NHS and Reform of Social Security System

HL Deb 20 November 1985 vol 468 cc557-648

3.26 p.m.

Lord Ennals rose to call attention to the state of the National Health Service and to the recommendations for the reform of the social security system contained in the DHSS Green Paper (Cmnd. 9517–20); and to move for Papers.

The noble Lord said: My Lords, I beg to move the Motion standing in my name on the Order Paper. I greatly welcome the opportunity that this gives the House to consider the state of the National Health Service and the recommendations of the Government's Green Paper on social security. In saying that, I also welcome very much the number of noble Lords and noble Baronesses who have put down their names to speak in this debate.

We are at a certain advantage in choosing to debate this matter outside the debate on the Queen's Speech, because we now have news of a modest increase in expenditure on the National Health Service in the Chancellor's statement. Later, I shall try to put that into perspective. I agree very much with my noble friend Lord Cledwyn in that I too have long doubted whether Ministers really understand the degree of desperation of those who are now working in the National Health Service because they are having to postpone so many things which they wanted to do but which, because of financial cutbacks, they are unable to do. We must seek to understand that sense of deep frustration, which I find wherever I go.

We have two disadvantages in this debate. First, the long-promised Green Paper on primary health care has still not been published. It seems to be a case of this year, next year, sometime, never. I have counted up that I have asked seven times when that Green Paper is to come. I hope that when the noble Baroness replies to the debate she will give the House some indication of when it will be. I may tell the noble Baroness that I have a number of questions to ask, but I do not expect that she will be able to answer them in her opening remarks. However, I hope she will give some consideration to them when she winds up the debate.

The second disadvantage is that the social security Green Paper has denied to the public and to the many interested organisations which have taken part in the debate the figures of losers and gainers in this essentially cost-cutting exercise. However, before I come to an analysis of health service finances—which I shall go on to do, as well as dealing with the social security review—there are a number of quite specific issues which concern me and other noble Lords on these Benches. I will put them to the noble Baroness for her attention.

First, the Government are wise to take heed of the extent of public support for the National Health Service. I do not believe that there is any other public service which is more respected and admired by the British public than the National Health Service. I read the results of a recent public opinion poll, and I shall mention just three of its findings. People were asked what priority they gave to equal access to the health service by everyone who needs health care. A total of 99 per cent. said "very important" or "quite important". The second question was on free health care for everyone at the time they need it. Ninety-seven per cent. laid a very high priority on either "very important" or "quite important".

The third question related to whether the health service should be paid for out of taxes rather than fees or private health insurance. It is interesting to note that 84 per cent. said that it was either "very important" or "quite important" that it should be. I think we must recognise that there is a willingness by the public, which is shown in many opinion polls, to be prepared to pay a small additional sum of money on their taxes in order to provide more funds to improve the National Health Service.

Therefore, these are some of the questions I want to ask. Why are hospital waiting lists so much longer than they were under the Labour Government? On 10th June this year the noble Baroness told me in answer to a Question that the average number of people waiting for admissions to hospital between May 1974 and May 1979 was 558,000—too high, I agree. She also said that the average figure since the Conservative Party came into power is 676,000—that is, 118,000 more. I hope that the noble Baroness will explain why this situation should exist if the health service is so safe in the hands of the Prime Minister and her colleagues.

Will the noble Baroness tell me what the figure was at the latest count and how she explains this very substantial increase? Is she aware that recent figures published by the British Medical Association found that out-patient waiting times had increased by 20 per cent. between 1982 and 1983? The department represented by the noble Baroness was sceptical about this and so it was independently reviewed by the Health Services Management Centre in Birmingham, which came up with figures almost identical to those of the British Medical Association. I hope that we may have some comment on that.

I am very worried, too, by the situation concerning the welfare of children in hospitals. For many years it has been accepted by Ministers under successive Governments that children should be cared for in children's wards; not in general wards which can often make considerable difficulties and hardship for the children and for the parents who want to spend a long time with them to the children's great benefit. I understand from a recent survey carried out by the National Association for the Welfare of Children in Hospital that there are as many as 100 examples where children are in general wards and not specifically in children's wards. This is a matter of considerable concern and I want to know from the noble Baroness whether the situation is improving or getting worse.

I now move to the other end of the age parallel. Can the noble Baroness explain why it is that, while over the past five years spending on hospital services in general rose by 8.5 per cent. in real terms, spending on geriatric in-patient services rose by only 4.5 per cent.—that is, half the extent of the increase on the population in general—at a time when there has been a steady increase in the number of elderly people and the demands they make on the health service and when local authorities have been held back from expenditure that their social services departments need?

Will the noble Baroness confirm this quite extraordinary fact and the figures revealed in the recent study commissioned by the British Medical Association, the Royal College of Nursing, and the Institute of Health Service Management? The report showed that in 1983–84: Total spending on age-related services rose by only 3 per cent. when the demography rule would have suggested at least another £58 million in spending".

Why has there been such a slight increase in spending in terms of the elderly population? Is there not a danger that some people will reach the conclusion that the Government are giving inadequate priority to the ageing population? That must concern Members of your Lordships' House.

I shall certainly not mention mental illness and mental handicap because I am delighted that we are to have a debate on that subject next week, or the week after, which is to be introduced by the noble Lord, Lord Mottistone, and I am most grateful to him for that.

My next question is: why have the Government been cutting back on medical research and placing such obstacles in the way of improving training for nurses and for professions supplementary to medicine? I shall not go into detail, although clearly I could do so in my capacity as president of the College of Occupational Therapists. It is reported that scientists from four countries are about to announce a major advance in identifying the defective gene which causes a crippling congenital disease affecting 4,000 young people in Britain. However, according to a recent survey carried out by the Observer it is suggested that Britain's health service is ill-equipped to take advantage of the new tests. The Government recommendation in 1979 that every regional health authority should employ two consultant geneticists has not been implemented because of lack of funds; two regions still do not have a consultant and four more have only one.

I well remember the decision that was taken in 1979 and I am deeply disturbed that what seemed to be a very proper recommendation has not been carried out. I ask the noble Baroness whether she is satisfied that the recent announcement of £1 million to tackle the growing problem of AIDS in our community—which we have discussed in this House on a number of occasions—really is an adequate response to a very desperate problem. If the American pattern is followed here in Britain it could bring devastation to individuals and families. Is not this sort of expenditure a pathetic drop in the ocean in the light of the size and the fearful nature of the problem?

Is it not true, in respect of the treatment, care and rehabilitation of drug abusers, that one of the most disturbing elements in our society is that it is now plagued not only by drugs but by violent crime and inner-city conflict unknown before this Government came to power with what I believe to be their distorted priorities? Is the noble Baroness satisfied that the Government, with the funds they are making available, are responding effectively and adequately to the challenge of increasing drug abuse in our society?

Will the noble Baroness help the House to unravel the uncertainty about the number of beds available and patients being treated in National Health Service hospitals? This is an issue which arose during Question Time and figures were given by the noble Baroness who was answering. Ministers have made much play of new facilities completed between 1980 and 1984—most of which, I must say, were planned and started when I was Secretary of State. They quote the figure of 11,000 new beds but they have not mentioned that the average number of available hospital beds actually decreased by 12,900 during this period from a total of 356,000 in 1980 to 343,100 in 1983. Therefore, is it not better that we should look at the available beds and consider the number of beds closed and not merely talk about the new beds?

The Government quote a 12 per cent. increase between 1978 and 1983 in the number of in-patient cases treated and the shorter stays in hospital. On the face of it, if one does not seek to examine the consequences of these statistics, we could all cheer and say that that shows not just how much healthier we are but how much work the National Health Service is doing. But I must say to your Lordships and to the Minister that it is my clear impression—and I have asked many people about this—that sometimes patients are discharged too soon and therefore have to be readmitted. So they are counted twice because the figures that we are given do not represent the number of patients but the number of admissions.

Elderly people may often have two or three spells in hospital in one year, and these people too are counted twice or three times. When the noble Baroness comes to wind up the debate, can she give some figures of patients treated as opposed to this inflated figure of admissions to hospital? This applies to out-patient units as well. A better measure of the extent of inpatient services may be the average number of beds used daily. Perhaps the noble Baroness could give some figures that would help us on this.

We also have staff problems. Every Minister who talks about increases in nursing staff always says, "up to 1983". For some reason or other they stop at 1983. The reason is that 1984 was the first year since the National Health Service was created in which the number of nurses actually decreased. They also give their figures without taking into consideration the fact that the hours worked by nurses have quite properly been reduced from 40 to 37½, so in order to do the same amount of work obviously more nurses are necessary. Can the noble Baroness give us some figures about that and particularly about the future intentions of the Government in terms of this manpower watch. If they have now started to reduce the number of people who are working in the health service—and this is not really just a local matter but is a decision taken by the Secretary of State—is this a long-term intention or is it intended for just one or two years?

I am sorry to continue to ask questions but they are pretty vital ones. Will the Minister also accept from me that as regards health visitors and district nurses, who are vital elements in community care, the number of staff rose less than did the number of people they visited?

I want to obtain the Government's view about the results of the Griffiths Report and the appointment of general managers. First, I have strongly objected to excessive interference by Ministers in who is appointed to regional and district posts. I believe it is quite wrong that the assumption that Whitehall knows best should be applied to the health service. There have been many cases where appointments which have been properly made by health authorities have been overruled by Ministers, which I think is a very unsatisfactory situation. Does the noble Baroness share my deep concern about the effect of the whole of this reorganisation on the very heart and soul of the National Health Service; namely, the nurses, who, after all, form 50 per cent. of the staff of the NHS and a much higher proportion of its caring personnel?

What conclusions does the Minister reach from the following facts—and in putting these facts I am delighted to see that the noble Baroness, Lady Cox, will be taking part in the debate and I hope that she will have something more to say about them, too. If we look at regional general managers, only one nurse has been appointed out of 14 appointments in England; as district general managers, 4 nurses have been appointed out of the 189 appointments which have taken place in England; as unit general managers, so far 22 nurses have been appointed out of the 200 appointments which have so far been made. As your Lordships can see, this represents about 11 per cent. of posts going to nurses.

There are other aspects of this matter about which I believe your Lordships should be concerned. The appointment of general managers is only one dimension. Once in place, the new general managers will review the structure which will be answerable to them as general managers, and in these reviews the position of nursing and nursing advice is being considerably weakened. The Royal College of Nursing has examined 110 out of 191 authorities, and found that 24 district health authorities—that is, 22 per cent.—now have no chief nursing officer in their proposed structure. I could give a number of other examples but time simply does not permit. I think it is a very serious matter indeed if the position of nurses is not properly protected in the management reorganisation within the National Health Service.

The questions that I want to put finally relate to resources. First, we must take into consideration that costs in the National Health Service rise much faster than the retail price index, and secondly that 0.5 per cent. is calculated by the DHSS to cope with the cost of medical innovation—and our National Health Service must keep pace with new discoveries and developments. If we add to that the 1 per cent. which is needed just to cope each year with the increasing demand on the health service of very elderly people, the figure comes to about 2 per cent, which means that anything under a 2 per cent. growth rate is in fact a cut in real terms.

If we look at the last few years, in 1980–81 the real-terms growth rate was 1.2 per cent., in 1981–82 it stepped up to 3.3 per cent., in 1982–83 it was 1.2 per cent. in 1983–84 it was 1.4 per cent. and in 1984–85 it was 1.1 per cent.; nil growth was prophesied in the White Paper before the Chancellor came to make his Statement. Let me make it quite clear that I welcome the fact that it was decided that, unless the National Health Service was to begin to crumble, it was absolutely vital that the Chancellor should find some more resources. I thank him for small mercies; but it is a very small mercy because it does not really mean—particularly with the continuation of the RAWP (Regional Allocation Working Party) formula—that in some parts of the country there will not continue to be major cuts, since I have not mentioned the fact that a great deal of the money that has been found by the Chancellor is to enable health authorities to pay for their own staff. It was an absurd situation that the Government agreed to an increase in doctors, nurses and other staff, but then said, "We shall pay only 3 per cent. and all the rest has to fall on the health authorities".

This leads me to the last point I want to make on health before I move on very briefly to social security. In view of what I have said and the circumstances that have developed, after eight years of RAWP—which has made a major contribution to the equalisation of the resources available in regions across the country—I honestly believe it is time it was reviewed. I do not say it is time for it to be stopped. I remember that when I introduced it I called it a blunt instrument and it was then my intention as Secretary of State to monitor it very carefully. It underestimates a range of factors—and I shall just mention inner city needs, which are the concern of your Lordships' House and the country as a whole. I would be interested to know whether the Minister feels that the time has now come, after eight years, for a review of the application of the RAWP formula.

I have left myself too little time for the rest of my remarks and therefore I shall continue very rapidly. I am delighted that my noble friend Lady Jeger, who will be winding up the debate, will deal at greater length than I shall with the question of Norman Fowler's review of the social security system. It is just as well that I am not going to deal with it in detail because I have documentation, which is at least a foot high, from almost every organisation which has submitted representations and in almost every case 98 per cent. of the evidence is against the recommendations that have been made by the Government

I was looking at an interesting study that has been made of 60 of the most important organisations. Two bodies appeared to be very solidly in favour of the Government—two out of 60. One was an organisation called the Monday Club, which is not always noted for the most progressive views; perhaps even the Minister would agree with that. The other was the Institute of Directors, and I say nothing against that organisation. But those two organisations showed consistent support for the Government's recommendations, and almost all the others on every single issue said, "No". I am not surprised, and I hope that the Government will take that very seriously indeed.

Let us look at a number of the particular proposals. I want to mention briefly the state earnings-related pension scheme. When announcing the results, the Secretary of State said that this was the first major review of the social security system since the days of Beveridge. First of all, there is no state social security system; there are a variety of systems to deal with a variety of needs. Child benefit is clearly totally different from an earnings-related pension scheme.

When I look at what has come out of the review I can only reach the conclusion that it is not an attempt to improve the benefits that we provide for the people in greatest need in our country but a cost-cutting exercise to provide additional funds for the Government to use at the right time, as they think, in pre-election tax cuts—pre-election tax cuts paid for by those who suffer the greatest need in our society.

The process of consultation on SERPS lasted many years. I was involved in it in 1958, and Parliament went through years of consultation until we reached absolute agreement across the Floor of the House. I have to admit that the Liberals did not join in the agreement. We worked very hard as a government. We can see if we look back at the comments made then that Norman Fowler and Kenneth Clarke, then in Opposition, supported the measure. We thought that we had taken future benefits for the elderly out of party politics and that we should not have another period of kicking back and forth arguments on the needs of the elderly in their retirement years. It is appalling that we are now thrust back to that situation.

Let us look at other issues. The claim is made that the cost of SERPS is now too much and facts have changed. The costs of the scheme were fully recognised at its outset 10 years ago, and even the Tory Reform Group, which I put into a quite different category from the Monday Club, acknowledged that in its response to the Green Paper proposals. It said: The Green Paper's references to emerging costs seem to imply that the full cost of SERPS was not known in 1975. However, Edward Johnstone, the Government actuary and a member of the pension review team, has made it clear that this is not so.

It condemns the Green Paper—and I quote the group s words again—for its rather dubious statistical arguments".

The only change that there has been is in the number of unemployed people.

I should like to have said more but I shall not do so as time does not permit. I could have said a great deal about the effect on disabled people and the effect on families with young children if we do not continue child benefit. I could say much more about how much means testing there will be, and about the abolition of the death grant, cuts in maternity grant, and so on.

In conclusion, I say to the noble Baroness that whatever happens in another place—and I think that there will be a major debate over many months once the White Paper is published—if the proposals in the Green Paper now appear in the White Paper, in this House on these Benches we shall fight them tooth and nail because we believe that they will damage not only the general structure of our welfare state but the people who are most disadvantaged, for, as I say, the simple and unworthy purpose to make room for tax cuts. I believe that it would be a moral outrage if we approved the recommendations that we have so far seen. I beg to move for Papers.

3.55 p.m.

The Parliamentary Under-Secretary of State, Department of Health and Social Security (Baroness Trumpington)

My Lords, I am grateful for this opportunity for the House to discuss an issue as important and as far-reaching as the future of the health service and social security. The terms of the Motion tabled by the noble Lord, Lord Ennals, are extremely broad, and I have no doubt whatsoever that your Lordships will take full advantage of the opportunity to range widely over the whole field before us today. So I hope I shall be forgiven if I do not attempt at this moment to cover all the many issues which are likely to be raised. The noble Lord has already asked many questions, and I know that I can rely on your Lordships to ensure that I have plenty of other issues to pick up in my wind-up speech!

I want therefore to concentrate in my opening remarks on a few key points. First, there is the question of resources. I need hardly remind your Lordships that health and social security between them account for around 40 per cent. of all public expenditure. Now from time to time I hear talk—indeed, I heard it in this House last week and again today—concerning "cuts in the health service". So my noble friend Lord Stockton and noble Lords from Opposition Benches will be delighted to hear me when I say that there can be no dispute about our commitment to continue support for a National Health Service financed largely from taxation and providing comprehensive health care for all. That commitment is quite clearly illustrated by the record amounts of money which we are devoting to the health service. Since we came into office, spending on the health service in Great Britain has more than doubled. After allowing for general inflation, that represents a real-terms increase—or an increase in the cost to the economy and the taxpayer—of over 20 per cent. Over the same period, public expenditure as a whole rose by just half that amount—about 10 per cent., in real terms.

This priority for the NHS continues to be reflected in our plans for public spending over the next three years. These were announced by my right honourable friend the Chancellor of the Exchequer in another place on 12th November. In broad terms these plans show total expenditure on the NHS in Great Britain set to rise by nearly £2.8 billion in 1988–89. That means that in every year since we came of office in 1979 to the end of the current planning period a real-terms increase in NHS spending has either taken place or is planned, whereas under the last Labour Government there was actually a real-terms cut in 1977–78. It is funny how the noble Lord, Lord Ennals, conveniently puts his head in the sand and fails to remember the days when he was associated with the Labour Government.

Let us look at what this means for the health service in England. For the hospital and community health services it means an extra £650 million next year. This is an increase of 6.7 per cent. compared with a forecast increase in general inflation of 4.5 per cent. On top of this, health authorities will have the benefits of their growing cost improvement programmes, which are expected to yield £150 million this year. This pool of resources will be used to meet pay and price increases, to provide for the growing numbers of very elderly people and to continue to improve services. In 1987–88 we have planned further cash increases of more than 1 per cent. above the level of forecast inflation.

We have already substantially increased the level of NHS capital spending. This has risen about a quarter in real terms since we took office compared with a real-terms cut of one third under the last Labour Government. We are now further increasing provision for hospital capital spending. Together, the additional cash and income from sales of surplus land will enable authorities to carry through major programmes of capital investment to replace and modernise outdated hospital buildings. Much has already been done. Since 1979, 24 major hospital building schemes have been completed. Over the next three years we plan to start 43 more, each costing over £5 million. In all, nearly 250 schemes costing over £1 million each are being planned, designed or built.

I might at this point answer one of the questions of the noble Lord, Lord Ennals. He made the point that the number of beds in the NHS has fallen. That is true. However, the essential point is not the number of beds—we do not treat the furniture—but the number of patients. As the noble Lord recognised, there has been a substantial increase in the number of in-patient cases since we took office. The NHS has become more efficient. Modern medical techniques enable people to be treated more quickly. The noble Lord suggested that patients were discharged too early and that the measure of the number of in-patient cases simply reflected repeated admissions caused by too early discharge.

First, the number of in-patient cases has always been used to measure the use of NHS services, even under the Government of which the noble Lord was a member. Secondly, I would be surprised if our doctors and nurses allowed that to happen. I do not think that they would much appreciate the remark of the noble Lord. Thirdly, a research study on one region showed that the number of patients rose broadly in step with the number of cases.

Spending on the family practitioner services has increased to £2.5 billion and will continue to increase in each of the next two years to meet current estimates of rising demand. These sums are enormous by any standards and should silence once and for all those who denigrate our success and simply wail about cuts. How are these resources being used to deliver services to patients, which at the end of the day is what the health service is all about? The figures speak for themselves. Our hospitals are now treating more people than ever before. In 1984, in England, they had, as has already been mentioned, 800,000 more in-patient cases, 340,000 more day cases and 3 million more out-patient attendances than in 1978. Between 1983 and 1984 alone, output rose by nearly 3 per cent. These increases more than meet rising demand due to demographic changes and represent a real improvement in services. We plan to build on these successes.

In addition, we plan to continue to provide for increasing numbers of elderly people, and take advantage of advances in medical techniques. We are also expecting health authorities to make further real improvements in key services, such as treatment for renal failure—where targets have already been agreed—hip replacements, care in the community and services for drug misuse.

I have referred to the very substantial cost improvement programmes which have secured major savings to be devoted to patient services. Now I want to say a word about management. The health service is one of the largest enterprises in western Europe. It needs leadership and management of the highest quality. It is precisely those issues of quality of management and effective use of resources that this Government—more than any other—have tackled. Primarily, this is to benefit the patient, to ensure that every last penny possible is being devoted to improving the standard of care for the individual. But it is also important for the morale of staff, for the calibre of future generations of managers and. of course, for the quality of service offered to patients that the National Health Service should be an attractive place in which to work as well as a compassionate and effective place in which to be treated.

Our record boasts a whole range of initiatives designed to improve the quality of management, to remove structural and other obstacles that impede good management and to improve the use of resources. Collectively, these amount to freeing managers at all levels to be better able to provide the best standard of service possible, as both they and we want. Ultimately that must result in a more satisfied workforce and better served patients.

During this past summer, I have had the great good fortune to have visited hospitals and other places concerned with the National Health Service throughout Britain. I cannot agree with the exaggerated remarks made, I regret to say, by the noble Lord, Lord Ennals, in his speech, and by the noble Lord, Lord Cledwyn, during Question Time regarding the "desperation"—I think that was the word used—felt by those working in the National Health Service. I totally refute that assumption.

I am well aware that dedicated people who serve the NHS sometimes feel that they have suffered from too much reorganisation. When people recount the changes to me, I must admit that the expression "to be RAWP-ed" sometimes conjures up the wrong impression in my mind. Be that as it may, we are committed to RAWP. I have not heard criticisms of the introduction of the Griffiths Report proposals as such. In fact, the whole concept is welcome. These proposals concerned, as your Lordships will know, the introduction by authorities of general management without changing any health authority boundaries. This was an entirely new concept to the NHS and is designed to ensure that accountability for use of resources and for producing necessary changes and results effectively and efficiently are focused on identifiable individuals.

The appointment of general managers at regional, district and unit level has now been going on for just over a year. I would say to the noble Lord, Lord Ennals, that the results are encouraging. All regional general managers, all but a handful of district general managers and well over 200 unit general managers have so far been appointed. Nearly halfway through the appointment process, the results show a heartening involvement of different disciplines and a balance from inside and outside the service. Well over 20 per cent. are of doctors and nurses and 15 per cent. come from outside the service. Over 40 per cent. of the appointments that have been made represent the introduction to, or the unearthing within, the NHS of new managerial talent. This infusion of new blood cannot but benefit the service over the coming years. Your Lordships will also be pleased to learn that many authorities are appointing senior managers to be responsible for the quality of patient care and services—a very welcome further development.

Nurses and doctors are keen to play their part in the management of their service. Who better than these professionals to tell health authorities what patients' expectations are? The way the health service is developing will, I think, ensure that their talents, managerial as well as professional, are put to good use, and I am sure that the service will benefit greatly. At the same time, we have paid particular attention to the way in which resources are being used. We have established a system of accountability and performance reviews, all designed to ensure that authorities are responsibly addressing national priorities, achieving the objectives they set themselves and using money and manpower effectively.

As part of our drive to secure value for money we have also required authorities, first to institute cost improvement programmes; that is, to look at better ways of achieving better use and deployment of resources; secondly, to invite tenders for the provision of support services to patients, a policy which alone has registered savings so far of £28 million a year which are now being redeployed to improve patient care; and, thirdly, to introduce Rayner Scrutinies to take a fresh look at a particular activity to see whether it might be done more efficiently. The nine scrutinies published so far indicate that many millions of pounds can be ploughed back into patient care. Health authorities are putting the scrutiny recommendations into practice, and more scrutinies are now under way.

Fourthly, we have required authorities to implement energy conservation programmes. Currently expenditure in the NHS in Great Britain is some £325 million a year. Without the energy conservation measures already taken this would be nearly £70 million more. We are on course for a continuing fall in energy consumption of 1½ per cent. per year, offering the prospect of further cumulative savings exceeding £1 billion by the end of the century. Fifthly, we have required them to release all underused or unneeded land thus saving £50 million last year alone.

That amounts to an impressive record. It is to the benefit of patients, taxpayers and NHS staff and will lead to further improvements in the performance of the NHS which has already risen dramatically. I have given your Lordships some of the key figures. The point I want to make at this stage is that the health service has responded with enthusiasm to the challenges it faces. A revolution is taking place in management, and the effectiveness with which so many more patients than ever before are being treated indicates clearly that staff on the wards and in departments have the motivation—and the resources—to go on to achieve yet greater things and I pay tribute to them.

