoman task and that they have faced up, so far as possible, to modern forms of care.

However, families and professionals are becoming increasingly concerned about recent media reports that mentally handicapped people are being abandoned in the community. Living in the community is not just a matter of finding individuals bed and breakfast accommodation and then leaving them to walk the streets throughout the day. That is what is happening. I see it happening at a park near where I live in Birmingham. I do not know about the rest of the country. It worries me when I see it. If this happens, we are probably putting at much greater risk those who are in what is considered a much more humane situation in the community.

If community care is to be successful, success has to be measured, as the noble Lord, Lord Pitt, said, on the help it is going to give, and in this case that help is to the handicapped. Sending people out of hospital, or preventing people from needing hospitalisation, will be an ongoing financial commitment, a very heavy financial commitment. This is not a cheap option. I think that at one stage the Government thought it would be; but it is not, because it is very staff intensive. It cannot be just bed and breakfast, as I said: it needs holiday relief; it needs weekend relief; it needs crisis relief; it needs home helps; it needs day activities for people: it needs recreational clubs. We are all aware that the resources of adult training centres do not in any way meet the demand.

Again, as the noble Lord, Lord Pitt, said, the community health team needs not only general practitioners and social workers but also physiotherapists, speech therapists, occupational therapists and psychologists. All these people are in short supply. I would ask the Minister whether he is satisfied that there are enough of these kinds of people in training, or whether there are sufficient training places. Care in the community, in the long term, is going to involve all those specialists.

Any legislation passed by the Government without serious consideration being given to ongoing resources to be made available is double talk. Local authorities require much more positive financial incentives to enable them to develop services if care in the community is to become more than a plan. It has to be recognised that the constraints now being put on by the Government, with very much tighter control on local authority spending, and with rate capping, make joint financing much more difficult. The point made by the noble Lord, Lord Rea, about looking at joint financing in a different way needs serious consideration, because, on the one hand, local authorities are now having to work on very strict annual estimates while, on the other, the health authorities have a much longer-term planning cycle. It is very difficult for local authorities to play their full part in care in the community if they do not have the long-term planning cycle which the health authorities have.

I should like to pose two or three questions to the noble Earl. I know very well that he might not be able to answer them tonight, and I accept that. If any statistics are being kept about discharge of patients from hospitals, can he say whether the progress of the discharge of the mentally handicapped from hospitals in the community is spread fairly evenly round the country? Are some health authorities and local authorities being more progressive than others? If so, is there a pattern that the Minister should be suggesting to all the others?

The other fact which causes concern to me, as a magistrate, my fellow magistrates, and people who serve in higher courts, is that on so many occasions the courts are not able to send people to mental hospitals or any other units because there are no places available. These people find themselves placed in prison. I should like to ask the Minister a question about the regional secure units. I think he must agree that they have made a very slow start. Can he tell the House the number of units that are open, the number under construction and the number that are in the planning stage? What percentage of those were envisaged under the national programme? In other words, are we three-quarters of the way through the national programme, or have we fulfilled only 2 per cent. of it? Will the closing of the large mental hospitals cause difficulty in making provision for those secure units which are not at present in a programme?

Like the noble Baroness, Lady Cox, I am concerned that there ought to be some monitoring of the care in the community programmes. I should like the Minister to look at monitoring of the breakdown cases, where people have had to be returned to hospitals from the community. He should ascertain the reasons why they have had to be returned—whether there has been a failure at local authority level, or whether it has been a failure of the condition of the person. If we are to have a radical change in the care of the mentally handicapped, it has to be monitored very quickly.

I want to refer now to the point about children in hospitals for the mentally handicapped. I am fully aware that the number of children in hospitals for the mentally handicapped has been reduced very substantially. The figures given to me—they are from a source which can be trusted—show that there has been a decrease of approximately 50 per cent. in the number of children in these hospitals—from 2,421 in 1980 to 1,250 in 1983. Are there available any records to show where these children are now? It is important, especially with young children, to find out where they are. All mentally handicapped children, however severely disabled they are, are entitled to education provided by the local education authority. It is important that parents should be made more aware of this than they are. We had a debate in this House on the 1981 Act relating to special education. The law is still very weak in regard to education for the handicapped up to the age of 19 years.

My greatest concern is for all parents who care for handicapped children. At present the majority of such children are being cared for at home by their parents. As has already been said, very often this is a great strain on families and on marriages. When you speak to mentally handicapped groups, the main question of the parents is: "What is going to happen to us as we get older and cannot cope, and what is ultimately going to happen when we die?" That is always the fundamental question you are asked.

I end my contribution to this debate by supporting what the noble Lord, Lord Prys-Davies, said about recognising that there is an urgent need to face up to the challenge of long-term care as the large institutions are closed. What is going to replace them in the long term?

8.20 p.m.

Lord Banks

My Lords, the whole House will be grateful to the noble Baroness, Lady Jeger, for initiating this debate this afternoon. We have had a wide-ranging debate, but, of course, the terms of the Motion are themselves very wide. As far as the National Health Service is concerned, I think that there have been two sentiments predominating in our debate; namely, the sentiments of pride and anxiety—pride in the achievement of the National Health Service and anxiety that we may allow it to decline. My noble friends Lord Winstanley and Lady Robson spoke about that matter, and I just want to add the comment that the confident statements that are made by Government spokesmen in this House about the current position of the health service always seem to me to contrast very strangely with what one reads in almost any local paper that one picks up.

I should like to concentrate on that part of the Motion which deals with social security. The Motion mentions the changes in the social security system. One of those changes was referred to by the noble Baroness, Lady Jeger, when she spoke about the greater reliance on supplementary benefit, which has been one of the less fortunate aspects of our social security system in recent years. Of course we know that the main cause of that is the great increase in the numbers unemployed.