We would be wrong to think that the health service is only a hospital service. Nothing could be further from the truth. This country has one of the finest primary care services in the world, which is used by millions of people every year. We are already reaping the benefits of the change in status of family practitioner committees which we made in April of this year. Our underlying objective was to provide a new focus for the development of the major component of primary care services while at the same time improving efficiency and securing greater accountability in their administration.

Collaborative arrangements between health authorities and FPCs are developing well. A system of computerised committee, records is being introduced which will improve efficiency and greatly facilitate preventive measures such as cervical screening and the production of age-sex registers for primary health care teams to use as an aid to health maintenance.

It is clear from the review process that the new FPCs are actively reviewing important areas of their work such as complaints procedures, deputising arrangements for general medical practice, emergency dental services, arrangements for health care of homeless people and the standards of practice premises. They are also examining critically their own management arrangements.

The composition of the committees is broadly based, and a very wide range of interests and occupations is represented among their chairmen and members. We were encouraged by the large number of people who came forward in a spirit of public service to offer the considerable amount of their time needed to make the new arrangements work well.

The provision of a full range of care to the people of this country does not begin and end with the hospital service or even with the primary care services. The role of the personal social services is crucial and this Government are committed to promoting the development of joint planning between health and local authorities in which the voluntary sector too should play a full part. The annual allocation of funds for joint finance has increased by over 50 per cent. in real terms since 1979 and is currently £105 million. Joint planning is crucial to the development of a range of services to meet the needs of vulnerable people, such as mentally handicapped, mentally ill, physically disabled and the elderly. It is also crucial to provide those services in the most cost-effective way: matching the needs of individuals and avoiding gaps and unnecessary duplication in services.

We are also committed to the development of care outside hospitals in the community for people who would otherwise have had to go to hospital, perhaps for long periods, and for people discharged from hospital after a long stay. Our care in the community arrangements have removed obstacles to the transfer of funds with patients from long-stay hospitals to community care. In addition to a number of care in the community projects with local fundings, a programme of 28 pilot projects has been launched with central funding and will be evaluated and the results shared. There is no doubt of the importance of this field of activity. Community care has been something of a buzzword, but the Government are putting effort and resources into making it a reality.

There is no question of our throwing patients out of hospitals and into the street without providing the necessary back-up services. I was able to reassure the National Schizophrenia Fellowship on this point last week. I also told them that money received from the sale of mental hospitals would be used for care in the community purposes and would not disappear into other NHS pockets.

I should now like to turn to the other major topic of today's debate—the reform of social security. We have been engaged in a debate on the reform of social security for two years now. The debate has involved people outside government on an unprecedented scale. Apart from outside members on each review team, we drew the public at large into the consultations. Their interest and the scale of responses show how right we were to do so. Over 4,500 individuals and bodies sent evidence to the review teams. Over 7,000 responded to our Green Paper proposals. The debate has ranged over the whole complex of issues in our social security system. It has raised the general levels of awareness about the value of social security to our society; about the aims of that system; about its problems. I believe that it has also been a unique debate in that, having tackled such a large, complex and emotive area, we have arrived at a broadly-based consensus. It is that our present social security system suffers from serious problems. Change is not going to be easy, but change there must be. I would only add to that ringing statement this coda: and change there will be. For, having taken up the challenge two years ago, this Government will not shirk their responsibility to society.

Let us take a brief look at this Government's record. Above all, we have slashed inflation from the high point of 27 per cent. reached in the mid-seventies to below six per cent. now, and it is still falling. That achievement alone is of the utmost importance for all those on low incomes. But, further, next week's uprating of benefits will bring spending on social security to well over £40 billion, nearly one-third of all public spending. And that is an increase, in real terms, of over 30 per cent. since 1979. In that period we have more than honoured our pledge to maintain the real value of pensions. We have doubled the mobility allowance and taken it out of tax. We have introduced the new severe disablement allowance. We have introduced a new mobility supplement for war pensioners, and we have taken war widows' pensions out of tax.

That same positive and constructive approach has characterised our proposals for reforming the social security structure. We want a system that is simple to understand and easier to administer. That way claimants will know more clearly what they can and should be getting and staff will be able to deliver the service more quickly and effectively. We want a system that will be fairer to those at work on low incomes and which will not undermine their motivation to work harder and increase their earnings. We want a system that will not bind a future generation to financial commitments that we know now to be unreasonable. And we want a system that is geared to the needs of today, a system that gets help to those who need it most.

Meanwhile we have taken and are continuing to take positive steps to improve the service to the public. I shall not detail the initiatives here but will mention that we are also embarking on the biggest computerised programme in Europe to ensure that our staff in local offices will not have to depend almost entirely on manual records. This is a long-term programme which will yield its full benefits in the next decade.

All these measures, I would emphasise, are designed to ensure that we shall deliver the social security system to the public as efficiently, as accurately, as speedily but—most important of all—as courteously and sympathetically as possible. I should also like to take this opportunity to pay tribute to the many staff in local offices who work so hard in sometimes the most difficult of circumstances.

However, there is one area of concern that I should like particularly to mention and that is the sick and disabled. Of course, as we have made clear, the review did not seek to cover benefits for sick and disabled people because we need reliable, up-to-date and comprehensive information about the number, circumstances and needs of these people if we are to develop our policies in the longer term toward a more coherent system of benefits for the disabled. The full-scale survey that is now being conducted will give us that information.

Disabled people will of course get particular help from the premium in our proposals for the income support scheme to replace supplementary benefit. The premium will be payable automatically to anyone who gets invalidity benefit, severe disablement allowance, attendance allowance or mobility allowance or to someone who has been incapable of work for 28 weeks. This will be a clear-cut entitlement that claimants can understand and that can be administered without fuss. I ask your Lordships: do you really think that the needs of disabled people are being well served by a system that requires them to answer questions about the number of baths they take in a week so that DHSS staff can work out how much they should get in benefit? We also propose special treatment for families with disabled children; they will get a double family premium. And the severely disabled—those getting attendance allowance and mobility allowance—will continue to get those allowances in full, in addition to the disablement premium.

As I said earlier, the debate on the reform of social security has been wide-ranging. It has covered every aspect of our proposals—from the escalating cost of the state earnings-related pension scheme to local schemes in housing benefit. We are now considering all the very many responses we have received and we have listened carefully to all the views and concerns expressed—as we shall listen to your Lordships today. There has of course been a good deal of speculation about what our final proposals will be, but I know that your Lordships will not expect me to comment on such speculation, much less fuel it, particularly when I say that our final proposals will be published in a White Paper within weeks.

This has been a brief look at some key points. The health service and social security have seen some major changes over recent years, but many of these changes have led to significantly better services for the people of this country. There are more changes to come, and it is the Government's aim to ensure that they too lead to improvements for people who need health care and social services and social security. We have achieved a great deal already and we are determined to achieve yet more in the years to come.

4.22 p.m.

Lord Kilmarnock

My Lords, I am sure the whole House will be grateful to the noble Lord, Lord Ennals, for giving us the opportunity to debate these important subjects which did not receive much attention in the debate on the loyal Address. There is always a great deal of argument, accompanied by claims and counter-claims, on health service expenditure. The Government say they are spending more than ever before in real terms. The noble Baroness has just been making such claims in her speech. Despite the bullish talk about spending at the macro level, this happy scenario is all too frequently not reflected at the micro level. For example, the Medway district stands at only 77.2 per cent. of its RAWP spending targets. The noble Lord, Lord Ennals, was talking about reform of RAWP. Only this month a man who has had an accident at work is to go before a court and faces the loss of his house. The reason is that he has been off work as a result of the accident and is awaiting an operation on his knee. May I——

Baroness Trumpington

My Lords, I am terribly sorry. I always have the same trouble with the noble Lord, Lord Kilmarnock. Can he possibly get under the microphone? Otherwise I shall not be able to answer any of his questions, because I shall not have heard them.

Lord Kilmarnock

My Lords, I shall try another microphone to see whether it picks me up better. I was saying that in the Medway district a man who had an accident at work is going before a court and faces the loss of his house because he has been off work as a result of the accident and is awaiting an operation on his knee. The consultant cannot promise him anything better than a three-year wait. So he can give no assurance to his mortgage company about a speedy return to work which might secure him a stay of execution. In the same district, a woman who needed to have a broken bone reset in her foot had her operation deferred six times because of pressures from emergencies, motorway accidents and other casualties. She was in constant pain throughout this long ordeal. This is the reality of the health service in the Medway towns, whatever the rhetoric of the Government.

Let us consider some of the realities on the big screen. In the first place, the United Kingdom's absolute level of spending on health care at 5.9 per cent. of GDP in 1984 was the lowest in the OECD, apart from the Netherlands and Belgium. All our other major competitors spent more, with the USA at 9.8 per cent., West Germany at 8.2 per cent., France at 8.1 per cent., and Italy at 6.7 per cent. This relatively low expenditure has been masked by the efficiencies that came initially with the structure of a service paid for out of taxation with relatively low administrative costs. We started from a lower base and we got good value for money—better than most other countries. I believe we can still get it, because our basic structure is better. But it has to be recognised that spending on health care has risen at least as fast as real GDP throughout the developed world, so we need a realistic allowance for growth in future health spending. We need to find the right growth path and we need to stick to it without annual fluctuations and crises.

Government claims to have increased health expenditure over the period 1979–80 to 1984–85 by 17 per cent. in real terms are reduced to only 7.2 per cent. if we take into account the relative price effect, which is the extent to which health care costs rise faster than costs in general. Over five years this would represent an average increase of 1.5 per cent., but this is without allowing for the increase in the elderly population or for technical innovation. The National Association of Health Authorities has calculated in its annual report that the average increase for this period was 0.8 per cent. per annum, which is significantly less than the Government's own rule of thumb of 0.7 per cent. for demographical purposes and 0.5 per cent. for the technological factor, respectively—that is to say, 1.2 per cent. to stand still.

What is the point of all these statistics? I am not trying to outsmart or outpoint the Government, because that is what politicians do to one another. I and my noble friends are interested in how statistics are reflected in patient care and how far the Government are fufilling their own stated policy objectives. To find some answers I turned to a report published by the Centre of Health Economics at York University called Public Expenditure on the NHS: Recent Trends and the Outlook, written by Mr. Nick Bosanquet, senior research fellow. The centre is widely respected as responsible and impartial. The introduction tells us: it became widely accepted that a certain amount of extra expenditure was required in real terms in order to maintain the service at a constant standard in the face of changing needs and changing technology. This is the 1.2 per cent. that I have already referred to, and it should be noted that this would ensure a constant and not an improved service.

But this minimum is only valid, the report tells us, if price and wage inflation are within the Government's assumptions and if optimistic estimates of "efficiency" savings are met. The report, in its restrained style, then suggests: there is at least the possibility that the NHS may be trying to cover multiple tasks with the same funds". I repeat that phrase: "multiple tasks with the same funds".

That brings me to policy objectives. Since the early 1970s there has been a considerable shift away from the hospital services—some would say not enough, but it has been happening under successive Governments. In 1970–71 the hospital services absorbed 44.1 per cent. of total current spending. By 1983–84 this was down to 37.2 per cent. I believe most of us would welcome the shift from large institutions towards primary care and care in the community. But here some harsh realities have to be faced. Let me take first the community care for priority groups; that is to say, the elderly, the mentally ill and the mentally handicapped. I am delighted to see that the noble Lord, Lord Mottistone, has a debate on this subject on 4th December. Here I want to quote a very significant passage in the report of the York Health Economics Centre. It reads: It may be that in the long run community care will prove a cheaper option but in the initial stage the costs are likely to be higher as the investments are made in the new system at a time when much of the old system is in being. This is what the report calls an "uncosted policy aim", which seems sloppy at least with a cost-conscious Government in charge.

I shall not go into joint financing, the reluctance of local authorities to accept long-term commitments for people released from hospital, and so on. But I want to ask the Government some concrete questions—I hope the noble Baroness can hear me now—on the new money for hospital building announced in the Autumn Statement. Much of that will come, if I understand correctly, from the sales of NHS buildings, residential accommodation and surplus land, which, according to the Sunday Telegraph of 11th November, may be expected to yield £750 million over three years. That is excellent news. But how is that money to be apportioned?

The York report—I always call it that for short—speaks of, The heavy investment required in community care over the next few years", and suggests that this, along with certain specialist acute services, will require a year-on increase of 0.5 per cent. per annum. That is an additional increase of 0.5 per cent. per annum. But if all, or most, of the money is to go on new hospital building where are the funds to come from for the grossly under-funded community care sector? I think I heard the noble Baroness say that the sale of mental hospitals would be ploughed back into community care, and perhaps she would confirm that at the end of the debate.

There is also of course the £1.7 billion backlog in repairs and maintenance which the NHS currently suffers, and the Building Employers' Confederation has put it as high as £2 billion. How is this to be funded? The York report concludes: … in the light of the multiple objectives set for the NHS 2 per cent. a year increase in real spending for the next three years is the minimum required for general managers to carry out their tasks". What is the Government's response to that? Are they going to tie their new general managers' hands behind their backs before they start?

There is the additional problem for general managers of how to meet the awards of the review bodies which are consistently higher than the Government's assumptions on wages, in some cases with devastating results. Here is another example from Medway. A county councillor writes to me: Quite suddenly and without warning, we have had an announcement of wholesale hospital closures which the authority says will be needed by 1986–87 to finance the nurses' pay award". Yet no one in his right mind can suggest that the nurses are being overpaid. So where do we go from here? Will the Government make up the difference every year between the review body awards and their own calculations if there is a gap? Will they commit themselves to that?

There are certain objectives of Government policy which are actually stated in White Papers and circulars. The White Paper on Public Expenditure 1985 sets out the following aims:

1. "(a) to meet greater demands for services which will be related to the growing number of elderly people;
2. (b) to take full advantages of the advances in medical technology;
3. (c) to combat social problems of alcohol and drug abuse'——

Baroness Jeger

I cannot hear.

Baroness Faithfull

Slow down.

Lord Kilmarnock

I am sorry. (d) to continue to improve community support for people who do not require continuing hospital care by strengthening primary care and community health and social services All extremely worthy, but there was never any explicit costing for community care, so how are Government policies in that field to be implemented? I believe that what the public most appreciates in politicians is honesty and frankness, and so the Government owe the public an answer to this question.

There is of course another option, which is to scrap the whole idea of returning the elderly and the mentally ill and handicapped to the community, reverse the policies of the last 30 years, stop the sales of Victorian institutions and fill them again with their erstwhile inhabitants. It would be cheaper. It would cost the nation less.

But if the Government do not want to return to Victorian values of that sort, they must stump up the money. There is no alternative. Instead, therefore, of congratulating themselves and looking for adulation for their programme of hospital building, largely financed by sales of existing property and conveniently timed to coincide with the run-up to the next general election—their conversion to this type of public investment is remarkably sudden—the Government should be setting out to answer the questions I have asked them. Not only I but the voters of the Isle of Sheppey and all sorts of disadvantaged districts up and down the country want to know the answers too.

I want to turn briefly to primary care. We really must hope at least in this Session of Parliament that the Government will finally produce their Green Paper. This really is becoming a stale joke. It simply gives the impression that the Government are racked with indecision. Even if they are, what is the problem? After all, Green Papers are for discussion. That is their purpose. They are part of the consultative process. The response to the Fowler reviews is rumoured to have caused the Secretary of State to have second thoughts on his pensions proposals. Fine; that is what it is all about. So why not shed this secrecy and caution so that we can all get on with the vital debate, and pressing debate, on primary care?

There is no doubt—my noble friend Lord Winstanley will correct me if I am wrong—that the family doctor service is now in better shape than it was in the early 1960s. There has been a reduction in list sizes. GPs are referring only 155 patients now per 1,000 compared to 320 20 years ago. This is a remarkable achievement but it needs to be carried further by a continuing reduction of list size and extension of GP services and facilities to absorb even more of the hospital out-patient workload.

This is not the place to go into great detail as to how this might be done. Our original idea was that FPCs should be abolished and their functions subsumed into the DHAs. We lost that argument (or, anyway, we lost it in terms of votes) and certainly we would not now seek to subject the NHS to further upheaval—along with Griffiths—but it remains absurd that the FPCs should be separate from the community health staff responsible to district, with all the overlapping that this entails.

Various recommendations have come from the Royal College of Nursing and the Health Visitors' Association to the Cumberlege Inquiry, and the Royal College of General Practitioners have published their views, all of which deserve study. The leader of my party has suggested that rather than some blanket reorganisation of primary care, an NHS development fund should be set up on which general managers and family doctors could draw, and pilot schemes could be funded arising out of local initiatives. This would help compensate for the undoubted fact that the more GPs do in providing new services and taking on new work and staff, the greater their personal financial loss.

But the first step is for the Government to put their own ideas on the table. In the meantime we simply speculate and slake our thirst on leaks. We assume that the Government will want to be fairly radical about making it easier to change one's doctor, about information on practices, about the retirement age, about quality assessment—a matter with which the Royal College of General Practitioners is specifically concerned in its admirable paper, Quality in General Practice.

These are all legitimate areas for improvement, and I think there is a professional will at work to secure this improvement. But there is a note of warning I would utter to the Government before they finally give us the benefit of their long rumination on these matters. Do not try to create a two-tier primary care service by artificially stimulating private practice. Private practice is perfectly legitimate, but the overwhelming majority of the British public wants a good family doctor service within the NHS.

Perhaps there is something of a drift into private schemes where hospitalisation is involved and the NHS has a bad record on waiting lists through starvation of funds; possibly 7 per cent. of the population is covered in this way either individually or through company schemes. But only 1 per cent.—I discovered this only the other day—an incredibly low 1 per cent. of primary consultations take place within the private sector at present. This has not increased since the foundation of the National Health Service. I find that a remarkable statistic. It is a pretty good vote of confidence for the family doctor service, whatever its shortcomings, and I suggest to the Government that they would be extremely unwise to dismantle it or undermine it in any way. The noble Baroness referred to one of the finest primary care services in the world, and I hope she heeds her own words and the Government heed them too.

My Lords, I shall say very little about social security as my noble friend, Lord Banks, who is the acknowledged expert, is to speak shortly. Also we await the White Paper. But I will repeat our opposition to, or severe reservations over, several proposals which figured in the Green Paper. We oppose the cuts in housing benefit. The IFS—the Institute of Fiscal Studies—estimates that of the £450 million saved, £350 million will go towards family credit. This is redistributing from the childless elderly poor to the working poor with children—the poor paying for the poor.

We oppose the payment of 20 per cent. of the rates by all households. The effect on those of low income will be adverse and in some cases punitive. Fifty per cent. of pensioner households will lose more than 1 per cent. of income and 11 per cent. will be more than 5 per cent. worse off. We cannot support that. We are totally opposed to abolition of the death grant and believe it should be raised to £250 and made reclaimable from the estate of the deceased, if there is any.

We have severe reservations about the "Social Fund". If it is cash limited and runs out in its tenth month, what happens to the applicants then? The Family Credit Scheme has some merits but we very much dislike its payment through the wage packet as this means a major redistribution of money within the family from women to men, where the woman is often unable to earn any income of her own owing to family responsibilities. Possibly, this is a technical problem which can be overcome during the passage of the Bill. We shall have to see.

It is difficult, if not impossible, to discuss pensions in any detail without the White Paper but I note with interest, in passing, the rumours in the press that the Secretary of State is backtracking on his original proposals to abolish SERPS and is now thinking of remodelling the scheme along the lines suggested by us as a possible basis for an all-party agreement. We fear that we shall not get an all-party agreement because the Labour Party has committed itself, if it comes to power after the next general election, to the reintroduction of SERPS, unmodified, with all its huge cost implications for the future. We should consider this to be wholly regrettable, in view of the long-term costs of SERPS and its inegalitarian features. For example, a couple earning less than £6,500 will not benefit at all under SERPS. We prefer the solution originally advanced by the Liberal Party, with which my noble friend Lord Banks is particularly associated, of a substantial rise in the basic pension should SERPS be abolished. If the Secretary of State now has other proposals, we shall have to study them very carefully to see whether they do anything to make SERPS more egalitarian by giving more help to the low or intermittent earner. Only then can we decide whether we can give them our support.

As is often said in this House, we are in an extremely complex field of policy, not helped by the ad hoc way in which our social security system has developed. However, if anything is certain it is that any proposals that have the effect of making the poor poorer over time and widening the gap between them and our more prosperous citizens will be strenuously resisted from these Benches. That goes both for health and for social security.

I have just spent two months in Catalonia, a small nation of some six million people without the status of a nation-state but with many similarities to us: they are manufacturers, traders and passionate lovers of liberty. They cannot be accused of being way out to the left. Indeed, their present regional government is centre right. However, everywhere on Catalan lips one hears the phrase, "teixit social", social fabric. This tends to be rather derided over here as a cliché of sociologists. However, there, in a very business-minded community, it is seen as essential for economic success to preserve social cohesion. I commend the idea to the Government.

4.42 p.m.

The Lord Bishop of Durham

My Lords, debates about the National Health Service and about the future of our social security system are bound most of the time to be about details. We are anxious, and some of us sometimes are angry, about the way matters have developed, particularly in individual cases or areas such as those referred to by the noble Lord in the previous speech. We are all very concerned about the decisions which need to be taken and which will be taken for the future. Clearly, for example, if we move into the area of the proposals in the Green Paper on reform of the social security system, vital questions will arise, such as: at what cash level are the Government proposing to move in implementing their various proposals for income support, family credit, social fund and so on? Alternatively, what are the probable effects of those likely moves on certain groups of persons who are dependent on social security payments and who are the concern of particular pressure groups and specialist agencies, like the family service units, the citizens' advice bureaux, the Child Poverty Action Group and all the rest? Clearly, much turns on the details. Therefore, we must obtain detailed information, we must have detailed reflection and we must take detailed decisions.

Yet, in the middle of all this, I sometimes have the disquieting feelings that, despite all the detailed investigations, the compiled statistics and the urgently prepared briefings and documents which we no doubt all receive by each post, we are still in danger of missing the points which really matter. These are the details of what life is actually like to particular men, women and children in their daily and weekly experiences—for instance, their daily and weekly experiences of making ends meet, or of living with the almost certain knowledge that the ends available to them never will meet in any foreseeable or imaginable future. "My child wears through its shoes", in a way which is not related to social security regulations; the cheque does not turn up for some suspicious reason such as, "I have been looking regularly for work, so they think I am in work"; or the whole business of "My application which has been passed three times before being turned down now": none of these matters can be dealt with directly by central legislation, regulation or administration.

Moreover, before limited means of finance, time and personnel can be applied to varied, clamouring and growing needs, people and circumstances, all these people and circumstances must be turned into statistics, and clearly hard choices must be made about priorities. It is exceedingly difficult—is it not—to discover and to work out the practice of what might be called "statistical compassion". How can regulations and budgets promise, produce or allow space for relevant and careful caring?

People must be treated as people or mistreated as non-persons at face to face and local level. That is clear. Also scarce resources must be distributed and regulated, by and large, at a national level. Therefore, perhaps the best we can do is to have proposals in a Green Paper; proceed through extended debate and criticism to a White Paper with legislative proposals; debate, amend and pass these, and then do the best we can with what we have.

However, I am still compelled to wonder, and to ask your Lordships, and indeed the Government, whether there is not a dimension which we are ignoring and which we could, if we gave our minds to it, both rediscover and relate to practical politics. This dimension, which was touched on by the noble Lord as he finished his speech, I think lies somewhere in the following area. Debates and decisions about arrangements for social security and for running the National Health Service are also about social cohension and—if your Lordships will allow me the expression and give me a moment or two to explain what I mean—about social symbolism.

This is to draw attention to the fact that what we do about social security and about the National Health Service sends out very powerful messages; messages to people about how organised society regards them and what kind of society it is which is causing them or allowing them to be treated in this way or that way. The operation of the social security system and the functioning of the NHS is not just a set of Government programmes costing a lot of money and one set of programmes, among many, competing for scarce resources in a period of acute economic uncertainty. It is of course that.

However, let us for a moment take the social security system, apart from the NHS. The social security system speaks directly and daily to millions of people—people who may be called claimants, clients or pensioners, but who are certainly citizens and neighbours. It speaks directly to them as to who we are and how we regard them or us collectively, and what we are trying or hoping to be. The Green Paper on social security, at the end of chapter 6, says, I think correctly: Social security cannot prevent the causes of poverty, it can only alleviate the symptoms. Problems, such as unemployment, that can lead to poverty must therefore be tackled at their roots. This can only be done by creating the conditions for sustained and real economic growth. If we are to achieve this, the cost of social security must not be allowed to become a millstone preventing the general economic improvement on which the real alleviation of poverty depends". Clearly this is true as far as it goes, but it seems to me that if we are not careful it may be too narrowly interpreted. General economic improvement is a very long haul and we shall need the support, the collaboration and the gifts of what we may call the poor, as well as the efforts of all those who are immediately in a position to be competitive and, in a narrowly economic sense, productive. The social security system and the running of the National Health Service surely are directly and urgently related to how we retain the poor as full members of our society, how we keep our society together in the difficult and certainly conflictual times through which we are now living, and how we mobilise our total national resources of people. and communities for building a new future.