The noble Lord, Lord Wells-Pestell, spoke about the cuts which there had been in social security, and I think particularly of the cuts imposed by the two Social Security Acts of 1980, after which the then Secretary of State said that £1,500 million per annum had been cut off the social security budget. Then there was the reform of supplementary benefit, but it was conducted on the basis of "no cost". There was to be no additional cost as a result of that reform, although it is generally recognised that the supplementary benefit level is not really high enough. That is the view of the Social Security Advisory Committee.

The noble Lord, Lord Stallard, spoke to us about the introduction of housing benefit. He went into that matter in some detail and pointed out that, although the aim was good—namely, to get rid of the choice between rent and rate rebates, on the one hand, and supplementary benefit, on the other, with many people taking the one that did not suit them best—it had been introduced with a considerable degree of muddle. We on these Benches have always been doubtful about the wisdom of handing this over to local government. No sooner was it introduced than we found that it was being cut.

Age Concern has said in its evidence to the housing benefit review: Age Concern has come to the conclusion that the Housing Benefit Scheme contains so many inherent defects that it cannot be made equitable and efficient in its present form". Another change was the introduction of statutory sick pay. The information about how that is working is only now becoming available, but even so there is a Bill before Parliament to extend the eight weeks to 28 weeks. Another change was the change in the available scale margin. If I have the figures right, that resulted in a net saving of £65 million from the pensioners' heating addition.

The noble Lord, Lord Stallard, the noble Baroness, Lady Jeger, the noble Baroness, Lady Robson, and the noble Baroness, Lady Macleod, all referred to the board and lodging arrangements, which are at present subject to a freeze and which are shortly to be the subject of further changes to be brought before Parliament. The Government have been alarmed at the escalating cost, but it is by no means clear that that escalating cost is due to higher charges: it seems to be largely due to greater numbers. I thought that the noble Lord, Lord Stallard, dealt with that particular point very thoroughly. There is no doubt that there is a considerable fear of hardship as a result of these new arrangements (as far as we understand them at the moment) and it is not surprising that there have been 500 representations, as the noble Lord, Lord Stallard, pointed out, to the Social Security Advisory Committee.

Another change has been the introduction of the severe disablement allowance. That allowance, fortunately, got rid of the household duties test. That change was welcome, but through the disability qualification it kept out most of the married women who did not previously qualify for the housewife's non-contributory invalidity pension. The Government made very clear that the reason for that was the cost. They did not oppose in principle bringing in all the people who were not previously eligible, but there was the problem of cost.

Another change which I do not think has been mentioned in our debate is the continual decline in the position of people with families in relation to the rest of the community—a point which the Child Poverty Action Group are always stressing.

I have mentioned nine changes, and, on the whole, I do not think that they are changes for the better. Of course there have been some improvements. The noble Earl, Lord Caithness, mentioned a 6 per cent. increase in supplementary benefit, which is welcome as far as it goes. The noble Earl also mentioned that retirement pensioners had had a real increase in their pension during the term of the present Government. That is true, although he did not go on to mention that the Government had broken the link with earnings and, of course, it is the link with earnings which ensures that from time to time pensioners get an increase in real value. There are undoubtedly still grave inadequacies which are admitted by the Government.

The right reverend Prelate the Bishop of Carlisle reminded us that the long-term supplementary benefit rates are not available to the long-term unemployed, although it would seem to be logical and just that they should be so available. The noble Baroness, Lady Cox, the noble Lord, Lord Rea, the noble Baroness, Lady Fisher, and others spoke about the importance of care in the community. There is a very real need for a "carer's" allowance. The invalid care allowance is too small and too restricted.

There is also the need for a disability income. The Government agree that that is so, but feel that it would be too costly at the moment. There is also the question of abolishing the earnings rule. I think that the noble Baroness, Lady Lane-Fox, referred to that matter. She certainly referred to the therapeutic earnings rule, but I think that she also referred to the pensioners' earnings rule. The Government are committed to abolishing that, although they are somewhat tardy in doing so.

There is also the situation of old-age pensioners, where the oldest will be the poorest, as far as the state pension scheme is concerned, well into the next century. The House of Commons Select Committee on Social Services and the Social Security Advisory Committee have both said that resources will have to be found to rectify that position. Of course, we are putting the burden of pensions on to future generations, which I have never thought very wise.

But the overall picture seems to me to be one of cutbacks, of "no cost" alternatives, of acknowledged inadequacies, of some improvements, but often with more losing than gaining. The Government want to do more, and they say that they want to do more, but they cannot afford it because, as the noble Baroness, Lady Jeger, said, they are obsessed with the need to keep Government spending down.

Moreover, there was alarm at the fact that, as the noble Baroness, Lady Lane-Fox, pointed out, the real cost of social security during the lifetime of this Government has increased by over a quarter. But, of course, we know that that is due very largely—to the extent of over 60 per cent.—to the increase in unemployment as well as to the fact that there are more pensioners now (which we knew would be the case) and, unfortunately, more one-parent families, as the noble Earl, Lord Caithness, himself pointed out in his speech. It seems that the cost is now stabilising at 12 per cent. of gross domestic product. But is that a reasonable level? Is 12 per cent. the right level or should it perhaps be 14 per cent. of gross domestic product?

In trying to find an answer to that question, we must hear two things in mind: first, that social security payments are transfers of income—they do not consume resources as does building a hospital or building a school; and, secondly, that transfers of income can be made through the social security system or through the tax system. I want to ask whether our present method of assessing the cost of transfer payments is sound. It was rumoured a little while ago—in fact, I think that the Chancellor himself indicated this—that at that time he had in prospect £1½ billion to play with in his Budget next month. If he spent that on raising tax thresholds, it would mean no increase at all in public expenditure. But if he spent it on giving each person a cash payment equal to the saving which they would get through the raising of the tax thresholds, £1½ billion would be added to public expenditure. Yet the position would be exactly the same, would it not? and the economic effect must surely be exactly the same.