I fear that it certainly seems to me that the Green Paper proposals do not look like a satisfactory basis for the sort of social security system we need to take us into the 21st century and do not give us much encouragement that either the social security service or the National Health Service is safe in their present hands. This is regrettable—and very political of a bishop. Unfortunately, commonsense overtakes my ecclesiastical prudence.

It seems to me that unless we tackle the broader questions, for instance, of tax reforms, rate reforms and income support, we shall just not be facing up to how we can organise our society in regard to its social needs, its productive needs and its togetherness in the face of the problems that are before us. There seems to be a rather discouraging lack of vision about the newness that is required for a lively future for our society, or for the simplicity of both administration and understanding which is required. It seems to me that in the Green Paper so far there is simplification on one side and complexity on the other, largely because no fundamental questions have been asked.

Mind you, my Lords, that is very donnish of me. You can always put off practical issues by saying that there is one more theoretical question. There is only one thing which is equally horrendous to the irrelevance of the theoretical man and that is the impracticability of the practical man who goes on practising things which have already clearly been outdated. If we are not going to face the depth of the newness which is before us and the challenge about work—where will people gain their incomes?—how, in my part of the world, even if we get the best possible we can out of the best intentions of the Government, (or a government, it seems to me in many ways, of any sort) are we going to put people back into the sort of employment which many of them have been used to?

There is no use, I think in just tinkering with things, especially as (it seems to me it has to be said) the proposals look as if they are largely concerned with containing costs—containing costs within the case of the Green Paper; there are to be some simplifications and improvements for some target groups but complications and threats for other equally vulnerable groups. And the proposals do not really begin to measure up to how we sustain and motivate a large and disadvantaged section of our community. Surely it is necessary both to sustain and to motivate this section of our community if we are to move through what must be a painful interim; a painful interim of building up and benefiting from economic recovery, even if we assume that we are on the way to that.

Let us take the best possible scenario. For the foreseeable future, and certainly over the immediate decade, there are still going to be all these people who are disadvantaged and, through no fault of most of them, dependent upon this social security system. It seems to me that the message that is likely to be conveyed to people in receipt of social security, if the general direction of the Green Paper is followed up, is that they are a burden, a burden to be maintained at the lowest possible level of subsistence; that people are to be grudgingly allowed discretionary payments as long as funds last and that people are to be supervised at every turn about their needs and the conduct of their lives. The social symbolism here, the message conveyed, looks as if they will work directly against social cohesion and against the re-incorporation of the socially disabled into society. It may be that this will not be so. But the omens do not look very favourable.

If the development of the social security system is to be socially positive, surely at least the following, among many other things, will be required. It will not be possible for the present and for the immediately foreseeable future, say, five to 10 years, to reorganise at nil initial cost. It is true of course, and we believe it—and, after all, we always believe the statistics that are given to us—that 11 per cent. of income goes on social security and that when you add the cost of the health service you get a very high proportion. But this has got to be regarded, it seems to me, as social investment. Have we not got to go alongside the whole business of trying to deepen, renew and extend economic investment? And have we not also to be concerned at the same time, sometimes at the cost of not going so fast on economic investment, with social investment? Social investment cannot entirely wait upon economic development. Maybe we have to give up any notion of jam today in the hope of producing jam tomorrow. Surely it will be dangerously socially divisive if we start trying to scrape off what little margarine there is on some very dry bread which is all that people at present have.

So what sort of social symbolism is to be seen and what sort of social message is received if national assets are sold off in relation apparently to tax cuts, but many deprived members of society are at the same time discovering that there are cuts in their allowance for heating costs and that they may be required to contribute 20 per cent. to their rates? This is the symbolism. This is the message.

Secondly, the timing of the changes—and surely we are all agreed that urgent changes are required and deep thinking and political reflection are necessary—must be extended so that much more detailed consultations and working out of likely effects can be carried out. It is very difficult to keep on receiving assurances that all is well when, as happened to me last week—although I realise that I am not statistically significant—I am told by one clergyman of three cases known to him in his village where he has had to help people who had hitherto been anxious to take in an elderly relative, at least to care for them as long as they could. But they are now not ready to do this because, owing to the various cuts and manoeuvrings to do with accommodation for aged people, they know of one or two other families who, having taken on somebody for as long as they could care for them, found when they were totally desperate they could not get them taken into care. Therefore, this is having a devastating effect. No doubt the vicar should have told them to be heroic and that following God means that you take on any sacrifice and carry on like this. But I do not think that we can base our social security services on demands for neighbourly heroism.

Of course, that is not statistically significant. But when one hears echoes like that around the place, or echoes of people who are trying to run schemes for self-help but cannot get the unemployed in because the unemployed are afraid that if they turn up on more than two days a week their Giro will be stopped while investigation is made, and so on, one is obliged to believe that there is something in these echoes. Of course, I shall be told once again, "Give us the details of the case"; and for this particular one I can do it quite simply. But the point is not the details of the particular case but the whole feeling, the whole social symbolism, the whole social attitude; and this point has really got to be faced.

I think that the Government and the country as a whole must take time to work out these changes and to work out in detail how they will be applied and what they will mean, and to do that before they are applied; for people on social security cannot themselves afford time, cannot wait for something to be worked out or got straight. This is because one week's delay in producing an assessment or a payment causes real misery and hardship if people are totally dependent on the weekly Giro and if the cash that it is worth, even with careful management, only lasts them for five days out of seven. They simply cannot wait for other people to make inquiries up the line about what the regulations are or, even when they are told what they are, to work out what they mean. We who are in power and in prosperity must afford the time for careful working out and preparation, not the claimants, the dependants and the neighbours in need.

Thirdly, it seems to me that nothing must be implemented until staff are trained and brought up to strength. This is vitally necessary for the staff of the DHSS as much as for their clients. I myself have fairly recently been involved in at least a couple of incidents where my attempts to draw attention to poverty, misery and particular cases have been misinterpreted as threatening the DHSS staff. This was not in any way my intention. My naivety is being rapidly rubbed off, as you can imagine. I imagined that everyone was so concerned about the issue that to bring it to public notice would help all concerned. However, it was not taken so.

I am quite clear that the DHSS staff, being as human as anyone else, do a magnificent job, on the one hand, but that at other times they get involved in the sheer miseries of the situation and the frustrations and difficulties of their clients which brush off on to them. Of course, we are all human beings and there is an urgent general point here. As there is misery and anger among claimants, it brushes off on to staff and, as staff are human beings like the rest, they find this very threatening and they can become very defensive. Surely the important point to recognise is that all staff and clients in some areas are under nearly intolerable pressures.

It is therefore vital that the Government do not press ahead with changes which both demand more and more staff—like the highly increased discretionary element, without appeal, and so on—and at the same time make it more likely that there will be frustration, bewilderment and anger among the clients. That is a recipe for increased tensions both for the DHSS officers and for people in the multiple-deprived areas. I greatly fear that if we are not careful we shall be strengthening a tendency in society as a whole which sometimes seems to be supported by measures promoted by the present Government. But we are too ready to direct the pressures and sufferings of our society on to some of our paid servants: for example, in some cases the police and in this case the DHSS staff. They do not deserve, and cannot bear, the pressures and conflicts we are forcing upon them.

It therefore seems clear to me that money, time, training and more personnel must be made available so that as the new system works out there are people there who can cope with it. Surely it is very greatly to be hoped, and an urgent necessity, that in going forward on social security reform and in caring for the National Health Service the Government will think very hard, consult very widely, take the necessary time and be prepared for a period to commit the necessary increased expenditure to ensure that our social security system and our National Health Service speak to people in need of a society that cares now, not of one that promises them dividends tomorrow when economic recovery can be shared with everybody—not least because to get economic recovery or to live creatively in continuing economic struggle we surely must have social cohesion. For this, and for social morale generally, the social security system and the National Health Service are not just programmes but an essential means of social caring and social growth; so we need, however urgent, to take time in both cherishing them and changing them.

5.2 p.m.

Lord Wells-Pestell

My Lords, over the years I have introduced a number of debates in your Lordships' House on the National Health Service and social security, and I have come to the conclusion that it is a most depressive, useless and pointless exercise. When I listen to the Government, as I have done over the years when we have been discussing this particular matter, there has always been a tendency to leave it to the Minister and play it at low key—so much so that I have got to the point that I look round to see whether my noble friend Lord Boyd-Carpenter is there. He is my friend, and if he is there I think it means that he has been given the official responsibility of rescuing the Government party in a debate of this kind. I am sorry if it offends the Minister, but that is exactly how I feel—that he is going to throw a lifebelt in to try to help.

We on this side often feel that there is a lack of interest in the future of the National Health Service by the members of the present Government party. Perhaps it is due to the fact that they know so little from practical experience of the working of the National Health Service. I would not like to test it, because the rules of your Lordships' House would not allow me to ask: "Put up your hands those of you who use the National Health Service. But I am pretty certain, from what one knows and hears, that not many members of your Lordships' House who sit on the Government side are regular users of the National Health Service. I am not opposed to private medicine. People have the right to choose the kind of treatment they wish and where to get it in the way they want to, but I feel that the National Health Service should not be the poor relation as it is today and as it has been ever since its inception.

It may well be some noble Lords are surprised that we feel so strongly about it. We feel so strongly about it for no other reason than the fact that we regard this as the finest piece of social legislation which has taken place in this country during this century. Many of us can remember what the old methods of treatment were—the local authority hospital or the voluntary hospital—and we know what that meant. I do not feel that the concept of a National Health Service has been accepted as it should be, in its entirety, to make it a first-class service; I do not think it has been accepted by noble Lords opposite.

There is perhaps one notable exception, and I hope the noble Lord will not mind my referring to him. I refer to the noble Lord, Lord Tranmire, who when health Minister (I believe it was in the late 1950s) did a great deal to help the National Health Service and worked very hard on its behalf.

Lord Boyd-Carpenter

Hear, hear!

Lord Wells-Pestell

My Lords, I should like to feel that I could say that of his successors. This afternoon I want to confine my remarks to the National Health Service, to which my colleagues and I attach considerable importance. As I have already said, we fear it has not received the enthusiasm of the Government. The recent Autumn economic statement by the Chancellor no doubt will have pleased noble Lords opposite, who quite genuinely feel that the Government have done as much as they possibly can in the circumstances. In point of fact, I think that really was the tenor of the speech made by the noble Baroness the Minister. What astounds me is that a Minister can get up in your Lordships' House and say, "Yes, there are empty beds, but we are dealing with more people than ever before." Why are the beds allowed to remain empty when the waiting lists are so long and when people have to wait so long to be seen and treated?

Reference has been made to the fact that the grant that is to be made in the foreseeable future for next year will do very little more than meet the increase in the salaries of doctors and nurses. We on this side are not opposed to that. We recognise that many of them are underpaid and work far too many hours. But if I may say so, that is not going to produce any situation other than a standstill situation, because the National Health Service will still be starved of what it needs to be an efficient and effective health service. There are too many people, both in Parliament and outside it, who feel that the National Health Service is an extravagance. Although many noble Lords opposite will deny it, I am quite certain in my own mind that there is a feeling that spending on the National Health Service is an extravagance and that it is not a bad thing to cut it.

Reference was made by my noble friend Lord Ennals to the fact that, according to a recent survey in the Guardian, more than half the population of Britain believe that health should be the Government's main priority spending. A Gallup Poll in the Sunday Times showed that 75 per cent. think that too little is being spent on the National Health Service.

It is the duty and responsibility of every government to keep in the forefront of their thinking the needs of those sections of the community which are medically vulnerable, particularly when we are living in a community where there are something like 10 million old-age pensioners; 3½ million unemployed and 3 million disabled persons as well as others outside those groups, who need medical care and hospital treatment more often than many of us know. The Black Report, Inequalities in Health, which will be familiar to a number of your Lordships, clearly shows the links between personal health and poverty and poor housing.

I was interested to read recently—and I do not say this in any sense to score—that a former well-known Conservative on, I think, the Cardiff City Council who recently left the Conservative Party and joined the Labour Party, said: The overall effect of the Prime Minister's Government has been a catastrophe. Britain is like a house that has not been maintained", and that is perfectly true. I ask your Lordships to look at every walk of life in this country at the present time affecting the life and happiness of individuals. There is not an aspect of it that has been properly maintained.

I doubt whether a week passes without several newspapers and periodicals commenting on the limitations of the National Health Service, particularly the plight of those awaiting admission for treatment and operations. The Government assure us from time to time, as they will today, that they are pouring more and more money into the National Health Service. Ministers seem to have missed the statement made only a few months ago by the Permanent Secretary at the DHSS, who said that current spending on the National Health Service in the past year fell. If the noble Baroness the Minister is to ask her advisers to give her any facts and figures, will she ask them to give true ones? It is surprising how we on this side—and I can call in the Alliance parties for that matter—differ so much and so fundamentally in our figures from those that are produced by the Government.

Baroness Trumpington

My Lords, if I may interrupt the noble Lord, I resent his remark about asking my advisers to give me true ones. I have never knowingly misled or lied to the House and I should be grateful if the noble Lord would take back that remark.

Lord Wells-Pestell

My Lords, I did not say that the noble Baroness had done so. I said would she ask her advisers, which is rather different. She should not be so ready to take exception.

On 10th October, the Guardian newspaper stated An attack on claims by Mr. Norman Fowler, the Social Services Secretary, that he was providing record levels of care in the National Health Service has been launched separately by Dr. David Owen, Leader of the Social Democrats, and medical statisticians working for the health service. Dr. Owen, in a speech to a Royal College of Nursing conference in London, yesterday accused Mr. Fowler of being 'outrageously inaccurate' in claiming that record numbers of patients were being treated. It went on: government claims that health spending had risen by 17 per cent. over four years were proved wrong by the all-party report—which showed it was nearer 4 per cent. Claims that new hospital beds had increased by 11,000 had been disproved by the British Medical Journal which had shown beds had decreased by 12,900.". We ought to be able to get accurate information and that is all that I am asking for.

I understand that the number of patients on the in-patient waiting list in March last was somewhere in the region of 670,000—that is 8,000 fewer than in September 1984—but it is the stories behind the waiting which should be exercising our minds. They are stories of excruciating pain that continues for months, but that would disappear in a day following an operation. It is not sufficient for Ministers to say: "We are reducing the waiting list." The question is: are they doing it fast enough? And the answer is: no.

The BMA undertook a survey into waiting times and asked the Health Services Management Centre to analyse the data. The result showed that between 1983 and 1984 there was an increase in both the average minimum and the average maximum waiting time in every specialty in 163 English districts. In orthopaedics, which are the cause of so much incapacity and pain, the minimum waiting period was 16.1 weeks and the maximum waiting period was 31.7 weeks. That is something like eight months.

If you have never experienced the physical pain, it is difficult to understand what the problems are. Yet all over the country we have not hundreds but thousands of men and women in these specialties which are producing a devastating existence lasting sometimes for as long as eight or nine months before they can be relieved. Whatever method of analysis is used, one cannot avoid the conclusion that the outpatient waiting time deteriorated between 1983 and 1984. It is quite scandalous that this situation is allowed to go on.

I know that in the next two or three years the Chancellor of the Exchequer expects to receive something like £ 14½ billion from privatisation sales. Is it seriously contended that there will not be enough money to provide a better National Health Service? And it is not only £14½ billion from which he will benefit in the next three years. There will also be all the money that is coming in from gas, electricity, water and various other undertakings which may not yet be up for privatisation.

I shall not put this question to the Minister because she cannot answer it. However, is it beyond the competence of the Government to spend some of that money on the National Health Service? This need comes before a reduction in other things. I know that the Chancellor has already hinted that there will be tax reductions next year, perhaps of 2p. It is also being said that there will be tax reductions in the following year of 3p. Are we really justified in putting money into the pockets of a large number of people who do not need it? I do not say that there are not some people who would benefit from tax reductions, but I am sure that those people are from that section of the community who meet among their own friends and relations men and women who have been waiting for a long time to go into hospital for treatment. They would cheerfully forgo a tax reduction in order that more money could be made available for hospital treatment.

I ask noble Lords opposite to take this matter seriously. I have never really thought that noble Lords on the Government side were as concerned about it as many of us because the need does not arise for many of them. They could make an arrangement tomorrow and go into hospital the next day. Some people ask to do so but have to wait for nine months. There is a moral obligation in this respect on every government, and particularly on this Government because they are going to come into a vast fortune in the next three years. I have not mentioned oil revenue. I should like to know what the revenue from oil has been since 1979. It could be tens of billions of pounds. When one considers the enormous amount of money that has passed through government hands and the enormous amount of money that is going to pass through their hands within the next two or three years, one can see no justification whatever for this penny spending. That is all it amounts to. When one considers the amount that is already being spent on the National Health Service, £600 million over the next two years is really a very small sum in comparison.

5.22 p.m.

Lord Boyd-Carpenter

My Lords, the noble Lord, Lord Ennals, is not at the moment in his place but he knows that I have the very greatest admiration for him, not least for the courage with which he has faced up to quite serious physical disability very recently. That no doubt accounts for his absence at the moment. But even in his absence I should like to say, as I would have said with greater pleasure in his presence, that I think he made a mistake in asking your Lordships to debate this afternoon both the National Health Service and the problems of social security. Both of these are enormous subjects of the highest complexity and of the greatest possible importance. Each one of them would have made a much more satisfactory debate than I am afraid we are going to get out of the mixture. It is a mistake which derives from the mistake made some years ago—I have always thought that it was a very bad mistake—when the old Ministry of Pensions and National Insurance was merged with the Department of Health. Both of those departments had an important role to play and I have never ceased to criticise the folly of those in both parties who brought those two departments together. I should myself like to see them divorced.

The noble Lord, Lord Wells-Pestell, made a remarkable observation about me. He said that he thought my role was to throw a lifebelt to my noble friend on the Government Front Bench. I am bound to tell the noble Lord that, of all the people I know, the noble Baroness, Lady Trumpington, is the person least in need of a lifebelt that I have ever met. I do not regard the highly supernumerary activity of providing the noble Baroness with that facility as being any reason for me to intervene on those lines. As the House knows, the noble Baroness is more than capable of looking after herself.

I rather resented the implication throughout the speech of the noble Lord, Lord Wells-Pestell—I hope the noble Lord will accept this—that noble Lords on this side of the House and my right honourable and honourable friends in the Conservative Party in another place have a lack of concern about and a lack of interest in these subjects. That is just not true. For my own part, I gave 6½ years of my life—I think it is the longest stint anybody has ever done—in the old Ministry of Pensions and National Insurance. Many of my colleagues have served there, including I am very happy to recall our present Prime Minister.

In this House we have a great many people—my noble friend Lady Faithfull is an example that leaps to mind—whose record of social service, social care and social concern is as good as that of anybody else in the country or in any political party. We care at least as much as the noble Lord, Lord Wells-Pestell, but where we differ, and where we are entitled to differ, is not about the end but about the means. It is no use caring about and having a great enthusiasm for a subject unless you are prepared to back the most effective practical method of achieving the best possible results. That is where, legitimately, there is a difference of opinion. I hope that the noble Lord, Lord Wells-Pestell, for whom again I have the very highest personal regard, will realise that he does give some offence to his own friends and admirers on this side of the House when he suggests that we are not very interested in this subject.

Finally, as regards the noble Lord, Lord Wells-Pestell, the noble Lord will say when we come to questions of taxation that it is wrong to put money into the pockets of those who do not need it. That is a complete travesty of what may or may not be involved in what the Chancellor of the Exchequer does. It is not a case of putting money into the pockets of those who are better off; it is a case of not taking quite so much out of them. That is a totally different thing and is of course immensely relevant to that which we all care about, which is the efficient working of our economy and the creation and generation of wealth so as to have among other things an economy capable of sustaining the burden, the enormous financial burden, of our social services

I listened with enormous interest to the right reverend Prelate the Bishop of Durham. I agree entirely with what he said about the need to take time over these important matters. But, my Lords, this seems to be what the Government have been doing. We have had a flood of Green Papers. I have two of them here and there are two more on my desk. There have been consultations with all outside bodies and there is then to be a White Paper. Whatever the Government can be accused of in their proposals on social security, I should not have thought that indecent haste was one of them. They are moving with the urgency that the importance of the subject demands, as I am sure your Lordships will agree. However, they have taken an enormous amount of trouble to consult, to inform and to seek opinions on these matters, just as they are, as I understand it, listening to your Lordships' House this afternoon. Therefore I thought that was less than fair.

But what I was very unhappy about in the speech of the right reverend Prelate was when he said of the present Government that the social security system was not safe in present hands. I say with great respect to the high office which the right reverend Prelate holds that that was an uncharitable thing to have said, and more important it was absolutely baseless. If the right reverend Prelate studies the way social security has developed in this country since the war he will see that it has been contributed to by both the major political parties. Both of them, in office and out of office, have worked extremely hard in the development of our social security system. Just to say now, when spending on social security is at a record level, that the system is not safe in present hands is a remark which, on reflection, I hope the right reverend Prelate will regret.

The right reverend Prelate then referred to his theological prudence. Some of us might wish that he remembered it in the pulpit. He went on to say—and one understands very much of the feelings he has for the people of his diocese, which is possibly the worst hit economic area in the country—that he wanted to see unemployment brought down. There is no one who would quarrel with that. Indeed, my noble friend Lord Young of Graffham is doing his utmost to achieve just that. The right reverend Prelate went on to make a remark that I believe to be quite dangerous: that people should be given the sort of employment to which they have been accustomed. I suggest that such is a dangerous doctrine to propound.

The Lord Bishop of Durham

My Lords——

Lord Boyd-Carpenter

My Lords, if the right reverend Prelate will wait for a moment, I will of course give way to him, as is the normal custom of this House. However, perhaps he will find it more convenient to allow me to make my point so that he may answer it. He cannot anticipate the point I am about to make. My point is that we have a changing economic situation. There are a great many people, particularly from the heavy industries. in the North, who will never be re-employed in their old industries, and it is dangerous to let them think that they may be so re-employed. It is however essential to persuade the newer, high technology, developing industries, and thé rest, to move into those parts of the country and then to provide the employment which people in the right reverend Prelate's diocese desperately seek and which all of us desperately wish to see them obtain. I will now give way to the right reverend Prelate.

The Lord Bishop of Durham

My Lords, I thought that I had said precisely that which the noble Lord, Lord Boyd-Carpenter, has just said: that it is no use expecting the type of employment which existed before. I was trying to make the point that it is no use expecting full-time employment—40 hours per week for 40 years of a lifetime—for a very large number of people in my diocese. I was not suggesting that we should go backwards in any way.

Lord Boyd-Carpenter

My Lords, I am very grateful to the right reverend Prelate. However, I made a note of his remarks at the time and when he reads Hansard he may feel that, per incuriam, he did give a wrong impression, which I am very glad to have had the opportunity of enabling him to correct. I believe that the right reverend Prelate appreciates as much as anybody that it would be a most dangerous thing to try to persuade an unemployed man that, in some mysterious way, industries which are inevitably declining will suddenly be revived so that people may do, as of course they would like to do, the kind of work to which they have been accustomed.

Lord Jacques

My Lords, does the noble Lord not accept—and I speak from personal experience—that in the past it has been the experience that the kind of employment which has become available in the right reverend Prelate's diocese has been quite unsuitable for those who have been out of work there? In most cases, the type of employment available in the North-East is not suitable for out-of-work miners but is for their wives or daughters.

Lord Boyd-Carpenter

My Lords, there is of course some element of accuracy in that observation. It is all the more reason we should encourage the new, high technology industries which can offer employment to the former miner as well as to his family, to move to such areas. The noble Lord will understand as well as anybody that present legislation dealing with sex discrimination makes it very difficult, when establishing new industries, to see to it that the man rather than his wife gets the job. An employer who attempts to do so soon finds himself in court. Nevertheless, I take the noble Lord's point.

I want to refer now to two specific items and then to one general issue. Very recently, probably in the light of this debate, I received a letter from the parent of a young person now aged 17 who, when a child, was severely mentally handicapped as a result of vaccination. The parent received on his behalf in 1983 the sum of £10,000 as final compensation. The parent concerned is naturally disturbed to discover that awards made since 1983 have been at the level of £20,000 and that no attempt has been made to raise the orginal figure of £ 10,000 to the level of current awards.

As the disability is in all circumstances the same, it seems wrong that the mere accident as to when the application was made—and there is no question of inflation playing a part because it is only one or two years' passage of time—should result in such a wide disparity. I do not know whether my noble friend can answer when she winds up this debate, but I shall be grateful if she will look into this matter. On the face of it, it seems to be a real grievance.

My other specific point relates to war pensions. The older war widows still receive, as I believe is the case with all pre-1977 widowhoods——

Baroness Trumpington

My Lords, it is the case with all pre-1973 widowhoods.

Lord Boyd-Carpenter

My Lords, I am much obliged to my noble friend. In any event, they receive much less pension than those whose unhappy widowhood occurred a little later. I find it difficult to defend that situation. In fact, the older the widow the more likely it is that the greater will be her need. This is a very real grievance and one which the Royal British Legion, which does so much for the ex-serviceman and his dependants, has taken up again and again with Ministers without apparently persuading them of the wrongfulness of that discrimination. Again, I hope that my noble friend the Minister will be able to say something about that matter. Better still, I hope she can say that her right honourable friend is having second thoughts about that issue.

Finally, on the main issue of social security, I refer to that which is described by the rather disagreeable word SERPS. When I introduced in 1958 legislation the first graduated national pension scheme, we called it just that. SERPS is an intruder from later in time, and it is not a very pleasant description. The original 1958 scheme was very small but was a pioneer in relating pension to earnings during life. It was intended, first, to help those who had no private pension rights, and, secondly, to encourage employers to introduce private pension schemes.

If your Lordships will cast your minds back to 1958, at that time very few companies outside the public sector had their own comprehensive pension schemes. Many operated schemes for their senior people but few offered them to members of staff throughout their firms. Whatever else may be said of the 1958 proposals, they were highly sucessful in that regard. Since then, there has been a most gratifying growth in private pension provision. Indeed, it is for that reason that the Government are now legislating to help those early leavers who otherwise may not benefit fully from private schemes.

As regards the current SERPS, there is no doubt that the financial burden ultimately involved is very large indeed. It is not a question, as one or two noble Lords have been suggesting, of the immediate cost, or of the scheme's effects on the next two or three Budgets or on tax concessions in the next two or three years. It is a question of the burden we are building up for our successors in the next century. There is a lesson to be learnt from past experience in both social security and health.

In the moving speech made by my noble friend Lord Stockton the other day, which most of your Lordships heard, he pointed out that in the late 1940s we somehow kidded ourselves that after six years of war and destruction we were all much better off and were going to be very much better off", and could therefore afford massive improvements, including massive improvements in social security. As a result, the Government of the day went beyond what Sir William Beveridge recommended in respect of national insurance benefits and brought forward the payment of benefits at the full rate. Equally, the late Mr. Bevan introduced a wholly comprehensive health service.

As the years have passed the financial burden of both these has become very heavy, though if our economy is well managed I have confidence that we can maintain it. But there is a lesson in that, I suggest, for the future. We do not know how the British economy will function when we reach the 21st century. We hope that it will be doing extremely well, but it is possible that a great deal of the oil will have been exhausted by then and it is certain that the competition from many of the new countries, particularly of eastern Asia, on world markets will be very formidable. Therefore it seems imprudent to pile up for our successors the very heavy obligations which will arise under the present SERPS scheme.

I am not an advocate of abolishing SERPS. I think that would cause disappointment, break continuity and consensus, and I do not think abolishing it is necessary. However, I feel that it requires modification in one particular respect. Under the scheme as it stands pension benefit is assessed on the best 20 years of one's working life. Under my original scheme—the national graduated scheme—and others, it was assessed over life. If SERPS were amended so that one's earnings throughout one's working life provided the basis for the calculation of one's pension I understand that this would substantially relieve the future burden in the next century and I do not think that most people would feel that to be particularly unfair.

It is arguable too that the provision in the present scheme that a widow receives her late husband's pension in full is necessarily right. In many private schemes the widow receives two-thirds of her husband's pension. Account is taken of the fact that the husband, alas, no longer has to be maintained and therefore there is no need for quite so much pension. Therefore the suggestion which attracts me and, I hope, in due course will attract the Government, is that we should retain SERPS in its general structure but modify it in one or two ways such as those I have mentioned in order that we shall not again perhaps be making the mistake of imposing on our children burdens which they may find too heavy.

5.42 p.m.

Lord Rea

My Lords, I do not see the noble Lord, Lord Boyd-Carpenter, so much as the thrower of a lifebelt to aid the noble Minister in her reply but rather as a terrier who has been set to bite the heels of one or two other noble Lords and the right reverend Prelate who have criticised her speech. I thought that the noble Lord, at one point at least, barked at the noble Baroness when he threw at her something of a nasty about compensation for vaccine damage. I too should like to know the answer to that question.

I have to apologise to the noble Baroness who is to reply to the debate. I have a previous long-standing engagement and must leave before the end of the debate. I am to chair a meeting at the Royal Society of Medicine on the prevention of coronary artery disease. I think that is a suitable place to go from this debate.

I intend to concentrate on my own field of primary care, not only because I am acutely aware of some of the problems from an inside view but also because of its importance in the whole structure of the National Health Service and to everyone who seeks medical help. I am aware that this importance is recognised by the Government. As we all know, and as has been mentioned by the noble Lord, Lord Kilmarnock, a Green Paper on primary care—yet another Green Paper other than the ones we see lying on the Table—is to be published some time in the near future. Many of us working on the ground will be very grateful if a date for this could be given by the noble Baroness when she replies to the debate.

We hope that the Green Paper will indicate the Government's thinking on the future of primary care. The gestation period for this supposedly planned birth has been remarkably long. Sadly, it seems that one reason is that several foetuses have miscarried or perhaps were deliberately aborted. My information is that at least three rewrites of the Geeen Paper have been carried out in the past two years. I wonder what was wrong with the first two. Could it be that the department's soundings of opinion or recommendations did not meet with the philosophy of the present Government? I wonder. I am fully aware that Green Papers are intended to provide the basis for further discussions and are not definitive, but the wording and lines of argument in a Green Paper are very influential in shaping the White Paper and possible legislation which follows. So I very much hope that my words will be heard or read by those entrusted with the final draft of the Green Paper.

It is often thought that primary care is a euphemism for general practice. In fact, it is much more than that and includes all points of first contact with the health service. These include in the United Kingdom not only general practitioners but also the large number of nurses, health visitors, midwives and other paramedical workers and some social workers based in the community. It also includes other doctors in, for example, the school health service and occupational medicine and some hospital-based doctors such as casualty officers and the staff of sexually-transmitted disease clinics, which are so much in the news now with AIDS. In both those clinics there is open access, as in general practice. There is much overlap between the work of general practitioners in their surgeries or health centres and that of these other doctors.

There is no time in this debate to give an adequate historical perspective to the development of general practice towards the broader concept of primary care. Most GPs still value their independent contractor status, which has been an acceptable development from the original individualistic entrepreneurial basis of the profession—selling curative or comforting wares on the open market. Expansion of the role of the GP to embrace the help of others working in the community has been welcomed by most forward-looking GPs who have seen the advantages of providing the wider scope of care than can be offered in collaboration with a team of attached or employed nurses or other workers. Indeed, general practitioners, especially those in the Royal College of General Practitioners, have been in the forefront of promoting the team approach. That is in line with the recommendations of the World Health Organisation, which stresses the fundamental importance of primary care throughout the world.

Twenty years ago general practice acquired a new lease of life in what has been known as the GP's charter. Doctors were encouraged to employ more staff by the reimbursement of 70 per cent. of their salaries and some incentives were given to form group practices and to improve their premises. Since then there has been not enough incentive to improve methods of working; although general practitioners are now much better trained because of the vocational training scheme which is mandatory before appointment to a National Health Service principal's post.

The earnings of general practitioners now actually reach their maximum very early in their career—often by the age of 30—and there is very little financial incentive to change from then on. Any innovations are left entirely to the profession itself. That is perhaps as it should be in an ideal world and at least the department puts few barriers in the way of those who wish to innovate and even makes encouraging noises. However, that is not good enough. General practice, and with it the whole of primary care, still falls far short of what we would like to see. That is particularly so in some inner-city areas, particularly London. I think the chief medical officer, Professor Acheson, must be a little sad to see how few of his recommendations have been implemented. Left to itself I think that there will be a steady improvement because of the new recruits to general practice who are some of the best products of our medical schools. However, it will be slow if new and promising ideas are not positively encouraged by the DHSS.

In its publication of two years ago, General Practice—a British Success the BMA promotes the idea that general practice has done a good job and deserves to be further encouraged by the injection of more money and the reduction of average list sizes to 1,700 (from the present 2,200) without loss of remuneration. They have a point. General practitioners see 90 per cent. of episodes of illness that reach the National Health Service; but nowhere in this book do they suggest that there are bad or unimaginative GPs who could be encouraged to do better.

The Royal College of General Practitioners—and here I must declare an interest because I am a member—only includes one-third of established general practitioners among its ranks but it is trying to promote higher standards in primary care through its quality initiative. There is a recent publication called, Quality in General Practice that has just been produced this month, which I hope will be taken into account by the Government in their Green Paper. In effect the quality initiative is a form of self-audit by college members. It was launched two years ago and has been pursued in all its faculties throughout the country.

At this point I shall digress to list some of the services which I feel that primary care should be able to offer in addition to the role of caring in a humane way for patients when they present with symptoms. General practitioners are in the unique position of having a captive list of patients, a population to care for, and for this population they should be able to provide anticipatory or preventive as well as curative services. They can be provided either opportunistically when patients present with other symptoms—one has them there and can do some investigations on them—or by inviting patients to special clinics. Obstetrics and ante-natal care come into this latter category, and here general practitioners are encouraged to maintain skills by item of service payments which are higher if the doctor is on what is called the "obstetric list", which requires him to have additional expertise and qualifications.

I consider that the same system should apply to pre-school screening and surveillance. Ten years ago the Court report on child health care services suggested that each practice should include one doctor who had special interests and training in child care to supervise this aspect of primary care in association with nurses and health visitors. So far nothing has come of this recommendation and far too few practices run effectively, well-baby clinics of an adequate standard.

In this field I suggest that as well as an obstetric list there should be a paediatric list and that child surveillance should be run by suitably qualified general practitioners who should be remunerated for their expertise, as they are in Sweden for instance.

There are other screening, preventive and health educational activities which could be encouraged, the exact means for which are to be worked out: high blood pressure screening, cervical cancer screening and breast screening, to mention a few. Continuing care of many chronic diseases can be perfectly well carried out in the primary care setting with the aid of nurses and an efficient recall system rather than in crowded outpatient departments. Here and in other aspects a computer is useful, though not essential.

Diseases which GPs can look after well for example include diabetes and other endocrine deficiencies, such as thyroid disease or epilepsy. These are familiar examples from a long list. Many procedures now undertaken in hospital could be carried out in suitably equipped surgeries or health centres—for example, vasectomy, minor surgery and minor casualty care—and much of the work of the present inefficient and overcrowded outpatient clinics could be canned out better in general practice. More consultants could come out more often to see patients in the community in conjunction with their doctors and this would have a very good educational effect.

I could continue. Many of these developments will save hospital costs. The important point is that at present there is little incentive for these things to happen. Hospital consultants, by being reasonably assiduous at their work, earn merit awards; general practitioners have a fixed remuneration on a relative plateau throughout their career, whatever they do.

I am aware that the General Medical Services Council of the BMA is very suspicious of differential payments to general practitioners. The College of General Practitioners, on the other hand, has come out with a call to face this issue. It may be that those doctors who are prepared to contract to do more for their patients should be paid more. Maybe the time has come for the terms of service for general practitioners in the National Health Service contract to be rewritten. The Green Paper is perhaps the place to air this issue. The option of a salary for those who want it should also be on the table.

As my noble friend Lord Ennals has pointed out, it is very clear that the present system of care free at the point of service and funded from general taxation is popular with both patients and doctors as well as being economical, and it should not be altered. I suggest that any plan to introduce private practice into primary care in this country is likely to fall flat on its face. As the noble Lord, Lord Kilmarnock, mentioned, only 1 per cent. of the population uses private general practice. The present system needs to be upgraded and improved and not overturned.

This is a very large and rather specialised topic and I have only touched the edges of it. I look forward to the Green Paper. I hope it will encourage innovation, experiment and consultation with all concerned parties. The Government have an opportunity here to provide an imaginative lead. It will be tragic and a major disappointment if the opportunity is wasted.

5.57 p.m.

Lord Hunter of Newington

My Lords, I should like to say a few words about management in the health service; but first let me congratulate the Government on their wisdom in not tampering with the Public Health Laboratory Service. To have done so might well have put the health of everyone in this country at risk. The Public Health Laboratory Service is a vital part of the nervous system of the National Health Service, and is a highly sensitive screen for the protection of everyone. Organisms are no respecters of the boundaries of man-made administrations.

In relation to the development of management in the health service, there have been two important happenings in the past to which I should like to refer. The first of these was the development in this country, prior to the National Health Service, of the medical officer of health, now done away with in his original form. The medical officer of health was the chief medical adviser of local authorities and no mean manager of medical services and hospitals under his control.

The other piece of history which is relevant to this story is the experience of the emergency medical service in World War II. This produced between hospitals and specialists of the local authority and the voluntary hospitals a collaboration which in fact laid the foundations of the National Health Service in its development after the war. It is interesting to note that in the first months of the war, Walter Elliot raised the question of whether the emergency medical service should not be turned into a state hospital service. The management board and a string of general managers that the Government have recently introduced are concerned with those very hospitals and the regional and district authorities which run them and which are supposed to manage them!

The timing of this vitally important development could not have been worse. Many administrators and able managers left the NHS in the 1973 organisation, and with the dissolution of the area authorities in the 1980s some of the best took their compensation and left, confident that because of their quality they could get a job elsewhere. That does not mean that there are no able administrators within the service, but in the light of future needs that was most unfortunate.

I have gone into this in a little detail because it should be understood how difficult the task has been for those responsible for the development of management services in the NHS. They have in fact done remarkably well under the circumstances.

However, 12 out of 14 regional managers came from the NHS itself and were appointed before the chairman of the management board. I do not know how many of them had ever been on a management course. Now that the district and unit managers are being appointed, the need for management training courses has become urgent, and perhaps the Minister will tell us the estimated cost of training those already appointed to carry out their larger task. At district, of those appointed about 7 per cent. are clinicians, and at unit level the percentage of clinicians appointed as general managers is in the region of 15 per cent., so that the nearer the patients the more we have medically qualified general managers.

Doctors, like the members of many other professions, believe quite sincerely that any good doctor is a good manager and that a doctor requires only to apply himself to do well. Of course we know that that is not so; but fortunately doctors see no conflict in combining management with clinical work, which is important and necessary for clinical units. So things seem to be moving.

However, all that immediately raises a number of important questions. What will the managers do which is of vital importance to the NHS and which will give us a cheaper and more effective service? Everyone is anxiously waiting to see the results. One should remember that the profit motive and the balance sheet approach which exist in industry and which give a good guide to achievement are not present in the same form. Will the managers give us financial priorities in clinical services? A whole lot of new relationships will have to be worked out. One has to remember that the Conservative Government introduced consensus management in 1973 and many people have made that system work in spite of its having time-consuming disadvantages.

What will be the relationship between clinicians who are unit managers and the general manager? Are they directly responsible to the regional or district board or to the manager? We should also note that the Medical Research Council and the Science and Engineering Research Councils have become effective and world famous. All their unit managers are scientists and clinicians, and to my knowledge they have no general managers. Your Lordships should not misunderstand me. I am not against general managers; I just want to know what they will do in the NHS.

One question not unconnected with the management situation also remains to be answered. How necessary or effective is widespread public participation in the running of the NHS? Politically it is accepted as vitally important by all parties; but surely the reason is the size of the public health expenditure bill. Apart from the safeguarding of public money (which is so very important) does widespread public participation do the patients or the actual medical service and its management any good? I believe that that is difficult to prove. Sick people have no interest in how the NHS is run, but they are vitally interested in their effective diagnosis and treatment being carried out by people concerned with their welfare. If there is proof that wide public participation in management improves the care of patients I should like to hear about it, though, as I said, one accepts that it is a responsible way to control the expenditure of large sums of public money.

Sadly, the management proposals in the health service do not concern general practice. As your Lordships will remember, it is only a year or so ago that the general practice organisation was put directly under the Secretary of State; and yet I believe that there is a need for the methodology of general management to help develop the service. How big should a general practice be? How can one apply to general practice the new methods of diagnosis and treatment so that scanners and modern techniques are made readily available and patients do not have to wait weeks and sometimes months before they know whether they have cancer? What should be the shape and organisation of practice in the future? A new kind of secondary care centre, planned with modern management and technical skills, could be just around the corner.

Fortunately, as the noble Lord, Lord Rea, said, there is a lively ally in the Royal College of General Practitioners which has recently shown by research in general practice whether certain types of patient are being treated in the best way and whether doctors communicate well with their patients, keep good records and provide a quality service. In business that is the role of general managers, and the problem is already being tackled, as the noble Lord said, by the fellows of the royal college, and they want to be paid by results.

The noble Lord, Lord Wells-Pestell, referred to a recent study in the Health Service Management Centre at Birmingham University,and I was concerned in its foundation. It has been examining the waiting lists. We can accept that every organisation needs spare capacity, and beds in the NHS must always be free for emergencies; but it seems an incredible paradox that the researchers found that of 50,000 acute beds one quarter of the total are empty each day, while over half a million people are waiting for treatment. I am not suggesting that it is a simple problem; it is not. But it requires skilled and sympathetic managers bringing to the attention of the physicians, surgeons and boards concerned the true state of affairs and proposing plans so that such situations can be dealt with in the future.

I turn for a moment to consider the health service management board. I support the view expressed by a Nuffield Provincial Hospital Trust report edited by Gordon McLouchlan that a key appointment necessary to achieve the objectives declared is a director of information services as a member of the board. That need is only partly met by the development of a unit within the Department of Health and Social Security under a deputy secretary. But if there is to be improved policy, major innovations both in substance and in style are necessary.

The task is formidable—to co-ordinate all health information services; continuously to review management in the NHS; to ensure that on-line management is producing accurate information; and to propose changes in development together with supporting evidence. Without those and other facts, the NHS management board could well be ineffective. It has been calculated by the Nuffield Provincial Hospital Trust working party to which I referred that the cost of adequate information services is in the region of 1 per cent. of the NHS budget. That figure is taken as a proportion of the total spent in many industries on R and D and information. Will the Minister explain where the resources are going to come from to establish the complex, modern and adequate information service that is necessary? I hope that it does not come from the National Health Service itself. That, as we know, is already struggling.

The management revolution, coming at a time when district reorganisations were in progress, has caused concern in many quarters. That is very understandable. In these circumstances, the Government are surely prepared to produce additional resources to get the health service functioning again with the assistance of able general management. But it will cost money. We must remember that this is the third reorganisation carried out by a Conservative Government. I hope that it will be successful.

6.10 p.m.

Lord Pitt of Hampstead

My Lords, like the two previous speakers, I shall confine myself to the National Health Service. The aims of the National Health Service remain those set down in the 1977 National Health Service Act, which says: It is the Secretary of State's duty to continue the promotion in England and Wales of a comprehensive health service designed to secure improvement in the physical and mental health of the people of those countries, and in the prevention, diagnosis and treatment of illness". That is what the Act says. It goes on to say: and for that purpose to provide or secure the effective provision of services in accordance with this Act". This evening, I want to invite your Lordships to examine the question of the extent to which the Secretary of State is performing his duty in accordance with the Act. Since 1979, the National Health Service has had to cope with substantial financial constraints. These constraints are additional to the inherent inability of any health service to meet the real or perceived health care needs of the population it serves. I do not want anyone to tell me that the health service cannot possibly meet every need. That is not the point.

One of the consequences of this is the extension of waiting time remarked upon by the noble Lord, Lord Kilmarnock, and by my noble friend Lord Wells-Pestell. I shall therefore not go into that matter again. However, there are other consequences, short term or long term, whichever way you care to look at it, which are very serious. One example is our continuing to fail the community in the field of renal dialysis. This is particularly annoying because it forces doctors to play God when all that is required is a modest increase of resources to try to meet the need. We are still providing only 33 dialyses per million of population when what is required is 50 or 60. The United States of America provides 102 dialyses per million of its population.

I have previously suggested, and want to suggest again, that resources for the treatment of renal failure should be provided on a national basis. But this does not seem to have found favour. The department should be willing to add the renal programme to the other supra-regional programmes. I gather, in fact, that paediatric haemodialysis and transplantation are already in this list. All that is required, therefore, is that it should cover all renal dialysis and transplantation. I hope that action along these lines will be seriously considered.

While on the subject of supra-regional programmes, there is need for a comprehensive service providing for research, education, testing, counselling and medical care for patients with sickle-cell disease. This should also be done on a supra-regional basis. A great deal of work is going on in this field, but there is an urgent need for finance. This is a disease that could affect a substantial minority of the population. I would remind your Lordships that, in accordance with the Act, it is the duty of the Secretary of State to provide facilities for prevention, diagnosis and treatment.

There is also a serious problem in the case of heart surgery. We are falling short of the required amount of coronary artery bypass, and again the problem is one of insufficient resources. It is wrong that people should be made to suffer and to lead unsatisfactory lives simply because the Treasury refuses to provide the necessary resources to meet their need. I was alarmed to read a report in the News of the World on 5th May about problems affecting premature babies having to be turned away from hospital. There again the allegation is one of a shortage of cash.

The Government continue to claim—we have heard it again today—that the National Health Service is not starved of funds and that, on the contrary, there is a steady increase in the amount of money made available for the health service. But the proof of the pudding is always in the eating thereof. It is obvious that the resources allocated to the health service are not sufficient to meet the needs. Moreover, the United Kingdom spends very much less on its health service as a proportion of its gross domestic product, and also per head of population, than any comparable developed country. In 1980, the United Kingdom spent 5.7 per cent. of its gross national product on health care. In the same year, France spent 8 per cent. So did Germany. The United States spent 9.5 per cent.

The United Kingdom percentage has increased slightly. It was 5.9 per cent. in 1982. That is the last figure I have. However, the last figure I have for the United States is for 1983, when it was spending 10.3 per cent. of its gross national product on health care. As for health expenditure per capita, the United Kingdom, in 1980, spent £180 per capita, while France and Germany both spent £310 and the United States £470. Even in 1982 expenditure still amounted to only £290 per capita, less than was spent by France and Germany in 1980.

Some of this can be explained by the greater efficiency of the British National Health Service. Make no mistake about that! But we are taking too much advantage of the fact that the British National Health Service is efficient. We are carrying this much too far. We should build on the fact that we have a more efficient service and try to meet the needs of the community. Our greater efficiency means that we require a smaller amount and a smaller addition of funds than is the case, say, in the other countries that I have mentioned. We ought therefore to provide that addition.

Another area of concern is the effect of the application of the Resource Allocation Working Party recommendations. I was very glad that my noble friend Lord Ennals mentioned that that should be reviewed. There is not the slightest doubt that this matter needs to be refined. I was shocked to read that UCH and the Middlesex hospitals were proposing to close wards in order to meet required savings. For 35 years I practised medicine in Euston and those were my two main hospitals. They are very good and famous hospitals; and it is very sad to think that they could be reduced to this. The trouble with RAWP is that it is a blunt instrument. I was glad when my noble friend mentioned that fact.

If one takes the Thames region, that area is very much above its target. But the Thames region contains some of the most deprived areas and some of the areas with the greatest social problems. It is inevitable that those problems will reflect themselves in medical needs, and they should be taken into account in allocating resources. I therefore repeat that we need a refinement of RAWP. When I read of the RAWP allocations and hear of the problems that are created I feel that we are back again in this debate on allocation of funds to local authorities, because it is the blunt instrument of GREA and targets which have created a situation where the most deprived boroughs are regarded as the boroughs that are overspending and should spend less, when it is quite obvious that those are the boroughs that need to spend more. We are getting the same sort of situation in the crude way in which RAWP is being applied, and I appeal for the criteria for RAWP to be refined.

I want to comment on the manner in which the review bodies' recommendations are implemented. The review bodies report to the Prime Minister, who accepts the report and decides how the recommendations should be implemented. Having made the decision, the Government then expect the regional and district health authorities to meet the cost. The original grant which they received carried an amount to meet pay awards based on the Government's assessment of inflation and their hopes on pay increases. If the review bodies recommend more than that, the authorities are now expected to cut services to meet the pay awards. That is obviously wrong. For example, the under-funding of pay awards during 1985–86 led authorities to make short-term adjustments to the service. Some 17 authorities reduced current service provision; 25 authorities froze staff recruitment; 19 authorities chose to transfer capital to revenue.

Those authorities should not have been put in that position. If the pay awards are to be implemented, the difference between what is required to meet the awards and what was included in the original grant should be met from central funds. This should be routine and there should not be the difficulty which the authorities experience at the present time. These adverse developments can be corrected by the paying back of the sums of money withheld by failure to fully fund the 1985–86 pay increases. I am told that it amounts to over £100 million for England alone.

During 1986–87 there has been allocated an increase of 6.74 per cent. in the cash for the hospital and community health services. The Minister boasted about that a minute ago. But 5.8 per cent., even on the Government's optimistic expectations for cost increases, will be absorbed by pay and prices, and only 0.9 per cent. will be left for any development. Therefore, although the Minister was very happy about the increase, it will not make very much difference to the continuing deterioration of the service.

I should like now to say a word about the problems that have arisen over medical academics. That is another of these stupid problems which ought never to arise in the service but do so because of the procedure followed. The National Board for Prices and Incomes established the principle of parity in its report of 1968, which stated: since University and NHS jobs are interchangeable it follows that the salaries of medically qualified university clinical teachers must be linked to and move simultaneously with the salaries of full-time doctors and dentists". That was a principle established in 1968. But since 1979 a body called the Clinical Academic Staff Salaries Committee has been dealing with that. That body is comprised, on the one hand, of the Committee of Vice-Chancellors and Principals and, on the other, of the British Medical Association, the British Dental Association and the Association of University Teachers. The committee's remit is to assure the continuance of broad comparability of remuneration between clinical academic staff and their NHS counterparts.