If the Government put into practice the second of the two alternatives, the cash payments would be of different sizes because of the different rates of tax. But suppose the Government wanted to give all adults an equal payment and said that those paying tax could have it deducted from their liability to tax, whereas those not paying tax would draw it, say, at the Post Office, then only the amount drawn by those not paying tax would count as public expenditure. Incidentally, that is how a tax credit scheme would work. Redistribution to the rich too—and this is important to remember—can be achieved by reducing the higher rates of tax, and that does not count as public expenditure.

The idea that further transfers upwards towards the rich do not involve public expenditure while further transfers downwards to the poor do, purely on account of the mechanism used and, therefore, they must be avoided as far as possible for the sake of the public sector borrowing requirement and the medium-term strategy, sounds highly suspect to me.

Is there not a case for keeping transfer payments accounts separate from Government expenditure accounts? That of course would be facilitated by a tax credit system, because, instead of tax transfers and social security transfers, there would be one system of credits. You could have a Government spending account dealing with resources; you could have a Government transfer payments account. If you combined income tax and national insurance—at the present moment at 39 per cent.—you could split the income between the two accounts, with one share going to the transfer payments account plus a social security tax for employers to replace national insurance contributions. That would pay for the transfer payments account.

The two accounts would not necessarily be governed by the same criteria. You would have to consider the effect on incentives of the transfer payments account and on the balance between spending and saving. I think that much more research must be done before we can say what is a reasonable level of transfer payments to have at any one time. Until we carry out that research and are able to come to a conclusion, there is a danger that governments will go on trying to keep the social security budget down as low as demographic trends, unemployment figures, public opinion, the nature of the present system and their own conscience will allow, without any coherent idea of what level of transfer is just and feasible at any given time, and Motions like that of the noble Baroness will continue to appear on the Order Paper.

8.35 p.m.

Lord Ennals

My Lords, this has been a very valuable debate and of course in this House we have a vast wealth of experience. I hope that the noble Earl who is to reply will ask his right honourable friend the Secretary of State to read this debate, because it has been very interesting. Last week we had a debate on the Government's proposed limited list for prescribing. Not a single speaker in that debate except the Minister supported the Government's proposals. In today's debate, with only one exception, every speaker has been critical of the Government's approach. I believe that the Secretary of State for Social Services should have his attention drawn to this debate.

I entirely agree with the noble Baroness, Lady Lane-Fox, that the National Health Service is not breaking up and anyone who said so would be quite unwise to do so. But it is creaking; the quality of service in some areas is deteriorating. However, it is still a great service. All of us who care for it must ensure that it is not undermined. The noble Earl has a very difficult task ahead of him. It is rather hard on him to have to open a debate and then wind it up and at the same time have to answer 372 questions. However, I am sure that he will do his very best—he always does.

I should like to welcome the mood of the approach of the noble Lord, Lord Winstanley. He said that where we on these Benches agree, we should work together. I want to repeat that. Where we agree, whether it is about the health service or anything else—and this also applies to Members on the CrossBenches—we ought to work together. There is so much common ground and we should maximise that common ground.

I want to pick up just a few of the themes in this very interesting debate—I could not possibly refer to them all. Together with a number of other noble Lords, particularly the noble Lord, Lord Pitt, I was disappointed at what I felt was a very complacent approach by the noble Earl, Lord Caithness, when he read through a list of successes. What surprised me were his criteria for success in the National Health Service. The noble Earl referred to the number of new hospitals that had been opened. One has to ask: who started to build them. who planned them?—not who opened them. A period of seven or eight years elapses between the plans being made and the hospitals being opened. I am most grateful to the noble Earl for his kind words about a previous Government who planned these hospitals.

Then there is the matter of perinatal mortality. You do not suddenly change, by the flick of a wand, the figure for perinatal mortality. You have to go through a long process of building new special care baby units and the whole range of educational processes. All this takes time, and we are all delighted that, as a result of efforts that have been made, perinatal mortality is much lower than it was.

There is one other figure about which we ought to start being very careful indeed. It is the number of patients who have passed in and out of hospital and with that the number of patients who have stayed in hospital for a short period. I sometimes think that there is a link between these two aspects. If we go too far down the road of saying, "Get them in and get them out as quickly as possible", the quicker we get them out, the more they will come back in again. That can be carried to the point of absurdity. They can go out into a community that is not properly prepared to look after them and then they get readmitted before too long. They are a new statistic to add to the list, and by the time that the noble Earl, Lord Caithness, really is a Minister, he will come forward with some dramatic figures because the turnover will have been so much more rapid than it has been up to now.

I want to say a few words about resources, because I honestly believe that a great many misleading figures are being bandied around in this House and in the country generally. I should like to quote one paragraph from the House of Commons Select Committee's Fourth Report for the Session 1983–84. In it they refer to the last year's Expenditure White Paper which said: In the five years to 1983–84, expenditure on the NHS has doubled, representing an increase of some 17 per cent. measured against the retail price index and providing for significant real growth in services after allowing for the extra costs facing the NHS. The Select Committee then said: We have explored with the department, in writing and in oral evidence, the reality behind this 17 per cent. (in fact 16.6 per cent.) increase in expenditure. We sought details of what the rate of increased spending was when those 'extra costs facing the National Health Service' were allowed for: in other words, taking account of the relative price effect of the NHS over those five years. Evidence provided by the Department was that real input volume expenditure grew, not by 17 per cent. but by 7.2 per cent. We ought not to carry on misleading the country by saying that there has been a figure of a real terms increase which is not true.

When Ministers read out these figures, one wonders who they are hoping to impress. They are not going to impress the health authorities, almost all of whom—as was mentioned by my noble friend Lord Wallace—are facing a cash crisis of cuts of one sort or another. They certainly are not going to impress the professions. I was looking at a recent statement by the Royal College of Nursing. If the noble Baroness, Lady Cox, had still been here she would have applauded me. It said: Nurses want the public to know that standards of care are already threatened, that staffing levels on wards hover just above danger level and that out in the community increased numbers of patients are over-burdening community care and making good nursing practice practically impossible". In a recent letter in The Times the presidents of the Royal Colleges warned: Without adequate funding the future development of preventative medicine, health care and improvements from advances in medicine will be threatened". I give a third quote from a report by the Standing Medical Advisory Committee in October 1984. They found that, the constraint on resources have particularly significant implications for services to cancer patients. The gap between the level of services generally available and the level that it is now possible to achieve has increased considerably". I could continue with these quotes but I shall not do so, because I am simply asking the noble Earl who it is that he seeks to impress? He will not impress the public, as was said by a noble Lord on these Benches, who remarked that one reads constantly of cuts being made and sometimes one gets deeply involved in having to face the results. We have cuts threatened now at the Westminster Hospital, which is perhaps the nearest to being the hospital for your Lordships' House and Members of another place.

I find myself the chairman of a charity which is raising money to stop a vital unit in the Children's Hospital at Westminster from being closed. I find myself involved in a campaign regarding the cardiac unit which has worldwide fame, and which if it were to go would threaten the whole future of the Westminster Hospital, and the Westminster Medical School is under threat as well.

No one is going to be impressed by assurances that the figures are good. It is no good the figures being good, even if they are twisted or massaged, if the results are not good. The public knows that the services are in danger of deterioration. The inadequate resources made available by the Government—and I am certainly not blaming the noble Earl for this—are creating a serious challenge to the future of the National Health Service.

There are consequences from this cash shortage. The National Health Service is unable to respond effectively to the massive challenge of drug abuse. I do not mean just at the ports. I mean in terms of treatment centres. Happily, I was opening one new treatment centre, one detoxification centre, only a few months ago, but it is one of three detoxification centres in the whole country. I opened the other half of it when I was Secretary of State for Social Services.

I go on to another matter—it was touched on earlier today—and that is the inadequate challenge to the disease AIDS. We must say the disease AIDS, because we have heard a lot today about "aids" when we have not been referring to the disease. There are the lengthening waiting lists referred to by the noble Baroness, Lady Robson, and also by my noble friend Lord Prys-Davies.

As I understand it—unless the noble Earl can give me some figures to impress me—it is not true to assert that waiting lists for hospital admissions are not now the highest ever, except during periods of industrial action. There was a period of industrial action when Labour were in power and one when the Conservatives were in power. You have to rub out those figures. The figures that we now have for waiting lists to get into hospital are, so far as I know, the highest that they have ever been. That applies not just to how long you wait, according to my noble friend Lord Prys-Davies, to get into the hospital, but the time you have to wait before you see your consultant.

Perhaps the noble Earl may be able to confirm reports which have recently been made by epidemiologists that Britain risks outbreaks of polio and tuberculosis because of complacency over vaccination against diseases which had virtually been wiped out. We heard from the noble Lord, Lord Colwyn, the fears that the dentists have that there will virtually be no National Health Service if there are further Government cuts. We know the situation in which the opticians find themselves.

The noble Baroness, Lady Cox, my noble friend Lady Fisher of Rednal, the noble Lords, Lord Winstanley and Lord Rea, have all spoken about community care. This is a field in which lack of resources is creating monumental problems. As has been said by noble Lords and noble Baronesses, when patients are discharged from hospital if there is not a caring community ready-trained, efficient, and able to cope with them, then not only are they in a difficult situation themselves, but they may find themselves back again in hospital. They may also find themselves homeless. I was touched by the words of the noble Baroness, Lady Macleod. She referred to the campaign for the homeless and rootless, of which I was proud to have been the founder chairman.

I want to move now to the field of voluntary organisations that the noble Baroness, Lady Macleod, the noble Baroness, Lady Masham, and also my noble friend Lord Longford referred to. My view has always been that both in health and social services there is a vital role to be fulfilled by voluntary organisations in a wide range of service to the community. This was why, when I was Secretary of State, I launched the Good Neighbour Campaign and greatly increased the funds available to voluntary organisations.

The more that the community can share with the professionals the task of caring, the better it is. Theoretically the Government take the same approach. In fact they do almost everything possible to fetter the ability of voluntary organisations to do their work. I think of VAT at 15 per cent. which is hitting hard many of the voluntary organisation providing the same services as social service departments which are relieved of having to pay VAT.

I am extremely concerned—and my noble friend Lord Wallace and the noble Baroness, Lady Robson, made the same point—that, with rate-capping and the abolition of the GLC and the metropolitan authorities, many voluntary organisations are going to be hit hard. The problem that the Government are facing is how and where they are going to find the resources to ensure that many organisations do not go under.

One thing they have to do is to speed up their process. Yesterday, I was given a letter from an organisation with which I have had long contact, the National Cyrenians. The letter was dated 31st January. The first sentence said: I am pleased to be able to tell you that a final decision has now been taken on your Section 64 grant application for 1984–85". That means they have another two months to go. He did not actually say that he was delighted to say that the grant was being cut, but that was the fact. Now what does such an organisation do? It has an £8,000 cut; it is told this 10 months into its financial year; and it has no assurance about what its situation is going to be next year.

The last sentence actually made me laugh, almost. At the first one I had been laughing, but out of sadness. At the last one, I laughed perhaps out of cynicism: As a final point, perhaps I could ask you to submit your grant proposals for 1985–86 to this Department and to the Department of the Environment as quickly as possible in order that we can process matters speedily". I think they could say that again, since it was 10 months into the year before they got their reply.

I want to make another point about the National Health Service. It is also reflected in a number of other fields of Government activity. It is what I would call excessive Government interference in decisions that ought to be taken at a local level. Noble Lords will be pleased to hear that I am not going to make a speech about rate-capping or about the abolition of the GLC, or about any of those things, although it is part of the same pattern of "Granny knows best". In my recollection I do not think that there has ever been a Government which have been so bossy, so interfering, so interventionist—and this applies to the health service as much as to other things.