Since 1982—and only since then—we have had problems. Since 1982 parity between the NHS doctors' and dentists' salaries and clinical academics' salaries has been threatened because of the lack of finance through the University Grants Committee. In 1982 and 1983 the Government gave an allocation from central funds to meet the difference between the salary increases and the university cash limit of 3 per cent. Last year, however, the government did not give an allowance from central funds despite the fact that the amount was comparatively small: it was £700,000. But the universities absorbed that. This resulted in a considerable delay in translating the award made to NHS doctors and dentists to clinical academic staff.

This year the Committee of Vice-Chancellors and Principals stated that because of the severe financial crisis occasioned by the present and future reductions in levels of funding the universities are unable even to discuss the implementation of clinical academic staff salary awards until the outcome is known of approaches for additional funding made to the Secretary of State for Education and Science. The Committee of Vice-Chancellors and Principals began informal approaches to the Secretary of State for Education in January 1985; that is, before the review body reported at all. The committee made a more formal application following the publication of the report in June. But the Secretary of State was still unable to give it an answer on the additional funding, which amounts to approximately £1 million. At a meeting held last month, on 16th October, he told the committee that he might be able to reply within a month, but would definitely do so within two months.

This matter occasioned great concern. The considerable delay in passing on to the university clinical staff the salary increases received by their NHS colleagues is having a deleterious effect on staff morale. That is now showing itself in poor recruitment and retention of staff. Clinical academic staff work closely with their colleagues in the NHS in the provision of NHS patient care. This harmonious relationship is under strain, as one recognises, because the university clinical academic staff are now the only group of doctors and dentists who have not received a salary increase following the last Doctors' and Dentists' Review Body award.

The BMA has already received evidence which it has passed to the Secretaries of State for Education and Science and for Health and Social Security that clinical academic staff posts are remaining vacant through lack of suitable applicants. This is in addition to the reduction of 21 per cent. of clinical staff numbers which has taken place over the past five years. The implications of this for the provision of National Health Service patient care should be clear. Acute services will be severely reduced in teaching districts, because in those districts clinical academic staff provide over 40 per cent. of patient care. In specialties such as pathology it will be worse, because in pathology by and large they provide between 80 and 100 per cent.

The research and teaching content of the work of university clinical staff has been affected by cuts in university funding, and the failure to attract suitable applicants will preclude any significant development. I hope the Minister will note that this applies not just in the acute specialties but also in the other specialties of importance to the community, such as geriatrics and community medicine. I find it difficult to understand why the Government behave like this. The medical academic staff are working in the National Health Service. They should be paid the same as others working in a similar grade in the service.

I began my speech by pointing out the duty that was laid on the Secretary of State by the National Health Service Act. Therefore it is his duty to see that the people who work for him are paid. I hope that when the Minister replies (I noticed that she was listening quite intently) she will be able to tell the House how this matter has been dealt with, because it is disgraceful that this should be going on. I hope that during the time I have been in your Lordships' House I have shown that the Secretary of State is not quite fulfilling his duty as imposed on him by the National Health Service Act 1977. He needs to fight the Treasury for increased funding. The £285 million promised in the Autumn Statement is a step in the right direction but it does not go far enough. We need double that amount.

On previous occasions I have indicated that an increase of 10p on a packet of cigarettes, 30p on a bottle of spirits and 2p on a pint of beer would give us £500 million. In fact, an increase of 20p on a packet of cigarettes would give us more than that. What is required is an immediate injection of such a sum to meet the present difficulties and a continuing budgeting for an increase of 2 per cent. over inflation. We should then have a service that we could be proud of. There is no doubt that if there is a will, there is a way. I am appealing to the Government to recognise the error of their ways and to turn over a new leaf.

6.36 p.m.

Baroness Faithfull

My Lords, may I join other noble Lords in thanking the noble Lord, Lord Ennals, for initiating this debate. I am sure the noble Lord, Lord Boyd-Carpenter, will forgive me if I repeat what he said in congratulating the noble Lord, Lord Ennals, on his speech. I also say that it is difficult to join health and insurance, the supplementary benefits side, and it really warranted two debates instead of one.

Secondly, I never thought to join the noble Lord, Lord Boyd-Carpenter, in supporting a divorce. I agreed with the noble Lord that it was an unnatural marriage to join the Ministries of Pensions and National Insurance and I only wish that a divorce could take place and they could again be separated. I think that small is beautiful and that should make for great efficiency.

I also thank the noble Lord, Lord Boyd-Carpenter, for the generous remarks he made about me. But may I say to the noble Lord, Lord Wells-Pestell, that my noble friends on this side of the House have also given me great support. They are among many of those who feel deeply and work for the vulnerable in our society. I mention two examples. The noble Lord, Lord Home of Hirsel, was able to help me in a project at Dr. Barnardo's the other day and my noble friend the Minister rescued and greatly helped a project for children in which I am interested.

I had not meant to speak about the health service; nevertheless I mention one facet of primary health care which includes general practice. I say this from deep feelings and experience of my work. If we are to have good primary care and a good general practice service I suggest that in our inner cities particularly we must look into buildings for surgeries. I once took a very ill child to a surgery in one of our big inner cities in a dingy back street. He said to me "Oh, Miss, have I got to go into that dump?" I know that many general practices have improved their buildings, their rooms and their surgeries. Nevertheless there are many—and I am sure that the many noble Lords in the House who are doctors will agree—where improvement is necessary.

I come from Oxford, where we had an outstanding medical officer of health, who was referred to by the noble Lord, Lord Hunter of Newington, among other outstanding medical officers of health. He arranged and built seven health centres for a population of 110,000. These health centres are able to provide health care, social care and emotional care and far from keeping people away from doctors in their dingy surgeries, patients are willing and pleased to go. Where there is a good health centre patients will go to it rather than to the hospitals. I believe that that is a far better method of dealing with them.

May I also say, following I think the noble Lords, Lord Pitt and Lord Rea, that it is sad—and I am sure that the Minister will understand me if I say this—that it has not been possible to implement the Acheson Report and the Court Report.

May I now turn to the question of the social security side. I should like to make three brief points. First, the aspect of the social fund which deals with the lending of money, which replaces the present system of making grants. I am the first to admit that the present system has not always been wisely administered and needs inspection. I have sometimes been taken aback by the unnecessary profligacy of some supplementary benefits offices in making grants for carpets, washing machines, fridges, and so on. Some grants have bordered on the luxurious.

On the other hand, the making of some grants to meet basic needs has prevented families from breaking up and spared them severe physical deprivation. I consider that the giving of a grant for a cooker which can mean cooked meals and hot drinks is something positive and basic. To make grants for basic needs is cost-effective to the country. The cost of a child in care can be £2,000 or more, whereas the grant of a cooker and something simple may keep a family together.

As I understand the Green Paper, with some exceptions grants are to be replaced by loans. The repayment of the loan will be made by a 15 per cent. deduction from the supplementary benefit. I understand the principle, but the actual practice is simply not practical. If a family is living on supplementary benefit, which is just above the poverty line, to say that repayment should be made by taking 15 per cent. of their weekly allowances will, I fear, drive claimants to the loan sharks. Should not the supplementary benefit system bear in mind the dictum, "Neither a lender nor a borrower be"? It should be possible to make grants in such a way that a family can be re-established and held together not in a luxurious way but by meeting their basic needs.

I understand that social workers may be asked to write reports on claimants who are making application for a grant from the social fund. I do not agree with this. I do not consider that it is the role of the social services departments; nor do they have the personnel. May I return to this point a little later?

I turn now to the running of supplementary benefits offices. I was privileged to serve on the Fisher Committee, and I pay tribute to the chairman, Sir Henry Fisher. I have also visited supplementary benefits offices with claimants. I believe that the structure of our supplementary benefits offices needs to be reformed and revised. I pay tribute to all staff who work in supplementary benefits offices. They have one of the most difficult jobs in this country. Many of them work under good conditions, but some of them under sordid conditions. Emotionally, as well as from the point of view of discipline and intelligence, they have a difficult task to perform.

Having said that, may I ask whether we have the structure right? I believe—and I certainly found this in my own department—that the first impact of the claimant on those at the supplementary benefits offices should be on somebody experienced. As it is at the moment it is the younger staff who are on the counter; it is the younger staff who hide behind the glass so that you can hardly see to whom you are talking; and it is the younger staff who get the brunt of the bitter feelings that some claimants have. Do not let us underline, or say, how wrong it is for them to have bitter feelings. Many of us would have bitter feelings when things went seriously and deeply wrong. Therefore, one has to have the kind of person who will not be upset and who will not be distressed. It is amazing to me that some of the young staff on the counter do not get more distressed and upset, but it is an emotional strain.

I would make a plea to the Government to look at the way that the supplementary benefits offices are manned. I believe that it would be cost-effective, because if you have a claimant who is dealt with with maturity, humour, understanding and courtesy his deep feelings will diminish and you will not then have the trouble and distress among the population and the claimants who have to call at the offices.

I equally believe that in each supplementary benefits office there should be a person to whom claimants who need counselling could be referred. I do not agree—and the noble Lord, Lord Wells-Pestell, will remember that I said this in a speech when he was at the Dispatch Box—that there should necessarily have to be people in the social services offices who have to pick up the bits from the Supplementary Benefits Commission. There should be social workers and counsellors in supplementary benefits offices. I know that this is asking for a large piece of work to be done, but I would suggest that managerially if we could reorganise our supplementary benefits offices in the way I have suggested we would diminish a great deal of the trouble and distress that we have.

Lastly, I shall come to the question of child benefits. The Green Paper, which I have here, stresses nine times in Volume 1 the essential necessity to support families with children. This is clearly outlined in the Green Paper. But, when we come to look at the facts, are we supporting the families with adequate means and help for the children? The case for maintaining the real value of child benefit was referred to in a debate last week. The financial position of families with children has deteriorated relative to that of the childless in recent years, and growing numbers of children are being raised in poverty. Child benefit forms a significant proportion of the net incomes of poor working families and only a minority of them could be protected by means-tested benefits against the effects of a cut in child benefit.

The Prime Minister and the Conservative Women's National Committee have emphasised the importance of child benefit. As things are I understand from the Green Paper that child benefits are to be paid in a different way. I speak as chairman of the All-Party Parliamentary Group for Children, and as a member of the Barnardo's Council Executive Committee. We understand that the child benefit paid to the mother is now to be replaced by a family credit scheme, whereby payment is made through the pay packet. This means that the money will not be paid to the mothers. It will be paid to the family.

The Women's Equal Opportunity Commission in their report state: Support for low income families should be channelled through the person (usually the mother) who bears the main responsibility for child care.". They go on to say: Child benefit is a significant benefit in this respect and its value should be maintained.". I know that other noble Lords, particularly the noble Baroness, Lady Ewart-Biggs, are to speak on this subject. Therefore, I shall not keep your Lordships' House. However, I ask the Minister whether there is any possibility that her right honourable friend will reconsider the whole question of child benefits.

6.51 p.m.

Lord Bottomley

My Lords, it affords me much pleasure to follow the noble Baroness, Lady Faithfull. When I was chairman of the Select Committee on Race Relations in the other place, she gave me very valuable assistance in helping the committee to produce a unanimous report. On that committee was the present Secretary of State for Health and Social Security. I admired him for his compassionate and progressive views on social affairs and for that reason I was not surprised when he announced that he was calling for the first examination of the social services since the Beveridge plan was introduced. I had expected a statesmanlike approach from the Secretary of State, but I am afraid he has failed to live up to the qualities which I first admired in him.

There is no doubt that there was a need for reform and also a great deal of dissatisfaction with the present state of affairs. However, instead of improving upon Beveridge and bringing the welfare state up to a better standard, the main concern of the Secretary of State seems to be to reduce the cost of the social services. The Green Paper would make claims for social security benefits so difficult that many people would rather go without than submit to the new indignities imposed upon them by the Government's plan. I feel sure that what Sir William Beveridge would have wanted to do today would be to provide an adequate income for every member of society. This could be achieved by harmonising taxation and social benefits to create a coherent incomes policy.

The Government, to provide for reducing taxation have adopted a policy of selling off our national assets such as British Telecom, British Airways and British Gas. They are also pressing on with a plan to put the services of our National Health Service, such as cleaning, laundry and catering, into private hands. The declared object of these moves is to promote economy and efficiency.

As yet, this has been far from the case. In one large hospital in Cambridge, where the cleaning has been put out to contract, dust has been found gathering under the beds in the wards. Toilets were stinking, plastic liners, filled to bursting, were piled near the chutes and soiled linen was piled up in odd quarters. In another hospital, dirty mops were left lying about, a sink was blocked with dirty water and dirty crocks were left piled up for three days. There is bound to be a decline in quality and efficiency when private contractors, anxious to make the lowest tenders, hire low-waged, inexperienced workers and supervise them inefficiently.

The Government's reckoning is that by privatisation the cost of the National Health Service will be reduced. That is unlikely to be the case. Some health authorities have already found that they can run their own services more efficiently and cheaply than by private contract and have made the necessary changes. The Orpington Hospital terminated the work of a private contractor because it was not up to standard. At Gateshead, another contract was ended because of the failure to meet training and supervision specifications.

The British Medical Association, the Royal College of Nursing and leading medical authorities say that the waiting lists are growing and it takes much longer to obtain hospital appointments. I am the president of the Woodford branch of Arthritic Care. Last Friday, I took the chair at the annual general meeting. Many who were present told me of their difficulties in obtaining hospital appointments. One lady told me that she had been waiting for over 12 months for an appointment for a hip joint operation. I think it is shocking that the Government should allow a large number of health districts in the country to have no consultant rheumatologist at all. They really should do something about that.

Essential equipment is not being provided and hospital buildings are collapsing. The Government are encouraging private medicine. Private medicine is damaging the National Health Service by draining it of its resources and of National Health staff trained at the taxpayers' expense. National Health Service hospitals are much better equipped to deal with emergencies and complex operations than most private hospitals. Private hospitals are less able to cope with unexpected complications should they arise. The welfare state costs are rising, and we cannot ignore that, but they are rising substantially because of the Government's failure to ease the unemployment situation. That is compelling people to seek further aid from the state.

The Minister has said: Our tradition of state support for those in need is one which should be maintained and developed". However, this certainly does not appear to be Government policy. The Government's recent restructuring of the taxation system increases the burden on the poor and lightens that of the better-off members of society.

Last December's Economic Trends showed that the richest 10 per cent. of the population had an income after tax of £60 billion while £16 billion was provided for the poorer 10 per cent. The burden on the poorer section of the community has increased since this Government came into power in 1979. Britain has a more unequal distribution of wealth and of earnings than any other Western country and a lower expenditure on health and social security.

The Government claim that the report, Reform of Social Security, presented to Parliament by the Secretary of State for Health and Social Security, is bringing Beveridge up to date. Yet the Green Paper is not about reform. It is about economies at the expense of the social services. The Minister forgets that the Beveridge Report was not only a reforming instrument. It also had a moral appeal. Beveridge's promise of security inspired a generation that did not want to see a return to the poverty and indignities of the 1930s. It was The Times, then a paper respected the world over, which wrote about, democracy which maintains the right to vote, but forgets the right to live and work". It is a poor situation. While proclaiming his faith in democracy, the Secretary of State forgets the right to live and work. I have faith in democracy and feel confident that when they have the opportunity to do so the people will demand a return to Beveridge and all that that meant.

Let me conclude by thanking my noble friend Lord Ennals for introducing the subject for debate today and by saying that from my own point of view all those who have contributed—with the exception, I am sad to say, of the Minister—have given contributions which have made this debate of a very high standard.

7 p.m.

Lord Banks

My Lords, may I begin by agreeing with the noble Lord, Lord Bottomley, about the need to integrate, to harmonise—which is the word he used—income tax and benefits. However, unfortunately that had to wait for a further investigation and a further review. I am sure that the House is grateful to the noble Lord, Lord Ennals, for giving us the opportunity to discuss these two important subjects today; but, like the noble Lord, Lord Boyd-Carpenter, and the noble Baroness, Lady Faithfull, I feel that we might have done better to take them one at a time. I want to concentrate on the second part of the Motion, and on pensions in particular. I begin by declaring an interest in that I am an insurance broker specialising in pensions and life assurance.

There has been much criticism of the proposal to phase out the state-earnings related pension scheme, SERPS, the second tier of the state pension system. But I think that it is important to remember that SERPS is only a formula for determining entitlement. We often hear people say SERPS will provide a splendid pension at the end of this century or in the next century. Of course, SERPS will not do that; what SERPS will do is to commit the government of that time to provide those pensions, and the government of that time will have to turn to the working population of that time to provide the means.

It cannot be good policy to put on to future generations a commitment which we are not prepared to accept ourselves. I have always maintained that and have maintained it in all the various debates on the subject which we have had in this House. We on these Benches are committed to greater re-distribution of income so that we are prepared for some higher spending on current benefits; but that means grasping the nettle now rather than committing others to do so in the comparatively distant future. After all, good pensions are as necessary today as they will be in the middle of the next century.

It is interesting to see the weight of evidence which has been presented to the review body in favour of raising the basic pension. Among the bodies which have supported a significant increase in the basic pension are the Social Services Committee in another place, the Social Security Advisory Committee, Age Concern and the National Consumer Council. The Disability Alliance say that the consequence of failing to take steps to increase the real value of the state pension—and they are talking about the basic pension—when the Government are forecasting 2 per cent. to 3 per cent. growth in the output of the economy, is that pensioners' living standards will fall further and further behind the rest of the population. After all, SERPS, whatever its merit, does little or nothing to those already retired—some 9 million to 10 million pensioners. While the financial position of pensioners has improved throughout the post-war period, through an increase in the real value of the state pension and through the increase in occupational pensions, it remains true that about half the pensioner population is on or below the poverty line, defined as 140 per cent, of the supplementary benefit. SERPS pays a higher pension to the better off at the expense of the poorest and promises to pay more to tomorrow's pensioners than to today's. So I do not take fright at the suggestion that we might abandon the SERPS formula and seek another which would take all these factors into consideration.

However, the first criticism which I have of the Government's proposed new formula is that it makes no increase in the basic pension. The Green Paper proposes to phase out SERPS over three years for men under 50 and women under 45 while guaranteeing them accrued rights under SERPS to the date of abolition and enhancing those rights in the case of men over 40 and women over 35. Men of 50 and over and women of 45 and over will, according to the Government's proposals, remain in SERPS; and all those not remaining in SERPS will have to have paid on their behalf—2 per cent. coming from the employer—at least 4 per cent. into a private scheme. But the employer provides 2 per cent. and the employee supplies the other 2 per cent.

As I understand it, that private scheme may be either an employers' occupational scheme, a personal pension policy or a new 4 per cent. scheme; and simplicity is not the most notable feature of this arrangement. The employer, it would seem, would have the burden of administering the 4 per cent. scheme and, where there is an occupational scheme, of keeping separate records for the contributions of those remaining in SERPS, for the contributions of the remainder for the 4 per cent. scheme and separately for contributions for the rest of the occupational benefit. It is not surprising in the light of that that there have been complaints of complexity from both employers and insurers and those managing the pension funds.

We understand that the Government are having second thoughts on all this and I should just like to suggest how they might modify their own proposals for pension. The Government propose that all except those remaining in SERPS will pay national insurance contributions which will total 16.5 per cent., taking the employers' and employees' contributions together. To that will have to be added the 4 per cent. which is to be paid into the private scheme making a total of 20.5 per cent. in compusory contributions.

I would suggest that the Government should do this. First of all, end the SERPS formula as from 1987 if that is the date when it can be done; and that is the date that the Government have suggested it could be done. But I think that it should be a clean break at that time rather than one phased over three years which has administrative complications. Then the Government should preserve the accrued rights without enhancement to 1987 which would mean that virtually everyone in employment at that time would have when they came to retire, accrued rights of one kind or another; end contracting out because there will be nothing left to contract out of; and let everybody pay a national insurance contribution of £19–45 for employer and employee, which is the present contracted-in rate. And at the same time abandon the proposal for the 4 per cent. scheme.

The effect of that would be to transfer 3 per cent. from future benefits to current expenditure. That would be sufficient to increase the basic pension by 25 per cent. So we would have accomplished that with rather less being spent in compulsory contribution than the Government now propose. If the anticipated pension under the existing arrangements is compared with an estimate of what the pension would be under these proposals, it would be found that there has been some redistribution from tomorrow's pensioners to today's, and some redistribution from tomorrow's better-off pensioners to tomorrow's less well-off pensioners. The comparison is between the current basic plus current SERPS on the one hand and the increased basic plus accrued rights on the other. And of course of those who have already retired, the single person would receive an additional £500 and the married couple an additional £800.

Having got a reasonable basic through increasing it by 25 per cent. one thing remains, which is to provide an opportunity for an occupational scheme with employers' contributions for those not now covered. I say "an opportunity" and I suggest that all who are not covered by an occupational scheme should be able to save in a personal pension policy up to 3 per cent. of their earnings and have that voluntary contribution boosted by a matching contribution from a central account financed by a levy and all employers without a satisfactory occupational scheme.

The result of these proposals would be, first, to increase the basic pension by 25 per cent., and that immediately; secondly, to achieve this without any more compulsory contributions than the Government now propose; to ensure that no one is denied the opportunity to have a pension arrangement with an employee contribution if they are themselves prepared to save; to reduce the long-term commitment by about 15 per cent., I calculate, in the decade 2020 to 2030, while accepting that expenditure on state pensions needs to be increased further as circumstances allow; and, finally, to remove much of the administrative complexity of the current system while avoiding that implicit in the Government's current proposals, I hope that since we understand the Government are having second thoughts about these matters they will give these proposals, which are available in more detailed form, very serious consideration indeed.

7.12 p.m.

Lord Lovell-Davis

My Lords, I, too, would like to congratulate my noble friend Lord Ennals for initiating this most important debate and on the forceful way in which he opened it. This is a vast and complex subject, of which he has experience and knowledge to a far greater degree than I have. That is why I shall confine myself this evening to one aspect of the health service, but one which has become and will continue to be increasingly important as the population and patterns of care change. I refer to care in the community.

"Care in the community," as the noble Baroness the Minister has reminded us, is a declared policy of the present Government but it has become one of those deceptive phrases which the Government so often use to reinforce their belief in the dogma of the single answer to our problems, while at the same time concealing the real nature of those problems and, incidentally, the Government's true intentions.

Another one was, "The health service is safe in our hands". The idea is that if you keep on parroting these phrases people will go into a sort of trance state and believe that the Government are actually accepting their responsibilities and doing something. I think we are in the age of government by incantation.

No one could disagree with the concept of care in the community. There are people, many thousands of them, languishing in hospitals and mental homes, who simply should not be there. There are the elderly, who lead miserable, cut-off lives in geriatric wards, consigned to a lonely and meaningless journey out of this world. There are so-called patients in mental institutions who are no danger to society and who should not be forced to live their bleak lives in totally inappropriate surroundings. Some of them should never have been put there in the first place and then simply abandoned. I know of cases where people have eventually died, having spent 60 or 70 years in what are no more than the relics of vast Victorian lunatic asylums; and some of them were originally committed for quite trivial reasons.

There are people who remain too long in hospital after treatment, simply because their home background and the relevant community services cannot provide a proper level of care. Similarly children are often kept in hospital for longer than should be necessary because it is unsafe to send them back to a cold, damp home and because a proper level of nursing and medical care is not provided in the community. There will, of course, always be a need for a degree of institutional care, for secure or medium-secure accommodation for certain cases of mental illness, properly run homes for some psycho-geriatrics and other elderly people and hospitals for acute illness—but there is no doubt that a much greater degree of care should and could be delivered within the community.

But what exactly does this imply? It is one thing for the Government to present care in the community as the answer to overcrowded and therefore over-costly hospitals, but it is quite another to face up to what care in the community really means. For a start, it means supportive services so that people can stay in their own homes; it means purpose-built or converted accommodation where people can live in small groups in their own communities; specially trained nursing and other staff; specialist clinics to provide, for instance, centralised chiropody services for the elderly; training in new skills for nursing and other staff; more nurses themselves living in the community, instead of in vast homes, which the Government want to close down, anyway—though how nurses on their present levels of pay can possibly afford today's rents is another question left hanging in the air. More district nurses and health visitors are needed, and consultants who will emerge from their hospitals and deliver care rather than haul their clients into hospital.

The Government's commitment therefore is meaningless unless it is backed by real intent, and money. The family—another word used in an incanta-tory way by this Government—needs support if it is to be properly cared for in the home, in the community; and that costs money. Even being allowed to die at home with some shreds of dignity left to you is not a cheap option.