Privatisation is one example, as was said by my noble friend Lord Wallace. It has always been possible for local authorities to privatise. They can have their cleaning, their laundry or their catering done by private contractors. It has always been a possibility. One of the reasons why they have not done it is because it has not usually been either more effective or cost saving. In most cases now, the only way in which it is cost saving is because the people who are employed by the private sector are paid lower wages than would be the case if they were working within the National Health Service. But I hear more and more complaints about the cleanliness, the quality of service and the laundry work that is provided to those who have entered into private contracts. I do not object to them entering into private contracts: what I object to is Ministers telling a local authority (as was referred to by my noble friend Lord Wallace) that even though they have already received tenders and have done their own calculations, they must go private even though they have decided to accept an in-house contract. This is a disgraceful form of interference.

I see this, too, in the appointment of general managers. The East Anglia Regional Health Authority had decided who it wished to appoint as its general manager, and it was told that that simply was not acceptable. They had to appoint someone else—a businessman. He may be a jolly good chap, but I do not want to run across him, because I move quite freely in East Anglia. I wish him all the success in the world, but I really do not think that it is the job of the Secretary of State to start telling regional health authorities who they should appoint, any more than I think they should do so, at district level, as far as managers are concerned.

I was reading an article recently which showed that in West Lambeth Health Authority a job was offered to an applicant who was subsequently vetoed by Ministers—and I have a list of other similar situations in Wickham, in Milton Keynes and in East Berkshire. All of them have had Ministers intervening to tell them what people they should appoint or to call in their selection committees in order to see that the appointment was changed in accordance with the wishes of the Minister.

A third example—and I shall say no more than just a sentence—is the proposal in relation to the limited list of prescribing. That is one of the gravest forms of interference in the clinical freedom of doctors that we have had since the health service was created. It will come up again in this House, I assure the noble Earl. It will come up again because of this sort of intervention in the affairs of those who actually know best. I want to say to the noble Earl that the people who know best are the people on the shop floor, the people who are running the health service, the people who have to manage hospitals, the people who really live there. He really must get it out of his mind, or get it out of the mind of his Secretary of State, that Whitehall knows best, that they can always make a deduction as to what drugs should be on the list, what manager should be appointed. It really is, I believe, grossly unsatisfactory.

I have not got time to go over the field of social security, but there are two points that I shall make very quickly before I sit down. I think it was the noble Lord, Lord Banks, who in a very well balanced speech—and I am sorry that I have not said that about all the others; I thought they were all very well balanced speeches—referred to the reviews that had been carried out. I must say that I am deeply suspicious about these reviews, and I am made even more suspicious by a statement that was made this afternoon—and it is on the tape for any noble Lord who cares to see it—by the Secretary of State, Mr. Norman Fowler, in which he warned that far-reaching reforms of social security would mean that the Government would make cuts in benefits. It is not, therefore, just that this is going to be done on a no-cost basis: it is that it will lead to cuts in benefit. As has been said by a number of my noble friends on this side of the House, there have already been a number of cuts. The sort of survey which was referred to—and I agree with every word said by the right reverend Prelate the Bishop of Carlisle—is a rushed survey for the purpose of finding ways of saving money at the expense of the poor and the least competent in our society.

The final point that I wish to make—and I shall rush it because it is a huge subject—concerns the problem of the unemployed. I am not going to talk about economic policy: I am merely going to say to the noble Earl that I am convinced from all my experience today and in the past that we are building up for ourselves a terrible store of problems for the future as long as we accept the present unemployment figures. We can see already, by researches that have been carried out, the effects on physical and mental health; and we can see the effects in terms of crime. Only three days ago I was in a drug addiction unit and was talking to those who run it. I said, "Why do you think there has been this dramatic increase in drug abuse?" The young man who was running the centre said, "It's almost entirely based on unemployment"—and I believe that to be true. We are also building up for ourselves such a problem of broken marriages as will really do severe damage to the fabric of our society.

I want to say to the noble Earl that to come before your Lordships' House, where there is such a great body of experience, and to present a rosy, cheerful picture of the health and social service problems of our country is simply not good enough. I believe that I am speaking for the majority of noble Lords who have taken part in this debate.

8.58 p.m.

The Earl of Caithness

My Lords, with the leave of the House, I should like to try to sum up some of the points that have been made in this interesting debate which, by and large I have enjoyed. What I have not enjoyed listening to is the very blatant partisan approach by some noble Lords opposite which does no good to the National Health Service and only goes to lower morale. I say straight away that I shall bring all the speeches in the debate to the attention of my noble friend Lord Glenarthur and my honourable and right honourable friends in the department.

There have been suggestions in the course of this debate that the Government have failed to maintain a health service that is responsive to the needs of patients today. In my opening speech I was accused of being complacent. In no way are the Government complacent. All that I did was to present the picture of the National Health Service today. I said that we faced very real challenges and difficulties, but these cannot be waved away with a rhetorical wand, as some noble Lords' speeches have suggested. We are facing up to these problems and, I believe, in a more determined and so far more successful way than the last Labour Government did.

I will not tire your Lordships by repeating the facts and figures which I gave in my opening remarks. But, as I said then, the hard facts are that, however unpalatable this may be to some of the Government's political opponents, we have increased expenditure; the number of patients treated has gone up much faster than under the last Labour Government; the hospital in-patient waiting lists have come down; and the management of the service has been streamlined and invigorated.

Noble Lords opposite who pretend, in the teeth of the facts, that the National Health Service is being damaged do enormous harm to the morale of those who work in the service. Why do they not just join in with us in recognising that progress has been made in the last five years and that enormous achievements have been made by those who are caring for patients?