And there is another aspect to all this: monitoring, I do not mean simply applying performance indicators, which cannot measure the quality of care being provided, but the practical day-to-day monitoring of standards of quality. It is singularly lacking even today. As the population gets older and the health service reels under reorganisations, cutbacks, management reviews and all manner of Government interference—whatever happened to the Conservative promise of less, rather than more, central Government?—the private sector has moved rapidly into the geriatric business and is busily setting up more and more homes for the elderly and the infirm.

I am not saying that this market-led and booming activity means that we are back to sinister Victorian-style nursing homes. I am sure that many of them maintain high standards, although I am equally sure that some of them do not. You have only to look into their financing to feel uneasy about the care and comfort that is being provided. What I am saying is that we do not know what is happening because no one is monitoring the private sector. It should be monitored, and equally we shall have to monitor care in the community when it is delivered properly by the health service.

The present Government are always protesting that in real terms they are allocating more money to the health service than any previous Government. I always feel suspicious of that expression "in real terms" when it comes from a Government which I believe is quite unable to distinguish between what is real and what is unreal. I have to confess to a growing sense of unreality, as I think did my noble friend Lord Pitt, while I listened to the noble Baroness speak about the money allocated to various parts of the National Health Service and of having removed obstacles to the transfer of funds into care in the community.

I know that the Government "expect" health authorities to make improvements in care in the community. Until recently a district health authority member myself, I also know what a desperate time my district has had trying to determine where we could find the money even to start meeting those expectations.

The implementation of care in the community will cost money—a great deal of money. Where is it to come from? The Government say "efficiency savings"; the money must come from the acute units (the district hospitals) and through joint funding with local authorities. I am all for efficiency savings, as I am, with some qualification, for an effective management of the health service. But how far can health authorities go along the path of efficiency savings before standards of care in hospitals are threatened? It is a matter of growing concern among health authorities, community health councils and the doctors and nurses who have to deliver care on increasingly stringent budgets.

Many of the schemes which are needed to provide care in the community involve buildings and local government services, and therefore have to be carried through by health authorities and local authorities working together and finding the money together. But how can hard-pressed, rate-capped local authorities be expected to commit the resources that are needed for these programmes? Their budgets are so overstretched that they cannot even maintain their housing stock, much less meet the desperate need for new housing.

Care in the community is a goal that we must pursue. We hardly need the Government to tell us that. What we need from the Government is a real commitment—and money to back that commitment; pump priming money, money for buildings and services and, above all, money to pay the extra people who will be needed to deliver this care. I am convinced—it has been referred to earlier in the debate—that the vast majority of our people would rather have an improved and properly funded National Health Service than the tax cuts for which the Chancellor of the Exchequer is feverishly selling off everything in sight. It is astonishing that the Government do not see this "in real terms".

I should like to ask the noble Baroness the Minster, when she comes to reply, what the government are actually proposing to do "in real terms" to back up their words, and make it possible for the health authorities to disperse care into the community, thus improving the effectiveness of the health service and the lives of many thousands of people.

Almost the whole of my working life has involved travelling in many different countries and everywhere, even in the United States, our National Health Service was a source of admiration and envy. One could take pride in it, as one once could in many other aspects of British life. I only wish that one could feel the same about today's health service since it fell into the hands of Mrs. Thatcher's Government.

7.23 p.m.

The Countess of Mar

My Lords, in what is a very wide-ranging subject, I have one main point to cover and one or two questions to ask. Since the procedure for applications by pharmacists and doctors to provide pharmaceutical services was altered by the recommendations of the Clothier Committee, a number of difficulties have come to light. Presumably, these recommendations were intended to improve services to patients as well as to resolve a dispute between pharmacists and doctors, but in a number of instances they have created considerable friction between patients and practice staff. The formal rules and boundary lines defined in the memorandum have restricted the rights of the patient, who does not seem to have been considered. It is to those patients who attend doctors with what are defined as rural practices that the greatest problems occur.

When the new procedure became effective on 1st April 1983, there was a review of patients deemed to be living in rural areas. As an example, a dispensing practice near Huddersfield was sent a list of 102 patients who were no longer deemed to be "dispensing"; that is, they could no longer have their prescriptions dispensed by their doctor because they lived within one mile as the crow flies from a pharmacy. A little later, there arrived a list of 61 patients to be added to the dispensing list, including the local pharmacist and his family.

Among those who had been removed from the dispensing list were several patients who lived alone or were elderly and crippled by severe chronic illness. A number were on the practice regular visiting list and relied upon the doctors to take their medication to them. To make matters worse, although they were within a one-mile radius of the pharmacy, which is in the same village as the surgery, they were correctly classed as being more than three miles from the surgery by the doctor's ordinary route and he qualified for rural mileage allowance.

These patients are now suffering considerable hardship. They must either rely upon the goodwill of neighbours, if they have any, catch and pay for public transport if it is available, or walk three miles or more in hilly country to have their prescriptions dispensed. They cannot understand why the doctor who still visits them cannot bring their pills at the same time, as he used to do. The strict adherence to the rules by some family practioner committees also means that some patients who live just outside the one-mile boundary, who live near a bus stop and have much easier access to the pharmacy and who may prefer to have prescriptions dispensed there, are in a changed situation.

Applications by patients to be put on the doctor's dispensing list on grounds of difficulty were almost all turned down, because they did not satisfy the family practitioner committee that the difficulty was due to "distance or inadequate means of communication." There is no definition of "inadequate means of communication" and no account is taken of age, social circumstances, infirmity or disease which would stop the patients from collecting their medicines. In this practice there is an 80 year-old lady living alone, suffering from congestive heart failure compounded by a pneumonectomy for bronchial carcinoma and pernicious anaemia. She lives up a steep hill but within a mile from the pharmacy, and can do nothing but rely upon a neighbour, who is also elderly, to collect the drugs that she must have. That is near Huddersfield.

Similarly, near Kirklees a patient with bronchitis and emphysema, who must have oxygen in the house, is not allowed to have medication delivered by his doctor. In Powys, a patient within the one-mile limit must make a 10-mile journey to collect his prescription from Llanberis unless he dons a wetsuit and swims the mile across Lake Padern. Appeals against decisions of the FPCs are useless. In other areas, the FPCs seem to be more sympathetic.

In Cornwall, for example, where patients may live one mile from a pharmacy but must travel 14 or 15 miles by road around an estuary, the one-mile rule is not applied and doctors are given outline consent to dispense for these patients. In Essex, also, I understand that the FPC deals sympathetically with appeals. In another situation, a patient who transfers from the list of a non-dispensing doctor to that of a dispensing doctor without moving his home is not automatically transferred to the new doctor's dispensing list. Thus it is possible for some members of a family to be dispensing patients, while others are not.

I have given a few anomalies—there are many more. This Government profess to be the champion of freedom of choice, but patients have had their freedom to choose whether their doctor dispenses for them or they go to their local pharmacy removed under the Clothier rules. I ask the noble Baroness, Lady Trumpington, to look into the operation of these rules and to do all that is possible to iron out the anomalies. In particular, I ask her to investigate the serious difficulty provision. At present, there is no clear definition; "inadequate means of communication" is not clear. No account is taken of topography, age, disability or availability of public transport. The discrepancy between the one-mile rule and the three-mile journey needs to be cleared up, as does the right of some members of a family to be dispensing patients while others are not.

Doctors resent this further intrusion by the bureaucrats into the services that they can offer their patients, particularly the old and chronically ill. Patients, albeit a small number, resent the fact that their doctors no longer deliver medication to them as they used to, and blame the doctor for the change. It is the doctor who must explain at length the new regulations, not the pharmacist, member of the FPC or Ministers, for they are not on the spot.

After all the discussions we had on the limited list, I am sure that many of your Lordships will share my acute disappointment that the BMA has failed to agree upon the setting up of an appeals machinery for those patients for whom, for various sound medical reasons, the list is too restricted. There may be only two or three patients in each practice, but countrywide there are quite a number and they are probably those who would normally receive free medication. They are now having to pay for their medicines. I ask the noble Baroness to do all within her power to point out to the BMA the distress and hardship being suffered by patients of their members, and to ask them to reconsider their decision.

I realise that all the blame for these problems cannot be laid entirely upon the Government. Some must be allocated to those with whom they negotiate. But I do have a great deal of respect and admiration for the noble Baroness, Lady Trumpington, and I am sure she will do all she can to put forward the point of view of the patient; and what is more, my Lords, it should not cost a lot.

7.31 p.m.

Lord Prys-Davies

My Lords, I too should like to thank my noble friend Lord Ennals for his comprehensive survey of the state of the NHS. I was very impressed by his speech, which was constructed without the aid of a special adviser or a research assistant. It demonstrated the contacts that he has with the people who are at work in the NHS. Therefore, it appears to me that where my noble friend Lord Ennals gives a warning to the Government or alerts the Government to a risk, they should take note of his message.

The Government take comfort from the improved in-patient and out-patient throughput figures. I also welcome those figures. We must be concerned about the long waiting lists and we must be concerned about achieving good throughput figures, provided that the short duration of stay is not achieved by patients suffering as a consequence. I have no firm evidence that that is the case but I think it is fair that one should put in the caveat. The noble Baroness the Minister and indeed all health department Ministers, draw comfort from the fact that more money than ever before is being spent on the NHS, but the Minister will appreciate that that fact is at issue.

The difficulty that confronts the Government is that the additional funds which have been made available do not keep pace with inflation, pay awards, the continuing requirements of new technology, the new community and day-based services which are unquestionably important and unquestionably expensive, and the ever increasing patient workload. The Minister at least acknowledges the latter point. So there has been no real increase in NHS resources commensurate with inflation and all the increased demands which I have just mentioned. The increase in NHS resources comes nowhere near the 2 per cent. mentioned in the York study which was referred to this afternoon by the noble Lord, Lord Kilmarnock.

I have a feeling that the Government have made an assumption that there is an inexhaustible fat somewhere in the NHS. That at least could be one explanation for the underfunding, as we see it. Notwithstanding the consistent efforts of management over at least 10 years, if not 15 years, to make the service more efficient, the Government seem to think that the inefficiency still exists. If that is correct then it should be a matter of concern for noble Lords on all sides of the House. The noble Lord, Lord Hunter, drew attention to certain evidence which pointed in that direction.

I am reminded that an Under-Secretary at the health department once claimed that improved efficiency in the NHS meant either undertaking the same workload for less money, or undertaking a bigger workload for the same money. The health authorities have demonstrated that there is a third way of improving efficiency—by undertaking a greater workload for less money. I am not here to defend inefficiency. When I was active in the hospital service in Wales I did what little I could to make it more cost-effective. Of course, we want a more efficient service. One has only to look at the waiting lists which are today higher than they were 10 years ago. If we have regard to the waiting lists then obviously we must be concerned with efficiency; but at the same time it must be a humane service. The objectives are: a humane service and an efficient service. Those are not objectives which can always be easily reconcilable.

There is a very important difference between the NHS and other large-scale organisations. The noble Lord, Lord Hunter, referred to one aspect of it earlier on. The profit motive is lacking in the NHS. But there is another difference: the work that is done within the NHS relates urgently to people. If I may use the phrase without causing offence, it is people who are being processed, not things as in the case of factories. Patients may fail to co-operate fully. They may turn up late for appointments or indeed they may even fail to keep appointments. Patients very often prefer the local cottage hospital to the distant centre of excellence. There are many patients who have poor houses without an inside toilet and without a bathroom. They have inadequate facilities, to which they could be speedily discharged after hospital treatment. The NHS cannot rationalise a unit as if it were a factory producing things. I shall be very interested in the Minister's response to the comments made by the noble Lord, Lord Hunter, about the role of the manager and what the Government expect of him.

I return now to my original comment. On the one hand, we have the Government drawing comfort from the fact that the NHS has never had more money pumped into it. On the other hand, the critics of the Government point to evidence of strain and frustration within the service. They claim that it is very difficult to make more savings without damaging the service given to patients. That has been the evidence of the noble Lords, Lord Kilmarnock, Lord Wells-Pestell, Lord Pitt of Hampstead, Lord Bottomley and Lord Lovell-Davis. The Government may claim that the critics are exaggerating their complaints. I believe the Minister hinted at this; I am not so sure. But the Government cannot ignore the widespread and persistent criticism which has been voiced in this Chamber this evening.

I shall not detain the House long but perhaps I may give one or two down to earth examples of the considerable difficulties which are experienced in my part of the world. I live in Mid-Glamorgan, the heartland of industrial South Wales for the past 100 years. I do not know whether it will be the heartland for the next 100 years. The county itself faces immense industrial and social problems which I shall not particularise. The Mid-Glamorgan Health Authority covers one, of the biggest districts in England and Wales. It provides service to a little over 500,000 people, and the demands are growing.

Again, the throughput figures to which the Minister referred are reflected in Mid-Glamorgan. There was an increase of 7.8 per cent. in deaths and discharges for the year ending in March 1984; of 4 per cent. in outpatient attendances; of 12.7 per cent. in pathology services; and of 3.7 per cent. in radiology services. I have not seen the figures for 1985 but I am assured that demand is not standing still.

That authority faces deep-rooted financial problems. It has been obliged to bring in the well known firm of accountants, Deloittes, to examine its books and make recommendations as to how the service can be reorganised so that it can live within its budget. Whether that will lead in a month or two to a recommendation that wards or hospitals should be closed remains to be seen. In the authority, there is a marked shortage of community-based health facilities. It has been unable to develop day patient facilities and community-based facilities as it would wish. That is one effect of underfunding.

The authority has a large Victorian complex of hospitals for the mentally ill accommodating about 1,500 patients. It has also a large hospital for the mentally handicapped. The authority has not lost the message of Ely, which is only about 18 miles away, but those hospitals stand in splendid isolation in more than one sense. The movement of patients out of those hospitals into the community has almost ground to a halt.

The Government are interested in the machinery of increased efficiency. The Mid-Glamorgan Authority, which employs around 10,000 people and has a revenue budget of some £105 million per annum, has been unable to make an investment in microcomputers and new communications technology, which in turn could help it to evolve more effective cost-control of all its departments and to maintain more exacting and continuing scrutiny throughout its 37 hospitals.

I have mentioned some of the difficulties of one authority in a very difficult corner of the country. It is an authority that has striven for 10 years to achieve improved efficiency and which has brought about savings. However, I wonder whether the Minister will listen to the warning from the general manager of the Mid-Glamorgan Hospital Authority to that authority's members that: the continuing pre-occupations with financial crises can only harm the morale of managers and staff alike". I do not know how the Government can make an optimistic assessment of the situation unless they take on board the very sombre words of that district general manager.

Looking south from Mid-Glamorgan—and I shall be brief because I have already spoken for 13 minutes and there are more speakers to be heard—we come to the South Glamorgan Authority which delivers a service for a population of 400,000. In a recent report, the general manager of that authority advised it to introduce short-term measures which will not provide a permanent solution to the problems. He recommended that the authority delay the filling of staff vacancies and the planned replacement of plant and equipment.

He recommended also that some wards be closed, but rightly points out that the true cost of doing all that will be increased work pressure on dedicated members of staff who are already overworked. Will the Minister say whether the Government have been advised by the departments—and I use the plural form because we have a Welsh Office and a Northern Ireland Office—of the serious concern on the part of experienced managers and staff within the NHS? The Minister—and I say this kindly—gave no indication that such messages were coming through to the departments. Is that the fault of the departments or is it the fault of the Minister? Is that message falling on deaf ears? It would be an achievement, and I shall be grateful, if the Minister will at the end of the day acknowledge the concern expressed by many Members on this side of the House.

There are numerous signs of serious difficulties within the National Health Service, and notwithstanding the opening of major new hospitals, which is obviously to be welcomed, there can be little doubt that the service is not advancing as it ought to be, to keep pace with the demands of a modern and complex health service.

I read in my own local newspaper of a hospital ward being closed. I will not say that the NHS is being dismantled just because one hospital ward is being closed but I am entitled to ask this question: when does the process of dismantling begin? I do not know a great deal about the mechanics of rundown. Perhaps there are management consultants who can explain when the process of dismantling takes place. For example, if there is a hospital of 10 wards, does the erosion begin when five wards are closed, or two wards? Or does the erosion begin when just one ward is closed?

I suggest that when even one ward is closed—and here is my caveat—provided there is a demand for its services then it can be said that one is chipping away at the foundation of that particular hospital. Why do I say that? It is because if one ward is closed, it means that one ward is no longer available for the community. That means in turn a lengthening queue, and a longer waiting list and longer waiting periods for people who are without the means to jump the queue.

I have only one other specific point that I wish to put to the Minister. My noble friend Lord Wells-Pestell drew the attention of the House to the in-patient waiting lists for a number of specialties. He omitted to refer to one specialty which causes me a great deal of concern. I refer to the specialty that is described in books as psychogeriatrics. I do not like that term one little bit. It refers to the elderly and frail who are suffering from senile dementia.

My noble friend Lord Wells-Pestell referred to the figures for March, when about 700 elderly, frail people suffering from senile dementia were waiting for a bed. I cannot imagine the conditions under which those poor people are living, and they are the least able in the country to fight for their corner. Will the Minister assure the House that the department is insisting that area and district health authorities give very high priority to the interests of those people?

I come to the end of my contribution. If we are concerned about the quality of life—and that was the message of the right reverend Prelate and of my noble friend Lord Bottomley—then our plea must be that there should be more resources allocated to the NHS. The priorities which determine what slice of our national resources is given to the NHS and the priorities which determine which proportion of the country's spending goes to health care should be urgently re-examined by the Government. Meanwhile, the work goes on in hospitals, surgeries and clinics and I am more than grateful for the outstanding work and contribution of the staff of the NHS, notwithstanding all their difficulties and pressures. I think that I ought to give expression to that; and with that I am sure all noble Lords will agree.

7.50 p.m.

Baroness Macleod of Borve

My Lords, I shall be very brief because, as your Lordships know, we have a very long list of speakers this evening. I start by congratulating and thanking the noble Lord, Lord Ennals, on his speech this afternoon. I am glad that he is looking so much better, because he is in great difficulty. Last year I was on precisely the same two instruments as he is now on, and I know how very difficult they are.

I also congratulate my noble friend the Minister on the figures she gave this afternoon—especially the 800,000 more people who are being treated in hospitals compared with 1978. We must take great credit, and I hope the Government do, for those figures.

Although I am very interested in the health service, especially the voluntary sector, I am not going to make any comments on that this evening because I have one or two brief comments to make on the reform of the social security system. I deal first with a "Catch 22" situation which arises for the unemployed, those on supplementary benefit and ex-offenders. Those are people who have no fixed abode and very little, if any, money. They are offered jobs by employers who are anxious to take them, but they have no fixed abode. They try to get board and lodging from a landlady, but she of course wants money in advance. Unfortunately the job will not pay money until the employee has been in post for a week or a fortnight.

I hope the Government will take up the suggestion that when someone wants to employ one of those people—and there must be hundreds of them—the employer should write a note which can be shown to the social security people and also to the prospective landlady, saying that the employer will deduct the money that is owed to the landlady from the wages the employee receives in the first fortnight, three weeks or month. I think that if a letter can be sent stipulating that the money will be paid by docking it from the salary, more people, young people, will be able to take up work. This, I may say, would not cost the Government anything.

This evening I want to speak as chairman of the National Association of Widows. Few noble Lords will realise that 500 women are widowed every day. That is a vast number of women. Therefore I want to deal primarily, but briefly, with the Green Paper which refers to future widows. I welcome certain parts of the Green Paper. For instance, new widows are to be given a tax-free £1,000, which is to replace the amount now being paid over a certain number of weeks. The widow's allowance also will be paid immediately, I understand. However, as we know, so often unfortunately it is the funeral expenses that really hit hard at any family. We are pleased to learn that the money for funeral bills can, in certain circumstances, be obtained from the social fund as a loan. We are grateful to the Government for those imaginative steps.

However, there is a rub. The pension age is to be raised from 40 to 45 and the age for the widow's rate pension is to be raised from 50 years to 55 years. The present widows resent this very much indeed because of the reason given. We have been told that this five-year difference in both those categories is apparently to pay for the increase in the number of single parents. Widows are not single parents. They have been married and they have families of their own. The National Association of Widows thinks that this is very unfair.

There is one other point that I draw to the Government's attention. There are, luckily, very few widows who are made widows when they are pregnant, but there are some. Like other women, the widow who is pregnant will get the maternity grant. But even if she has been working before being widowed, she is not entitled to maternity allowance because that would constitute an overlapping benefit. As I have said, luckily there are very few pregnant widows, but there are some. Perhaps in due course my noble friend the Minister will draw the attention of those in her office to this seemingly very unfair anomaly. Those are my few comments, and I shall listen to the Minister when she replies to the debate.

7.57 p.m.

Baroness Masham of Ilton

My Lords, I should like to thank the noble Lord, Lord Ennals, for initiating this debate at a time when he is having to find extra energy to get about due to his recent accident. My remarks will be kept mainly to the National Health Service side of this debate and I hope very much that the noble Baroness, Lady Trumpington, will in her summing up be able to say something to help raise the morale of many senior nurses throughout the country.

The last Government shake-up to the National Health Service has been far more disturbing to some people than many had envisaged. Perhaps this has been an opportunity of getting rid of deadwood, but many admirable people who have given years of good service have found, or are finding, that reapplying for their jobs which have been advertised nationally is a traumatic experience.

I have always been of the opinion that the best and most competent nurses should be closest to the patients, but with the complicated machinery of the National Health Service it is important that their many management and training needs are fully heard, understood and acted on at the highest level of management. Who knows better the needs of patient care than the nurse who has to be present 24 hours, seven days a week, and very often is the only person present in the ward apart from the patients?

Nurses at present have anxieties following the introduction of general managers and I hope that these fears are ill-founded. Some of their worries are that the experience and skills of the managers above direct care level may not reflect the needs of the patient or relatives. Career progression within nursing along the management line will disappear and other lines of career progression and recognition of responsibilities along the education or clinical specialist expert line have not been developed. This will affect the future development and retention of those already in the profession and deter new entries for the future.

There is also anxiety about the ability of the direct care staff at the level of ward sister, district nurse and health visitor, to plan for the future allocation of resources and manpower and to manage the delivery of care on a day-to-day basis. The sheer volume of the tasks involved would detract from the delivery of care. The individual trained nurses at that level already have responsibility for managing the delivery of care and for educating potential trained nurses. The nurses feel that the support of nurse managers who can negotiate and bid for the necessary resources will not be available in the future.

Nursing advice to health authorities on the appropriate environment for delivery of care and level of resources required to meet changing patterns will not be available unless a stronger advisory machinery is developed, and this will take time. Understanding by other disciplines and authority members of the role of the nurse in health services of the future will be difficult to achieve, especially in view of proposed changes in nurse education, as will professional accountability of the individual practising trained nurse, changing models of care and nursing, and changing expectations by the public and the consumer, if there is no nurse manager at health authority and other senior levels to give advice.

Nurses seem to feel that they have been demoted. I hope that something can be done to restore their confidence. Also occupational therapists are greatly concerned about their pending degree courses. They want to raise standards and keep pace with other professions. They were not happy after a recent meeting with the Minister.

From recent questions in your Lordships' House about hygiene in hospital kitchens, it has become evident that there is concern among many people about Crown immunity. Hospitals seem to be becoming very dangerous places with so many cross-infections and outbreaks of salmonella poisoning and Legionnaire's disease breaking out in various parts of the country. I did not have an answer to my question asking if health authorities should lay annually before Parliament a report on their kitchens. I wonder if the noble Baroness asked her right honourable friend the Secretary of State about this matter. The noble Baroness said that she would do so. I am sure that it is our duty to try to protect the most vulnerable members of society—the sick and the frail who go to hospital. I asked BUPA what they did about their hospitals and the reply which I have had states: The kitchens of our hospitals, and I assume of all hospitals in the private sector, are inspected regularly and vigorously both h\ the health authority and by the local authority.". I should have thought that this practice should apply to all hospital kitchens whatever the sector to which they belong.

The Government should be congratulated on the serious and concerned way in which they are treating the terrible problem of AIDS—Acquired Immune Deficiency Syndrome. Having visited the haemophilia centre in Newcastle, I cannot praise enough the dedication and excellence of the staff who have been involved with many of their patients who have developed the AIDS antibodies through contaminated blood products. One of the hardest burdens which that team have to bear is not being able to look after their dying patients to the end, because they have to go to another hospital. I have also been told by a consultant from one of the London teaching hospitals that all the side wards in his hospital are taken up with AIDS patients.

I wonder whether some hospices should be set up to relieve the general hospitals of some of their AIDS patients and give the refuge of a dedicated hospital environment to these dying patients. Many hospices have expert home care teams who go out into the community. This would be of immense value. All patients should be able to die in dignity. The special care of the dying is not something for which busy general hospitals have much time, and the means for private counselling, which takes time and is vital for AIDS contacts so that the risk of spreading the disease is minimised, are generally inadequate or non- existent. As regards AIDS, the fear of the unknown is widespread throughout Britain.

The announcement of the setting up of a ministerial group for ensuring inter-departmental co-operation over AIDS matters seems a very wise move, but it is also vital that the Government should set up a task force, to encompass the many interested bodies across the board from both the voluntary and the statutory sides, so that no stone is left unturned and there is an up-to-date flow of information incorporating a confidential telephone advice service for all the people who need it.