I should like to start by dealing with one point which was made by the noble Baroness, Lady Jeger, and which was also picked up by the noble Lord, Lord Winstanley. It refers to the question of the private sector. Surely there should be no ideological boundaries drawn when seeking to serve the sick. The National Health Service patients are helped by the private sector and the private sector can help the NHS service in many ways; and that should be continued.

The noble Baroness raised the question of fuel bills, and I would say to her that people on supplementary benefit can claim help if, due to a period of exceptionally severe weather, they have had to use more fuel for heating than they have budgeted for. However, it is for the independent adjudication authorities, and not Ministers, to decide whether individuals are entitled to help and, if so, how much. We are publicising the help which is available to people living in parts of England and Wales who are entitled to claim help following the recent cold spell. The noble Baroness, Lady Jeger, asked me, "What about Scotland?" That is up to the Scottish Office. There is a leaflet about this which is available from local social security offices, explaining how and when to claim. I would just add that the heating additions have been increased by more than 20 per cent. in real terms since 1978 by this Government.

The noble Baroness raised the question of resettlement and re-establishment centres. We hope that the changes we are undertaking will allow for more effective resettlement facilities to be provided at about the present cost of running resettlement units. This is not privatisation for the sake of ideology; it is not a cost-cutting exercise; we are simply looking for a better way of doing the job. The money is to be used to fund alternative provision by the voluntary sector.

The noble Lord, Lord Winstanley, raised a number of points. He spoke with very great feeling about the proposed limited list. I must say that I wonder whether he listened to my opening remarks. I said then quite clearly that the list is intended to cater for all clinical needs; so there is no case for the anxiety that he referred to. I confirm to him that the list concerns only two categories of drugs: that is, tranquillisers and sedatives and remedies for minor conditions, such as coughs and colds. Finally in this regard, may I say, in view of the noble Lord's suggestion of discussion with the medical profession, that I cannot help regretting that the BMA refused to take part in the recent consultation exercise. I hope that he can get this across to the BMA because I think that they had every chance to put their house in order, as did the opticians. We legislated for the opticians, and that has been a very great success.

The noble Lord also raised the question of dental treatment and said that the average patient pays the full cost of dental treatment. That is not so, and in fact 45 per cent. of chargeable courses of treatment are provided free because of the range of patients who are exempt from charges.

The noble Lord, Lord Wells-Pestell, raised the question of aids for the disabled, and expressed his concern on this matter. On his general point, it is true that large sums are spent on aids. Some studies indicate that for a variety of reasons a significant number of aids cease to be used by patients. The DHSS is considering whether an initiative can usefully be taken in this area.

The noble Lord also referred to the future of the guide Equipment for the Disabled. The Government provide substantial financial help for this. It is true that officials of the DHSS have had discussions with the Oxford District Health Authority, but I give the noble Lord the assurance that no decisions have been taken to end funding, and we shall look very carefully at this matter. Perhaps, in view of the hour, I may write to him on the question of savings of benefit.

My noble kinswoman Lady Masham raised the question of AIDS, which we discussed at Question Time today. With regard to Factor VIII, we are very conscious of the difficulties faced by people with haemophilia and we are aware of the additional pressures which the attendant risk from AIDS must involve for the users of Factor VIII. We decided in 1982 that the United Kingdom must become self-sufficient in all blood products. To achieve that goal we commissioned the rebuilding of the blood products laboratory in Elstree and the project is presently on target for completion early in 1986. Self-sufficiency of itself will not guarantee AIDS-free blood products, but we shall then no longer be dependent on imported Factor VIII, produced from pool plasma given by donors who are paid for their blood. In this country we are very fortunate to have our voluntary donor system. The staffing of haemophilia centres, which was also mentioned, is, in the first place, a matter for the responsible health authorities; but if my noble kinswoman has any particular instance which she would like to raise with me, I shall certainly look into it.

My noble kinswoman gave me notice—and I am grateful for it—of her question referring to the reimbursement of GPs' wives for work undertaken in practices. I understand from what she said that she was particularly concerned about the wives who were professionally qualified or whose husbands had rural practices. In fact the existing scheme provides for doctors who employ a dependent relative with a nursing qualification and for single-handed doctors who receive a rural-practice payment. I am afraid that I cannot say whether it will be possible to broaden the present scheme, but I fear, given other priorities, that this is unlikely.

A number of noble Lords and Baronesses raised the question of community care and wondered whether it was being properly evaluated. The Government have reserved £16 million for the period to 1988–89 to fund a programme of pilot projects to show how care in the community can be made a reality. The projects will be evaluated, and information about the development of community care will be made widely available. The first round contains 13 projects receiving funding for three years from 1984–85. We hope to announce shortly a selection of projects for the second round.

The noble Lord, Lord Stallard, spoke about the problems in connection with the housing benefits scheme, and asked for an assurance that there would be no more short-term cuts or changes. The noble Lord will know that I am unable to give such an assurance, but the Government are aware of the problems over housing benefit and are reviewing the scheme at present. I cannot anticipate the outcome of that review, but the Government will be publishing their conclusions as soon as possible.

The noble Lord also referred to the Government's proposals on supplementary benefit board and lodging payments, as did a number of other Lords. This is an area where expenditure was rising out of control. During 1983 it rose from £205 million a year to £380 million a year. Latest estimates suggest a further 50 per cent. increase during 1984 and 1985 unless action is taken. The noble Lord mentioned some of the reasons for the increase, but they were by no means the only reasons. There is clear evidence of abuse and of people being maintained in expensive board and lodging accommodation who do not really need to be there.

The Government's proposals were referred to the Social Security Advisory Committee in November 1984 and extensive comments on these were made. The committee's report has recently been received. We shall be considering the representations made by the SSAC before making final decisions, which will be put before the House as draft regulations during this month.