It would be wrong not to mention that there is concern among many health service staff about the other horrifying, escalating problem of drug abuse, including the problem faced by paediatricians of babies who are born to mothers addicted to heroin and who are themselves addicted. At the moment I am looking at hundreds of excellent applicants for the Winston Churchill memorial fellowships. One of the categories is drug abuse, prevention and care. Many people, including doctors and nurses, have put in applications for the opportunity to study counselling. Sadly we can give only 12 fellowships in this category, and this is the largest number given of all the categories this year. Would it be possible for the DHSS to encourage health authorities to run courses for people who wish to educate themselves, so that in turn they can counsel and educate young people who are at risk? There is no doubt a continuing need for such a service throughout the country.

We hear a great deal about the youth training schemes. Like many people, I see a need for trained people working in the community to look after the growing numbers of the elderly and physically and mentally handicapped people. Care in the community will not be effective unless we have enough people to do the caring. Would it not be a solution to run YT schemes for training young people to do this work? They would then be assured of a job at the end of their training.

I end by mentioning the concern I feel when I hear that local education authorities will not be allowed to provide free school meals to anyone whose parents are not on supplementary benefit or income support, which is the new name. I visited a school on Teesside where the headmaster said that he had to give the children breakfast before they had lessons because they had come to school so hungry and tired; many of the parents were still in bed drunk from the previous night. I know that the Government want to make people responsible and stand on their own feet, but there is a percentage of totally irresponsible parents who cannot be educated overnight and who will use cash benefits for drink or drugs and the children will go hungry. I hope that the Government will take advice from the teachers who see and know these children. I cannot believe that hungry children is wise "reform of social security".

8.9 p.m.

Baroness Turner of Camden

My Lords, I too am grateful to the noble Lord, Lord Ennals, for initiating this debate and I welcome the opportunity to comment again on the Government's Green Paper on social security. It is heartening to glean from newspaper reports, which hopefully on this occasion are accurate, that the Government are having second thoughts about some of their propositions. In particular it is said that the Government are thinking again about the proposition to abolish the state earnings-related pension scheme—SERPS. However, SERPS does not yet appear completely safe. It may, we are told, be modified rather than abolished. I hope very much that the Government decide in view of pressure from all sides to let it alone.

Here I am sorry to disagree with the noble Lord, Lord Banks, particularly in view of his acknowledged expertise in the area. But I am sure that he will appreciate that there are other experts who are in favour of the retention of SERPS. I must say that it was difficult to take in his elegant formulae aurally, but it seemed to me that what he was proposing was an option that was open to us many years ago before both parties agreed that they wanted to see state earnings-related provision, as mentioned earlier by the noble Lord, Lord Boyd-Carpenter.

The present legislation, as has been said on many occasions, was introduced after 20 years of experiment in pensions and, as I said earlier, with all-party support. SERPS for the first time holds out to the mass of workers not in occupational pension schemes the prospect of a reasonably dignified and secure retirement. It provides beneficiaries with an additional pension of revalued relevant earnings on top of the basic state retirement pension.

Under SERPS employees do not lose out at all when they change jobs. The provision that the pension is based on the best 20 years' earning is very important, in my view. It makes it particularly valuable for workers with interrupted work patterns, of whom large numbers are women. It benefits not only those whose earnings reach a peak in their middle years, such as manual workers, but also those whose earnings fluctuate throughout their working lives. Moreover, SERPS provides a standard against which good occupational pension provision is measured. The proposition that it could be effectively replaced by providing personal private pension policies purchased on the market individually is, in my view, simply not viable. It makes sense only if it is the Government's intention that future generations of pensioners should have very low pensions.

The Green Paper concentrates on the public spending implications of future pension expenditure. However, if the role of the state is to be reduced, pensions would have to be paid for from the private sector or the pensioners would have to be poorer. If the Government believe that pension expenditure would become an insupportable burden for the state, it would be at least equally so for the private sector. The problem does not disappear because the costs are transferred from the state to the private sector; nor does such a transfer reduce administrative costs. The truth is the contrary. Major new financial and administrative burdens would be placed on employers if SERPS were replaced by compulsory personal schemes. Pensions schemes currently contracted out would face an increase of three percentage points in national insurance contribution rates.' It has been established that that could cost employers an additional £3 billion a year.

The practical implications of the phasing out arrangements—the noble Lord, Lord Banks, made reference to that—are considerable. Until the year 2002, employers will have to divide their employees into four main groups: men over 50 in 1987, men under 50, women over 45 and women under 45. There may have to be further subdivisions to determine the level of private contribution and to whom the contribution is to be made. It is possible that many small and medium-sized employers will have to make separate arrangements for every one of their employees.

The Green Paper proposals will also have a significant financial impact on occupational pension schemes. Younger employees may choose to opt out of the scheme to avoid pension commitments and leave the scheme to older members and those nearer retirement age. The result, would be that increased contribution rates would be necessary in order to maintain the same benefits. At the same time, younger workers who had opted out might find that they had not made sufficient provision for retirement, which would require higher contributions in later years to ensure a decent pension.

Moreover, if SERPS goes, so would the yardstick against which occupational pension schemes are judged. The contracting-out requirements mean not only that schemes must provide benefits in line with guaranteed minimum pensions; they mean also that the benefits provided must be of the defined type rather than the money purchase type. The 1975 Act heralded a major shift away from money purchase schemes. The Green Paper quite clearly indicates a reversal of that trend. That will be strongly opposed by trade unions, since the basic shortcoming of any money purchase scheme is that it creates insecurity about the level of future provision for retirement.

But personal pensions also undermine the principle of collective provision for the workforce as a whole. The collective pooling of risk involves an element of cross-subsidy. The money purchase principle inherent in the personal pension notion implies that the risks are borne by individual employees alone.

That means that individuals will have to make a choice between schemes on the basis of the various sales claims. The employer will have no responsibility in the matter; and sales claims can be very misleading. They may imply very high rates of return on investment and fail to take account of inflation. The more responsible insurance companies may not want to mislead contributors in that way. I think that many of them will not want to do so, but they will be caught in the competitive trap of their less scrupulous rivals.

The financial risks involved in personal pensions will be compounded by the fact that they are extremely inefficient and costly in administrative terms. The Occupational Pensions Board—of which, incidentally, I happen to be a member and which is very much opposed to private personal pensions—has estimated that the average administrative costs of personal pension schemes will be between 12 and 20 per cent. of contributions, as compared with 1½ per cent. for SERPS.

The proposed 4 per cent. minimum contribution to personal pension schemes will be required to provide not only a pension but also survivors' benefits. When that is compared with total employer and employee contributions of about 15 per cent. in the average good occupational scheme, it is clear that that is inadequate to secure anything like proper provision in retirement.

Moreover, it is quite clear, is it not, that private personal pension arrangements will require monitoring? The Government have already indicated in their original blue consultative paper that that will be a problem. Unless that is done, private personal pension policies will open up a vast new field for the cowboy operator in the insurance industry. The consumer lobby—rightly, in my opinion—will campaign for proper protection for individuals who may otherwise be taken in by smart sales talk and put their money into inadequate or even fraudulent ventures. How that monitoring is to be accomplished over such a wide area, with possibly millions of small pensions, I do not know. What is certain is that it will add enormously to overall costs.

For all those reasons, and not least because doubt has been cast on the long-term prognostications of the Government about the ability of the economy to bear the cost of SERPS, the Government would be well advised to leave it alone. There is no pressing need to do anything about it, despite the assertions contained in the Green Paper.

Before I conclude, I should like to make a few remarks relative to the position of women in relation to the Green Paper and arising from the possibility that SERPS could be disbanded. I said earlier that the proposal could have a particularly disadvantageous effect upon women. That is very unfortunate, because, as I understand it, the Government are disposed to treat seriously complaints that there remain some discriminations against women in pensions, notably in regard to pension ages (which clearly should be equalised) and also in regard to provision for survivors. I believe at one stage it was stated that the Government acknowledged that discriminations existed and were prepared to do something about it.

It is to be hoped that those discriminations are finally dealt with, but it would be a pity if improvements on the one hand were balanced by considerable disadvantages on the other. Women remain the principal carers for children. Their working lives are interrupted, and they tend to do more part-time and low paid work than men. Those caring activities exercise a permanently restrictive effect on their ability to earn and thus to provide for themselves at a decent level in old age and in sickness. And many more women need to provide for themselves because of the much greater incidence of divorce, separation and births outside marriage. It is no longer possible to make the assumption made by Beveridge 40 years ago that women with children will always have male financial support. It is for these reasons that a system which bases pension entitlement on the best 20 years' earnings revalued is of such importance to women.

That brings me to another aspect also touched upon earlier by the noble Baroness, Lady Faithfull. Child benefit and family income supplement are not benefits directed solely at women but they have a special relevance for women as the main carers for children in two-parent families. However, considerable concern has already been expressed at the proposal to pay the new family credit through the wage packet of the principal earner—in most families, the man—rather than as a benefit directly available to the woman, who is normally the person with budgeting and purchasing responsibility for children's needs. At present, either partner can cash FIS orders. This, combined with the lack of commitment to increase child benefit in line with inflation—there has already been an erosion in the value of the benefit—will worsen the financial position of the woman within the family unit.

The diversion of resources away from being a clear addition earmarked for the family and available to the mother towards being simply an addition to the wage is all the more serious because of the proposal to abolish free school meals and welfare foods, which are at present given to needy families and which can be used only for their intended purposes. Instead a cash equivalent is to be built into the family credit. Overall the proposals seem to have concentrated on alleviating the poverty trap, in itself a commendable objective, but the need for the benefit to reach the carer, normally a woman, has been overlooked. The unequal distribution of resources within the family unit is a factor that cannot be ignored in developing family support policy.

Therefore, although admittedly there are some aspects of the proposals to be welcomed as of assistance to women, the overall impact of the proposals is likely to be to their disadvantage. Most importantly, the proposals do not sufficiently take account of the social changes of the last 40 years. We have said on this side of the House that we do not oppose looking at social provision and adjusting in the light of these developments. There is a case for greater simplicity but not for uprooting large sections of the system altogether and not for departing, as the proposals do, from the concept of universality in the direction of means testing, itself a recipe for confusion, uncertainty and complication. I hope therefore that when the White Paper is produced we shall see that the Government have heeded the many criticisms that have been made of them.

8.22 p.m.

Baroness Cox

My Lords, may I join with other noble Lords in congratulating the noble Lord, Lord Ennals, on introducing this debate on such wide-ranging and important topics and for speaking with such verve despite his incapacity? My brief contribution will focus on my professional interests as a nurse because so many other Members of your Lordships' House, with far greater expertise than mine on other issues, have spoken on those topics. I shall limit my contribution to a few words on three topics concerning the National Health Service: funding, nursing salaries and the effects of reorganisation on nursing.

I begin by welcoming the Government's announcement of extra resources for health care. The appeal for an extra £250 million, made by the BMA, the Royal College of Nursing and the Institute of Health Services Management, has not been met in full. But the promise of an extra £220 million is obviously welcome in itself and as evidence that the Government have listened to representations made by the professions. It is therefore possible to this extent to say, for this relief, much thanks.

However, I must now reluctantly move from appreciation to concern. Nurses are deeply worried about the funding of future pay awards. Nurses' salaries are still unacceptably low, a point to which I shall return in a moment. But the profession is very anxious that future salary increases may have to be paid from money deducted from patient services. This creates an invidious situation which causes strain and tension for all concerned with patient care. It is a problem that has been mentioned by several noble Lords in the debate.

This leads me to the question of nurses' salaries. I do not wish to use your Lordships' House just to plead a special case. I believe, however, that most people, including I suspect many of your Lordships, are not fully aware of the continuing inadequacy of nurses' pay and that they would be deeply concerned if they knew the situation. Let me hasten to say that the profession is of course grateful to the Government for establishing a pay review body and for honouring their commitment to implement the pay review body's recommendations, although of course there was inevitably disappointment that the pay increases were phased and hence delayed.

The percentage increases which were recommended were generous in percentage terms and well above the national average. But even a large percentage of a small salary is still only a small sum. Consequently, even when the new salary levels are in operation after next February, a staff nurse will still earn only £6,000 on a salary scale that will gradually rise to a maximum of £7,500. Is a salary of £6,000 really adequate for someone who has successfully completed over three years' arduous training, who is likely to be carrying a large measure of clinical responsibility for patients and who, in the absence of a ward sister, may often be entirely in charge of a ward, perhaps in areas requiring specialist competence such as neurosurgery, cardiovascular medicine or terminal care? In addition to the strain associated with these responsibilities, there is the stress of working unsocial hours and the associated sacrifices that have to be made in terms of forgoing leisure activities which people in regular nine to five jobs can enjoy.

And, my Lords, the ward sister, the linchpin of hospital care, will still, even after the recent pay rise, only be able to earn a top salary of £10,000 even if she has been working in the National Health Service for 25 years, while her starting salary will still be a meagre £7,400. This is why many people hope that the review body will once again recommend sizeable increases for nurses' pay next year and why they also hope that such increases will not have to be funded in such a way as to detract resources from patient care.

I regret that there is another major source of anxiety for nurses in the ways in which some district health authorities are implementing the Griffiths reorganisation. This is a point that the noble Baroness, Lady Masham, has rightly pointed out. This country has led the world in nursing, and our profession has an international reputation. But, in some districts, nursing is now fighting for its life because of proposals to abolish key nursing posts. Some of those threatened are management posts so that nurses would no longer lead nursing. Others are in the arena of patient care. In some places it has even been suggested that there is no longer a need for a ward sister and that this time-honoured post could be filled by a ward manager instead of a qualified nurse.

There is a real possibility that the nursing profession as we know it may be in danger of being destroyed, perhaps unintentionally, by those involved in reorganising the National Health Service. That the profession will not tolerate. The Royal College of Nursing has given notice of its intention to consider taking major measures to fight to protect the profession—not, I must emphasise, on grounds of self-interest but in order to preserve standards of professional care for the patients for whom they are responsible.

I earnestly hope that the National Health Service in general and the nursing profession in particular will not have to experience further unnecessary conflict and tension. The nursing profession has set an example to the nation over the years in its steadfast and principled refusal to undertake so-called industrial action to protect its own interests, although nurses in other countries have taken such action, with dramatic improvements in pay and conditions of service. It would be tragic if our country were to reward this dedicated profession not only with remuneration which falls far short of other professional salaries but also by dismantling its professional structures so radically that it would lose the very essence of its professional autonomy and accountability. The profession will not stand for it; and I believe that the public would not wish it. I sincerely hope that my noble friend the Minister might be able to say something reassuring on these deeply disturbing matters.

In conclusion, no one who knows the National Health Service can be in doubt that in many places morale is low and uncertainty about the future is creating anxiety and disaffection. It would be a tragedy if an institution which was the envy of the world—and which is still envied by many—were to be destroyed either from without or within.

Let us hope that all who are responsible for it—government, health authorities and staff—will retain or regain enthusiasm and commitment so that one of the greatest humanitarian ventures the world has ever known can revive and flourish to the benefit of all.

8.32 p.m.

Baroness Ewart-Biggs

My Lords, I think there will be general agreement that if one is 21st in the list and one of the last speakers, one makes a long speech at one's peril. I am certainly not brave enough to do that. I should therefore like to confine myself, very briefly, to the second part of the Motion of my noble friend concerning the proposals for the reform of the social security system.

The noble Baroness, Lady Trumpington, in her opening speech quite rightly spoke of the need for a social security system which caters for today's situation and needs. That is exactly what we all want. However, it is the way to achieve it about which we disagree. The noble Baroness was good enough to say that she would welcome suggestions as to how to achieve this fair, efficient and speedy service. I should therefore like to make one or two suggestions, notably in the area of child support.

I know that this has been touched upon already by the noble Baroness, Lady Faithfull, and also by my noble friend Lady Turner of Camden, but I should like to amplify a little what they have said about, first, the downgrading of the child benefits scheme and the threat of further cuts in its real value in each year until 1989; secondly, the proposal to replace the family income supplement through the post office—in most cases to mothers—with the new family credit which is paid, as my noble friend said, through the pay packet; and, thirdly, the loss of free school meals to low-income working families, including many who will not qualify for family credit.

On my first point, there is indeed no recommendation in the Green Paper to increase the level of child benefit. Most understandably this has caused a public outcry. It is not as if the level of child benefits in this country is very high. The increasing rate for each child which is used in other countries in western Europe—notably Luxembourg, Belgium and France—helps families with young children to go through that very expensive time of their lives. It is realised in those countries that this source of income paid straight to the mother helps to fight the poverty trap and that it is the only way to transfer resources to taxpayers with dependent children at a time in a life-cycle when families most need help. There can be no doubt that the proposal to downgrade child benefit in favour of means-tested support will harm disadvantaged families.

The second change proposed in the Green Paper which will also disadvantage many low-income families, and consequently disadvantage the children within them, concerns the effect of the replacement of the family income supplement with family credit. This again has been touched upon, but I think there are many questions hanging over this new benefit which need to be answered. To mention but a few: how will poor, self-employed people be provided for under this? How is the scheme equipped to deal with people who have more than one job, who change jobs, whose marriage breaks up, or who move in or out of temporary work? How will they benefit from that fund? As I say, these are questions which many people are asking themselves and which need to be answered.

Furthermore, there is concern regarding the method of calculation and payment. There is concern that payment will be channelled through the wage packet when, as is known by all those concerned with child poverty, such funds affect the child in a more positive way if channelled through the mother. Of course in harmonious, stable families there is no reason why this should make any difference. But unfortunately not all families fit this description, and transferring child benefits from mother to father could threaten the interests of many children.

The third change closely affecting children is that regarding school meals. There is no doubt that until now the family income supplement has provided a passport to free school meals for those children who need them. However, under the family credit scheme, designed to replace that, the same will not apply. I know that the rates will be increased to provide some compensation, but the local education authorities will be confined to providing free school meals only to the children of parents who were on income support—which is replacing supplementary benefit—which means that thousands of children whose parents will not get family credit will lose free school meals and will receive either inadequate or no compensation. In either case, more childen risk not getting that vitally important nutritional meal in the middle of the day.

I think it would be true to say that the Green Paper contains a very basic contradiction. On the one hand, the Green Paper recognises that families with children are at present facing the most difficult problems; but, on the other hand, the review contains no proposal for overall redistribution to those families. I believe there must be general agreement among all those concerned with child poverty that the structure of family support—which gives pride of place to means testing—is at the same time inefficient and ineffective and highly divisive.

I should like to make one other point regarding the proposal in the Green Paper that when income support replaces supplementary benefit the current system of making single payments should end. I am concerned about this principally because these single payments are at present used extensively by community energy projects associated with an organisation called Neighbourhood Energy Action, with which I am concerned. These community projects, which are spread throughout the country, initiate home insulation schemes using the single payments to buy the necessary draught-proofing materials. These initiatives have gone a long way towards attacking fuel poverty and helping low-income families to do something about their energy efficiency and indeed to have warmer homes. It should not be forgotten that hypothermia is described as a British disease, and any practical and economic efforts made to eradicate that should be encouraged rather than sabotaged—which in this case has happened.

However, at the present time there are as many as 172 projects operating in this way throughout the United Kingdom. Furthermore, they employ 2,500 people under the community programme giving employment to these people. Around 100,000 of these insulation jobs—including loft insulation and hot water tank jackets, as well as the normal draught-proofing round windows and doors—are anticipated during the year.

The effect of ending single payments would be devastating, because claimants would not be able to pay for draught-proofing material out of weekly benefits and consequently many of these projects would have to come to an end, with the consequential loss of energy saving and of the employment of a great many people. Many lower-income families would still need the service but would not get it, and many small draught-proofing companies which supplied the materials would be seriously affected. I should like to ask the Minister if she will make some commitment that the White Paper will contain a provision to go on providing this highly important finance for a vitally important job about which the Government have always been extremely supportive. I hope the Minister will be able to answer that as well as my more general comments on child support.

8.41 p.m.

Lord Winstanley

My Lords, as the first speaker below the line on the list of speakers at the end of a long and complex debate of this kind I am expected somehow or other to dismiss the whole of the universe in a few easy phrases. I think it was the noble Lord, Lord Wells-Pestell, who some four hours ago said that his experience of both sides of your Lordships' House was that debates of this kind usually turned out to be depressing and useless exercises. I think that is right if the Motion is drawn too widely. Here I shall agree strongly and perhaps unusually for me with the noble Lord, Lord Boyd-Carpenter,. when he criticised the noble Lord, Lord Ennals, for the breadth of the Motion.

I have had cause to be grateful to the noble Lord, Lord Ennals, in your Lordships' House on many occasions and indeed in another place. But on this occasion by lumping together the National Health Service and the complex matter of the difficult and threatening social security reviews that in a sense almost lets the Government off the hook. It has been my experience (today, for example) that if we ask the noble Baroness 80 questions—we have asked more than 80 already—we know what will happen. She will answer those for which she has good answers and she will promise to write to all the other noble Lords and where does that get us?

Earlier the noble Lord, Lord Porritt, was present at this debate. He has now gone and I do not blame him. He is a very distinguished doctor and I was reminded that at the time I qualified in medicine the noble Lord, Lord Porritt, was the external examiner in surgery. When I went in for my surgery oral examination, which in my recollection lasted for three-quarters of an hour, the noble Lord, Lord Porritt, did not ask me 50 questions and allow me to choose one or two to which I knew the answers fully. He probed about a bit until he found a weak spot and he stayed on it for the whole of the 45 minutes.

What I am trying to suggest is that had we made this debate a little more specific we might have had more specific answers. I accept that it has been an interesting debate; perhaps it has been enjoyable and we have all benefited from it. Whether we shall receive the kind of answers we really want is a little less certain. For example, on social security reviews (on which I shall not say very much) if we posed the one single question to the noble Baroness: "How have the Government managed to create alarm and despondency among the whole army of the young unemployed?"—it is a very large army, with the extraordinary muddle over the board and lodging regulations, and is something, to marvel at—had we asked her that and concentrated on it for many hours and covered the many aspects of that matter——

Lord Ennals

That is tomorrow, my Lords.

Lord Winstanley

——we might then, my Lords, have had an answer. I say we might have had an answer but I am not sure because I suspect that the noble Baroness does not know the answer and I am convinced that her departmental officials out in the sticks, where they have to answer individual claimants, certainly do not know the answers. That underlines a point of immense importance, the problem of uncertainty and the damage that uncertainty in this field can do.

During my lifetime—not as long as all that, but fairly long—I have seen many changes in the public mood towards social security. I remember the length of time it took to persuade elderly people that pensions for them were a right not a charity. Many old people would not apply for their pensions. They did not want charity and it took us a long time to persuade those people that pensions were things for which they had paid through direct or indirect taxation or which had been paid for by others and consequently pensions were an entitlement.

Similarly as we moved into the 1950s and 1960s it seemed to me that we gradually gained the understanding throughout the whole community that benefits of one kind or another were an entitlement and that to get those benefits did not attract a stigma of any kind. That was an important exercise and it was successful. Indeed during the 1950s and the 1960s we had a time when there came upon young people a feeling of security in the knowledge that somewhere there was a safety net should the need arise for one. That was very important for those young people and did a great deal for the stability of society at that time.

It seems to me that with all the arguments, discussion, and uncertainty over these social security reviews and everything we have heard about the reviews and the possible outcome of them, that somehow the Government had managed to destroy that sense of security from the existence of the welfare state as it was in a few short months. It seems to me to be the work of an organising genius to destroy what took so many years to build up. I hope that the right honourable friend of the noble Baroness, the Secretary of State, will take on board the message that it is very important to end the uncertainty as soon as possible about many of these matters—I picked on just the board and lodging allowance as one example.

Baroness Trumpington

Tomorrow, my Lords.

Lord Winstanley

My Lords, the noble Baroness says, "tomorrow". By doing that we can at least begin to restore the confidence of claimants. That is important, but we can also remove uncertainty from those on the other side of the counter when the claimants go along to make their claims. The noble Baroness, Lady Faithfull, paid a well-earned tribute to the work of the people in the supplementary benefits departments. I know they work under very difficult conditions, but those conditions are made much more difficult when they do not know the answers to many of the questions put to them almost hourly by people who themselves are in great difficulties. As the noble Baroness, Lady Faithfull, said, claimants are often frustrated and resentful and sometimes they do not behave in a way which is conducive to a happy relationship between the two sides. Anything we can do to remove that uncertainty would be very valuable.

The right reverend Prelate the Bishop of Durham referred to this change in mood. He was right. I he noble Baroness knows that I have close connections with these matters in the north-west where I give regular advice via television. We rely greatly on departmental officials from the Department of Health and Social Security who help us by giving specific advice about benefits, and so forth. They give us a great deal of help. However, even among the senior officials in the region I am now finding that when I ask for their advice they cannot give it because they do not know. There are so many things which at present are unresolved and which need resolving. But what is even more disturbing is the number of letters that I receive from individuals scattered about the north-west of England complaining of harassment in some of these offices. They complain of being subjected to humiliating questions in a public forum overheard by friends and neighbours, and they complain that the whole atmosphere has somehow changed. I think it has; however, the fault does not lie with the individuals, who as the noble Baroness said are working under difficult conditions, but with the circumstances in which they are now being forced to operate. I hope that we can do something to change those circumstances.