The noble Countess, Lady Mar, raised the point of the need to ensure that mentally disordered offenders receive the right treatment outside prison. The noble Countess spoke with feeling, as did the noble Baroness, Lady Fisher of Rednal, about this need and I understand their concern. I can up-date them on the figures. By the end of 1984, seven permanent regional secure units which provide such treatment were open. These will eventually provide a total of 264 places, of which about 120 are now staffed and available. In most units, the places are being brought into use in stages. Seven further permanent units providing in total 141 places were completed and undergoing commissioning. These units are expected to admit their first patients this spring. In addition, two permanent units providing a total of 128 places are under construction and are expected to be completed during 1985. Four further permanent RSUs providing over 170 places are at various planning stages.

The noble Lords, Lord Rea and Lord Prys-Davies, asked whether the Government would exempt home helps and Meals on Wheels from rate capping; and I am grateful to the noble Lord, Lord Prys-Davies, for letting me know before the debate took place that this would be one of his questions. It is a misunderstanding to assume that authorities are set limits on their personal social services expenditure. This has never been the case. The Government's control of local authority spending is based on controlling their all-services expenditure. Priorities between services are left to authorities to decide, without any suggestion from central Government that cuts should be made equally across the board. That being so, it would not be right to make special provision for particular services.

The noble Baroness, Lady Robson, asked whether the Government will continue to fund the City Roads drug crisis centre. Funding has exceptionally been provided by the department to City Roads for a total of six years up to the end of the current financial year. This year our funding totals £39,600. The project is also in receipt of grants totalling about £225,000 from the Home Office and various statutory authorities. Taking into consideration income from hostel rents normally met by social security payments we are confident that the project should be able to provide a valuable service within the resources available to it. I should add that, as indeed the noble Baroness suggested, City Roads has applied for funds under the Government's central initiative and I understand that a decision has not yet been taken.

The noble Lord, Lord Wallace of Coslany, and the noble Baroness, Lady Robson, expressed concern about the funding of London districts and the noble Lord, Lord Wallace, referred in particular to Bexley. The recently published allocations for 1985–86 and resource assumptions for 1986–87 and 1987–88 also made it clear that our commitment to achieving a fairer distribution of NHS resources is equally firm. In consequence, the Thames Regions, historically funded at above average levels, will receive growth at levels marginally below forecast inflation rates for these years. However, this does not mean that no new developments are possible. We look to health authorities to subject all their activities to the most rigorous scrutiny in the search for cost improvements, which we are confident can release significant sums for the development and improvement of priority services. Last year, health authorities identified cost improvements in excess of £100 million across the country. As to the specific points made by the noble Lord, Lord Wallace, I will look into them and write to the noble Lord.

The noble Lord, Lord Wallace, and the noble Lord, Lord Molloy, expressed fears about the effects of competitive tendering for laundry and other support services. This point was also raised at the end by the noble Lord, Lord Ennals. The noble Lords miss the essential point of the Government's initiative, which is to ensure that these support services are provided as efficiently as possible. The savings made can then go to treat more patients and to treat them better. As to the standards of cleaning, to which the noble Lord, Lord Molloy, referred, health authorities must have regard to standards and competence when considering the tenders of firms.

The noble Lord, Lord Ennals, raised the point of contracting out and tendering. I understand the situation to be that we want local health authorities to put the contracting out to tender, but it does not mean that they have to privatise it.

My noble friend Lord Colwyn suggested that dental charges were having a deterrent effect and he spoke with considerable feeling on this subject. I shall certainly study the table which my noble friend has made available to me, but perhaps I may make two brief points. First, many of those less well off are exempt from charges and, as I have said, about 45 per cent. of courses of treatment are provided free. Secondly, I have to point out to him that 32 million courses of treatment were provided in 1983, compared with only 27 million in 1978—an increase of 5 million courses.

The noble Earl, Lord Longford, spoke with great authority from his considerable experience, and he also indicated a lack of confidence in my reply. I can only say to him that, contrary to what he implied, the Government do share his commitment to helping mentally ill people. This remains one of our priorities. The record shows good overall progress, more extensive psychiatric services in districts, more nurses in mental illness and fewer patients in mental illness hospitals, with more day hospital places.

The Earl of Longford

My Lords, may I—

The Earl of Caithness

My Lords, I would rather not give way. I have a good deal of material still to get through and I see that time is running on.

The right reverend Prelate the Bishop of Carlisle spoke with great concern about the social security reviews. If I may be very brief but not impertinent in responding to him, I would say that perhaps we can wait until we see the reviews and then reconsider his remarks in the light of them.

The noble Lord, Lord Molloy, is not here at the moment and so I shall write to him on his points. The noble Lord, Lord Prys-Davies, suggested that there had been a deterioration in community nursing services. This is not borne out by the figures. Between 1978 and 1983 the number of people visited at home by district nurses of health authorities increased by 10 per cent; the number of elderly people treated by district nurses rose by 24 per cent; the number of health visitors themselves increased by an estimated 12 per cent; and the number of district nurses increased by an estimated 15 per cent. I hope that that goes some way to assure the noble Lord and the noble Baroness, Lady Fisher of Rednal.

The noble Lords, Lord Prys-Davies and Lord Pitt, raised points concerning the DHSS action on waiting lists. The noble Lords asked about Government action on waiting lists for hospital in-patient treatment. As I said in my opening speech, waiting lists have come down, but they did go up under the previous Government. But we are not yet happy with the fall; it must go on. The latest action we have taken is to ask health authorities to check their waiting lists, which are often not kept fully up-to-date and so overstate the numbers actually requiring treatment.

The noble Lord, Lord Prys-Davies, also spoke about the length of time patients can wait in out-patient clinics. I agree that waits can often be too long. The department is about to issue some advice to health authorities on how to tackle this problem by better organisation of clinics and appointments procedure.

My noble friend Lady Macleod of Borve expressed her concern, which I understand, that local hospitals should not be closed without consultation. In reply, I would make two points. First, we have inherited a hospital network which in many places bears little relationship to current opportunities and needs. It is a major management and professional challenge to get the right balance between hospital in-patient and other care, and to make sure that hospital beds are as near as possible to the people who wish to use them. Secondly, as I am sure the noble Baroness knows, hospital closures are the subject of local consultation and the arguments for and against are considered by Ministers.

The noble Lord, Lord Pitt, said that it was not enough just to increase spending. In my opening speech I did not claim that it was just enough to increase spending. The most important thing is that the service is treating more patients and treating them better; but increased spending contributes to this. It is true that some other countries spend more of their GDP on health. I would make two points here: first, that the percentage has gone up in this country from 4 per cent. in 1979 to 5.5 per cent. in 1983; and secondly, that there is no clear evidence that a higher percentage of GDP leads to better health. Our life expectancy is much the same as that of the United States of America and our perinatal mortality is lower. Our general practice system acts as a check on unnecessary hospital treatment and we have better control than other countries over expenditure.

The noble Baroness, Lady Fisher of Rednal, suggested that the Government have seen community care as a cheap option. Community care is not seen as a cheap option but as a much better and more relevant use of resources to meet people's needs. The Government are helping to finance this move to community care in a number of ways. NHS funds are available to local authorities and voluntary organisations through improved joint finance arrangements. We have allocated £99.6 million to health authorities for spending in this way in 1984–85. Judging from past experience, about one-third of this will be spent on mental handicap services. Health authorities can also make money available from their main allocations to provide permanent funding for places for mentally handicapped people coming out of hospital. A special allocation of joint finance money of £15.6 million over the four years to 1987–88 has been made available for the care in the community programme of pilot projects: seven of these are for mentally handicapped people, and further applications are under consideration.

The noble Baroness also raised the matter of staffing, and I should like to comment in particular on one very important staff group; that is nurses. Nurses have an important part to play in preparing people to live outside a hospital and in collaborating with other agencies to provide the range of services needed in the community. The growth in the number of community mental handicap nurses, now 500, is most encouraging. In January the Minister for Health assured the English National Board for Nursing, Midwifery and Health Visiting that he accepted the need for a continued nursing role in the provision of services for mentally handicapped people. At the same time he welcomed the board's intention to introduce a new syllabus for mental handicap nurses which will offer more community experience.

I turn now to the points raised by the noble Lord, Lord Banks. He referred to the SDA. When only last week I was in Cardiff inspecting the local offices I talked in detail about this. I had the very encouraging reply that the transfer was working very well. Perhaps I can come back to the noble Lord on the other points he raised, because much of what he said is tied up with the social security reviews.

The noble Lord, Lord Ennals, asked whether the waiting lists are at the highest level ever. No, my Lords; the latest figures for hospital in-patient waiting lists show that at March 1984 they were down 60,000 on the March 1979 figure. The noble Lord, Lord Ennals, also accused this Government of interfering too much. I find that very difficult to understand because I cannot follow the exact thoughts of the party opposite on this matter. It was his noble friend Lord Prys-Davies and, I think, the noble Lord, Lord Stallard, who in their speeches wanted more central Government interference.

A noble Lord

No, my Lords.

The Earl of Caithness

My Lords, if the noble Lord would like to read Hansard, I am sure he will find that that is so.

I shall now conclude, and will write to any noble Lord or noble Baroness whose points I have not covered. I am sorry not to have covered them orally, but time does not permit it. In 1979 we inherited the ship of state relating to health and social services. The ship was in goodish order then, but was in need of refurbishment. Some noble Lords have, by their remarks, implied that since then the ship has been slowly sinking, or perhaps majestically sinking, beneath the waves. That is utter rubbish. The ship has been, and continues to be, refitted and refurbished. While we do not in any way underestimate the problems that lie ahead or those faced as a result of the adjustments that have taken place so far, that ship is better financed, carries more patients and staff and is more caring.

9.25 a.m.

Baroness Jeger

My Lords, we on this side would like to thank the noble Earl and congratulate him on his reading ability without spectacles, which some of us need on the NHS. I should like to thank everyone who has taken part in this debate. I only wish I could feel that the Government will take any notice of some of the comments that have been made because they were very genuine and very sincere anxieties.

There was one question I asked which the noble Lord has not answered. In fact, he seemed to brush me off when I asked him about severe weather conditions in Scotland and seemed to suggest that Scotland was not for him. When I put down a Question in this House last week, it was answered by the noble Lord, Lord Glenarthur, and I was informed then that there was nowhere in Scotland where it was cold enough to have a severe heating allowance. The noble Earl said he knew that Braemar was cold and I asked him what had been paid in severe heating allowances and he has not given me an answer at all. If he says he is going to write to me, well I hope he will, and I shall do my best to make that public.

The Earl of Caithness

My Lords, I am sorry if I gave the impression that I brushed off the noble Baroness. That would be the last thing I would wish to do, with her very great experience of these matters. I did say I would write, and of course I will. Once again, if I may just reiterate, I am drawing the whole of this debate to the attention of my honourable and right honourable friends and my noble friend Lord Glenarthur.

Baroness Jeger

Also, my Lords, briefly for the record, I do think that the noble Earl was unfair to my noble friend Lady Fisher. She certainly did not suggest that putting people from mental hospitals into community care was a cheap option. In fact, I got the impression from what my noble friend said that she had an anxiety that that might be the attitude. The anxiety on this side of the House, and I am sure that many other noble Lords share it, is that, with rate capping, it is not possible for local authorities to do all that they would wish to do in community care. It has been asked, and I do not think we have had an answer, if those elements in local authority expenditure which relate to community care will be exempt from rate capping; whether those matters are taken care of by voluntary authorities who are now being helped by local authorities or directly by local authorities. I know that it is not in order to ask the noble Earl to reply again, but I would just ask him to take those points on board, and perhaps when there are further discussions he will bear the points that I have made in mind. With that, I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.