I now turn at once away from the social security reviews (on which many things will be said by others on many occasions) to the National Health Service in which I am personally more concerned and about which I know a great deal more. We have heard a great deal about funding. The noble Baroness, Lady Trumpington, gave us a number of calculations explaining precisely what was being spent on the health service, and more or less making the case that enough was being spent. The noble Lord, Lord Ennuis, also produced figures showing that not enough was being spent, and so indeed did my noble friend Lord Kilmarnock. He quoted his right honourable friend Dr. Owen in a lecture which Dr. Owen gave in the Royal Society, to which I listened, where he proved with a lot of figures that not enough was being spent.

Who is right? Everybody is right in the sense that enough will never be spent. That is the message which has to be taken on board. I would say in all sincerity that health could consume all the resources there are without any waste in a strictly professional sense. If everything which could conceivably be done usefully from a medical point of view was done for everybody, we would consume all the resources that there are.

But there are other things upon which health depends than health care, as indeed the Black Report on the inequalities in health pointed out. There are housing, education, and things of that kind. Therefore, there has to be an element of rationing. I accept that. Those who get the money in the National Health Service, understanding that it has to be limited, that it is not enough and never will be enough, have to be prepared sooner or later to do cost-effective exercises in relation to their own work to make sure that such money as they have is spent in a way that brings the most return in terms of relief of human suffering. So I repeat that there will never be enough.

What I would say to the Government is this—and only this so far as money is concerned—that they should try to spend as much as they possibly can because if they do that it will not be wasted. We have heard a great deal of talk about waiting lists; waiting lists for so-called non-urgent operations. The actual urgency of an operation rather depends on who is going to have it. If it is your operation, you tend to think that it is not so non-urgent after all.

In an ideal world nobody whould have to wait for any necessary operation, urgent or otherwise. We could never arrive at a situation under which there were no waiting lists, and that once it was decided that somebody should have a hip replacement, or whatever, it would be done on Tuesday. No, my Lords, but let us move as closely as we can to that situation; and we can only do that by spending more money. I say to the noble Baroness: let us not have these specious arguments that we are spending more, and how much more do we need to cope with demographic changes, and how much more to cope with new technology which consumes more money.

As we get better, the whole thing costs more. There are millions of people at the moment alive and requiring regular treatment who, 50 years ago, would not have been costing anybody anything at all. They would all have been dead. As we keep people alive needing treatment, so we need to spend more and more money. This was a point made by my noble friend Lord Kilmarnock, and others, and I am sure it is acknowledged by the noble Baroness.

There is now universal agreement among workers in the National Health Service and among those who use it that the service is now overstretched. There is general agreement among those who know that the service has only survived in its present state of excellence (and I say "of excellence" advisedly) because of the dedication of those who work in it. That dedication is provided at considerable personal cost. The noble Baroness, Lady Cox, has said something about that. I agree with every word that she said, and we should not forget it.

However, there is also on the other side a growing belief that somehow the National Health Service has become a second-rate service. I think that belief is misplaced. There is far too much denigration of the National Health Service at the moment. It is right to point to defects, and it is right to try to remedy them; but it is not right constantly to denigrate the service and create the general impression that it is a bad seŕvice.

The noble Baroness, Lady Cox, said that morale was low. She is right. Here I am going to do something which is again unusual for me and agree once more with the noble Lord, Lord Boyd-Carpenter, who a long time ago talked of the old days when we had a single Minister of Cabinet rank who was responsible for the National Health Service and for nothing else—and how much I agree with him. Lumping in national insurance and pensions (which are really Treasury matters) with health was a great mistake. The sooner we go back to a single Minister of Cabinet rank responsible for the National Health Service, the more rapidly morale in the service will be restored.

Noble Lords may remember that when Mr. Enoch Powell was a Minister in that situation he used to send a personal message to all National Health Service employees every Christmas. I accept that now it would be difficult for him to send a message because he would not know what the message was, but there is a point there. There was a feeling of solidity throughout the service with a Minister responsible who was of Cabinet rank. I have said that at least three times in your Lordships' House. Today we have heard the noble Baroness, Lady Faithfull, say it and also the noble Lord, Lord Boyd-Carpenter. We have seen noble Lords on the Labour Benches nodding their heads warmly in agreement. Perhaps in the end somebody else might do something. If they do, that would be to the benefit of the National Health Service.

I have said let us not denigrate it but let us accept that the Black Report on inequalities in health has shown that for some—and for far too many—the National Health Service is failing. An area in which the service still stands in high esteem is the general practitioner primary care service. That has been referred to by many noble Lords, and the noble Baroness, Lady Trumpington, herself referred to this, and so did my noble friend Lord Kilmarnock. Let me say about general practitioners that at present—and we have been bandying statistics about for a long time today—20 per cent. of hospital investigations, laboratory investigations and X-rays, arise from direct general practitioner requests. That is an important and illuminating statistic.

Secondly, the number of referrals by general practitioners to consultants for out-patient consultations, or to hospitals, is now half of what it was some years ago. Those figures, if they mean anything, mean two things. First, that general practitioners are now doing better work, work of a higher standard, than they were doing before; and secondly those figures mean that the primary care service, the general practitioner service, is now saving the hospital service a great deal of money.

We must keep it that way. If we see the Green Paper referred to by my noble friend on the financing of family practitioner services, let us hope that it does not include some kind of cash limits, bearing in mind that I do not say that it can be wholly demand led but I do not believe that this, or any government, can predict with accuracy how many people will suffer from which illnesses and at what cost in any future period. The service has to be demand-led, otherwise potentially it could fail.

In addition we must look at the question raised by so many noble Lords and noble Baronesses in this debate on the review bodies' reports. What is the point in this Government, or the past or any government, appointing a review body to determine salaries in the public sector in the National Health Service and so somehow to remove them from the political arena with the gurarantee that the Government will always implement the review bodies' reports except in conditions of grave emergency if, having implemented the review bodies' reports, they say: "That is fine. Pay them that, but your must get all the money out of services to patients"? This point has been made over and over again. It was made with regard to nursing, and it must be made again with regard to general practitioners. If we go on on that tack, then we are on dangerous ground.

I must finish. I should like to have followed a lot of other themes such as community care which was mentioned by the noble Lord, Lord Lovell-Davis. However, we shall have an opportunity to do that in a fortnight's time. I would say with him that community care is not a cheap option, but it is a better option for some patients and therefore somehow we should afford it. I should like to have followed the noble Lord, Lord Boyd-Carpenter, in his question about the anomalies arising from the Vaccine Damage Payments Bill, and the up-rating from £10,000 to £20,000. I should like to hear the answer to his question some day. I should like to know the answer to another question relating to that; namely, what is now being spent on something much more important, which is the poineering and development of a vaccine that does not cause brain damage? I should like to say a little more about research referred to by the noble Baroness, Lady Masham, and by others into AIDS, legionnaire's disease, drug addiction, and so on.

But I shall say no more except to finish by making a request to all those noble Lords and noble Baronesses in your Lordships' House who believe in the National Health Service and who wish to see it preserved in the form in which it was originally introduced. I think there are many in your Lordships' House—I should like to think all, but certainly they are in all parties and sitting in all parts of your Lordships' House. What I should like to say to those noble Lords is this. If any of you should have a need for medical services—as I cast my clinical eye around your Lordships' House, I can see one or two for whom that day is not all that far away, though I shall not name any names—and if you should have a need for health services, for goodness sake use the National Health Service. If you do not use the National Health Service, the next time that need should arise—should there be a next time—you could well find that the National Health Service is no longer there.

9.1 p.m.

Baroness Jeger

My Lords, I must say that, after this very long and very interesting debate I feel rather like the road sweeper after the Lord Mayor's Show. I know there has been some criticism about the fact that this Motion was so widely drawn and I know that has contributed to the difficulties of the debate. However, I would explain that we do not have many Labour days in the course of the business of the House and there was great anxiety among many of my noble friends because during the debate on the gracious Speech there was no opportunity to discuss these important matters. In fact, the gracious Speech itself was very dismissive and curt about this.

Because so many of my noble friends were anxious about the whole range of these subjects, we decided to let everyone have a chance to say what they cared most about. I think that is true of everyone who has spoken today. Your Lordships will be relieved to hear that I do not propose to comment in detail or to ask the noble Baroness another 80 questions.

If we had looked in depth at these subjects today in the spirit of the speech of the right reverend Prelate the Bishop of Durham, for instance, our debate would have ranged even more widely. For instance, we are waiting for the White Paper on social security changes, but I am even more impatient to see the Green Paper on personal taxation. I think it is a total nonsense for us to talk about social security separate from personal taxation. That is really at the heart of so much of the poverty, contradictions and problems in the country. If we are to have a situation where reduction in personal taxation is more important than increases in social security, then we get into an impossible muddle. Thus I hope we shall receive that Green Paper soon, so that we can take a look at the whole picture of incomes and benefits.

When one talks about expenses in the National Health Service, I must say to the House that again it is not possible to isolate these from other aspects of social problems. I know of sickly children who are costing the health service a lot of money, of mothers absolutely broken down by crises of neurosis because they are among the thousands of homeless families who are living in bed and breakfast accommodation, where there are no decent cooking facilities, the children live on take-away meals and there is nowhere to play. This is a housing problem. We are a? the lowest level for very many years in the building of houses. Thus, if noble Lords think that our debate has been too wide-ranging, I can promise them that it could have been made even wider. The question of unemployment is closely bound up with all these problems.

It seems to me that we are not reforming Beveridge, as the Government at one time promised, but distorting what he tried to do. Beveridge formed his report in the context of full or almost full employment. He thought unemployment was a wicked waste. Thus it is impossible to fit this enormous unemployment welfare cost into a Beveridge framework because he did not intend that to happen.

I have a solution which I commend to the noble Minister. I think we should stop distorting the welfare budget by unemployment pay and I should put it direct on to the Treasury. It is the Treasury's fault, and the Government's fault, that we are having to spend millions of pounds on paying people to do nothing. Until the basic economic policy is changed unemployment pay is bound to take up far more than it should of our social security at the cost of other matters.

I do not want to enter into a lot of details. We shall not get the details right until we have the principles right. The tendency that there seems to be in the Government's thinking, that we should try to have a closer look at the special payments and single payments, can be very dangerous. I do not know why the Government seem to take the view that too much money is going out on supplementary benefit payments, because I understand that the take-up rate of supplementary benefits is about 70 per cent. We should be trying to attract more people, not fewer. As regards family income supplement, the figure is only about 50 per cent. Thus, if we are to rely more on means-testing we shall have an even lower take-up rate.

In my view, the history of any improvements in the Poor Law has come from attempts to replace administrative discretion by legal entitlement. Othewise we are going backwards towards the kind of Poor Law guardians by whom, if one went to ask for some money to buy some coal, one was told to pawn the clock on the mantelpiece, because the emphasis then was entirely on the discretion of the interviewer and not on the rights of the claimant. Maybe that is what the Prime Minister meant by Victorian values, but I do not think we want to travel down that road.

The people of this country, especially those in need, should be able to look forward to having their rights clearly set out, and not in a complex, costly and difficult way so that when they go to this social fund there is a subjective judgment made by someone who interviews them and against which they are to have no right of appeal. I think that really is a very serious step backwards.

I then have to mention that we are to have lower scales for income support and for the social fund for people under 25. Why pick on people under 25? They may be married; they may have children. It is only if they are lone parents under 25 that they are to have the average help.

One could go on asking questions of detail which really would not be fair to the Minister or to the house. I hope that the Minister will be able to tell us when the White Paper will come out and when the Green Paper on personal taxation will come out, so that we can take these arguments further. I imagine that the noble Baroness, like me, had her recess ruined by the mountains of representations that came from the interested bodies in reply to the Government's invitation. I was very glad to hear that there was such an enormous response. I brought down some of my papers in a taxi today and there was hardly room in the taxi for me.

We look forward to the consideration which the Government will give to all these representations; and I must say that the vast majority were critical in one way or another, as my noble friend Lord Ennals pointed out. There was an analysis of 60 charity organisations, voluntary organisations of the people at the sharp end of all these matters, raising very serious points. I thought I heard the noble Baroness say—and I made a note of it at the time—that among all this evidence there was some consensus. I was so worried by that that I went to the Library and looked up the word "consensus" in the dictionary because I thought that I must be misunderstanding the meaning of the word. I have to say that "consensus" means what I thought it meant: a general or widespread agreement. Anyone who has read those representations on the Green Paper cannot say that there was a general or widespread agreement, I am sure. So, if I misunderstood the noble Baroness, I am sorry.

The Green Paper has been criticised in many aspects by the Social Security Advisory Committee, which is a very responsible and expert body. But in fairness I will say that its final comment reads as follows: The Green Paper represents an attempt by the Government to tackle some extremely complex and contentious issues. As we have indicated, we support many of the proposals. Others we find deeply worrying especially in the area of provision for retirement". I hope that those aspects of the social security report which they found deeply worrying will commend themselves to the Government for revision. I hope the noble Baroness the Minister and her colleagues in government will not hesistate to alter their minds and to come back with changes in the proposals.

I leave her with a thought from one of my favourite authors, Emerson: A foolish consistency is the hobgoblin of little minds, Adored by little statesmen and philosophers and divines". There is nothing little about the noble Minister opposite in any way. Therefore, I look forward to the revisions and to the serious consideration which I hope will be given to all the criticisms and all the proposals and I trust that we may soon have an opportunity for debate.

9.12 p.m.

Baroness Trumpington

My Lords, this has been a Goliath of a debate, with an average of 20 minutes per speaker for 23 speakers. Your Lordships will forgive me for giving a sort of potpourri of replies to your questions. It was a great relief to me that the noble Lord, Lord Hunter of Newington, kindly agreed in advance that I could write to him in reply to the points that he raised in his thought-provoking speech. I will write to other noble Lords if and when I fail them. The noble Lord, Lord Ennals, whose debate this is, must realise that by coupling the National Health Service with social security his timing was unfortunate with regard to the latter subject.

Noble Lords can speculate on the White Paper in advance of publication; and it will be soon. I, on the whole, can merely assure them that their contributions today will be carefully noted by my colleagues in another place. This sentiment applies to the notable, as always, contribution by the noble Lord, Lord Banks, and to—if I may say so even if I did not agree with a word of it—what I thought was the damned good speech of the noble Baroness, Lady Turner of Camden.

The noble Lord, Lord Ennals, claimed that waiting lists were lower under Labour and that the health services saw some kind of golden age then. Let me tell your Lordships the situation which we inherited when we took office in 1978–79. During the previous Government, when the noble Lord was Secretary of State for Social Security, health service expenditure had been cut in real terms, capital expenditure had been cut in real terms by about one-third; there had been a highly damaging industrial dispute and this had helped waiting lists to reach an all time high. I do not grudge in any way the noble Lord's good intentions towards the health service, but it is actions which count, and the record of his administration is by no means without blemish.

Let me turn to the very difficult question of the role of nurses in the new, post-Griffiths management structures. It was a subject which was mentioned not only by the noble Lord, Lord Ennals, but by my noble friend Lady Cox and others. The noble Lord gave the figures for nurses appointed as general managers. I do not agree that this shows any diminution of nurses' influence and their role. I would have been more than happy to see more nurses en poste as general managers, but I believe that with more than half the appointments still to be made we have made a good start. I think the noble Lord may have had in mind the concerns that have been expressed in some quarters because not all authorities have appointed their top doctors and nurses to any management board or group they have set up. We have made our position very clear. It is that every authority must identify one doctor and one nurse who will be responsible for the professional advice to management and to the authority itself.

Clearly, to do that effectively they must have access to both as of right and be involved in the decisionmaking process; but we did not think it right to tell authorities precisely how they should achieve that. Most have appointed their medical nursing advisers to any management group, sometimes combining the advisory role with managerial functions. A minority have not done so but have made other arrangements to involve their medical and nursing advisers. If there is a genuine cause for concern that through these arrangements they are somehow missing out, we shall of course take this up with the authority concerned.

While I am on the subject of nurses, I should like just to take up the point which was made by my noble friend Lady Cox with regard to review body awards: the funding. She noted that the Government have implemented both the awards recommended by the nurses' review body in 1984 and 1985. These were very substantially higher than the average level of settlements generally within the public sector. Several noble Lords asked that the Government should commit themselves to using any additional cash available to fund any pay awards arising in 1986. I have to say that we have no plans to do so. The National Health Service cannot be insulated from the real world, which all other employers must face. Other employers recognised there may have to be a trade-off between pay and services, and the NHS cannot expect to be treated differently. The taxpayers' purse is not bottomless and it is unrealistic to think that it is. I am sorry: that is tough talk, but that is the way it is.

Lord Pitt of Hampstead

My Lords——

Baroness Trumpington

No, I am sorry: I must say to the noble Lord, Lord Pitt, that I am not going to give way. I think that everybody has had just about enough—and they certainly will have done by the time I sit down.

To continue with the questions that were raised, this debate is really that of the noble Lord, Lord Ennals, and so I think I should give him the major portion of the answers. He spoke about the spending on geriatric in-patient services not having kept pace with the rising number of elderly people. In fact, spending on inpatient services specifically for elderly people has kept pace with demographic pressure. Moreover, the noble Lord fails to recognise that elderly people use many other services: for example, district nursing, outpatients, medical and surgical wards have all increased substantially, and expenditure on district nurses has increased by over 20 per cent. in resource terms.

Turning to children in hospital, the noble Lord asked: are our services improving or not? As in so many fields in the health service, I would not want to claim that we have achieved perfection. There is still room for improvement, but in April this year the Consumers' Association published in Which? an article reviewing the position concerning children in hospital, since they had already produced a report on the subject in 1980. The article said that since the report of 1980 it seemed that the care of children in hospital had improved. More hospitals now had unrestricted visiting hours, allowed parents to stay overnight and nurse children in children's wards. I think we should take pride in this real progress. I will not touch on the position of children in mental hospitals because I feel sure that the subject will come up in a fortnight's time.

I am trying to choose the most important subjects that most noble Lords have talked about. Measures to tackle drug misuse have been mentioned. First, we have already acted to produce a national education information campaign against heroin misuse, thoroughly researched and targeted and aimed at young people and their parents. Secondly, we have asked health authorities, in conjunction with local authorities and other agencies, to give high priority to the development of services for drug misusers. Thirdly, on an exceptional basis, we are operating a £17½ million central funding initiative for health services and voluntary sector projects or local authority training schemes. Fourthly, we have issued guidelines of good clinical practice in the treatment of drug misuse to all doctors. We do not wish to underestimate the threat posed by this horrible drug misuse and we are tackling it with, I trust, the support of all parties.

It is a misrepresentation to say that the review is only about cuts. I believe I am right in thinking that the right reverend Prelate the Bishop of Durham also came in on this subject. We are spending over £40 billion per year on social security—a vast sum of money! Can we really say that we are wholly satisfied with how this money is being spent and with the distribution of that money among those who rely on benefits in varying degrees for different reasons? The purpose of the review is to reform the structure of social security, to get a system that is coherent and reasonably simple and, above all, to get the money to those in greatest need. Indeed, I must say we have made it clear that we will be directing more, not less, money to the groups that we recognise as having a special case; for example, families bringing up children on low incomes.

With regard to cuts in social security, which the right reverend Prelate mentioned, I think he was talking about adding a 20 per cent. contribution to rates. At present, over 3 million people do not pay rates at all. We believe that this has contributed to a weakening of the link between payment for and use of local services. We need to make everyone aware of the connection between their local authority's rating policy and its spending plans. It is very important that those subjects are not divorced.

In answer to the proposal made by the noble Lord, Lord Ennals, and the right reverend Prelate on the cost of SERPS, if the review has made one thing clear it is that something needs to be done to reduce the cost of SERPS. Despite what the noble Lord said about the numbers supporting our proposals, there was widespread recognition that the financial burden of SERPS is just too much to expect of the next generation. By any standards, projected spending of £23 billion by the year 2033 means a major public expenditure commitment. My right honourable friend made clear when SERPS was being introduced that he had reservations about pay-as-you-go schemes, which are a blank cheque drawn on the future. He also warned that the financing of SERPS could have become extremely onerous. Latest projections have confirmed how right he was.

Turning to the question of AIDS, I can assure both the noble Lord, Lord Ennals, and the noble Baroness, Lady Masham, that we regard the reduction of the rate of spread of this serious virus infection as a matter of very high priority. I shall not rehearse all the steps that we are taking, but suffice it to say at this point that we have provided an extra £1 .79 million to work on AIDS this year, which is in addition to the money that health authorities themselves are spending on the disease. There is certainly much more to do, particularly in educating people about the infection, and the Government are urgently exploring possibilities for a major health education campaign. With the help of the Government's expert advisory group on AIDS, we will continue to monitor the situation carefully in the light of further developments both in this country and abroad.

The noble Lords, Lord Ennals, Lord Kilmarnock and Lord Rea, asked when the long awaited Green Paper on family practitioner services would be published. We have been working hard on the Green Paper for some time but, given the importance and complexity of the issues involved and some ministerial changes over the past few months which have inevitably caused some delay, I can give no definite date for publication. But I can assure your Lordships that there will be no unnecessary delay.

The noble Lord, Lord Kilmarnock, raised the question of the costs of community care. It is clearly acknowledged that the switch to community care involves some transitional costs as the old service withers and the new one is built up. That is well recognised and many regional health authorities have set aside bridging funds for that purpose. We have also said that in some areas community care may become more expensive, particularly where the standard of the service needs to be improved. The resources we are making available, authorities' own improvement programmes, and income from the sale of old mental hospitals will help to do that. In their report on community care, the Select Committee on Social Services made a number of recommendations about financing as well as on many other aspects. We are considering those recommendations and expect to reply shortly.

The noble Lord, Lord Kilmarnock, asked several other questions but I fear that I shall have to write to him on them, although I have all the answers here. I am living in a forest of paper. If the noble Baroness, Lady Jeger, had difficulty getting into her taxi, I hate to think what would have happened if I had been in there too with all the paper I have here.

The noble Lord, Lord Wells-Pestell, who is actually a very dear man, was at his most waspish this afternoon. My noble friend Lord Boyd-Carpenter did me a great service when he explained to the noble Lord, Lord Wells-Pestell, that he and the Opposition Benches did not have a monopoly on caring. But both the noble Lord, Lord Wells-Pestell, and the noble Lord, Lord Ennals, queried waiting lists. We are making real progress. The latest figures show that, at 674,000, the waiting lists are some 80,000 fewer than at March 1979. It would have been lower still but for the industrial action in 1982 which led to a record level of waiting lists. They rose by a full quarter of a million under the last Labour administration.

The downward trend which we have achieved has taken place at a time when there is an increasing demand for treatment and the health service is treating more patients than ever before. To some extent waiting lists represent the problems of success. As the range of treatment available increases, demands and public expenditure rise. This was brilliantly put by the noble Lord, Lord Winstanley. There are no easy solutions but our objectives are clear and we are making real progress.

The noble Lord, Lord Wells-Pestell, commented on the fact that current spending on the National Health Service fell in 1984–85 and that spending has not risen by 17 per cent. but by only 4 per cent. The noble Lord suggested that we had been misleading the House and the country with our figures for health service spending. The noble Lord quoted figures from the social services Select Committee report regarding public expenditure. The bald facts, which the social services Select Committee implicitly recognised, are that the cost to the economy and to the taxpayer has risen by 20 per cent. since 1978–79. It is true that increases in National Health Service pay and prices have risen faster than prices in the economy generally, and that after allowing for this the inverse is somewhat lower. But the important measures are what the taxpayer puts in—20 per cent. more in real terms since 1978–79—and what the service delivers in terms of patient care, about which I have given the figures.

My noble friend Lord Boyd-Carpenter and the right reverend Prelate both spoke about SERPS and private pensions. I welcome my noble friend's recognition of the problem with SERPS and the question of the future cost. That is why we propose changes. We are aware of and will take full account of the concerns expressed about the pension prospects of groups who are specially favoured by the present scheme. Our final proposals for pensions will be in the White Paper that we shall be publishing very soon.

One of the major objectives of change is to increase the number of people getting a pension from their job. At present nearly half the workforce is without cover of an occupational scheme of any kind. Around 11 million people are in schemes, but more than 9 million are not. That position has remained more or less static for the past 20 years. It is a central aim of this Government's policy that that situation should be improved.

My noble friend Lord Boyd-Carpenter and the noble Lords, Lord Rea and Lord Winstanley, all asked about vaccine damage payments. The new increase to £20,000 is not retrospective. While we accept that the £10,000 payment has been eroded over time since 1979, to restore its value it would need to be about £ 17,000. We took the power to increase the amount in the new Social Security Act to £20,000, ahead of inflation, for new claims made on or after the announcement of the increase on 18th June. That seemed to us to be the fairest way of proceeding. We could not include those claims which were in the pipeline before 18th June. Some of them go back over many years and have still not been settled, mostly because various people have been trying to help the claimants concerned. Every time they have tried to help, the process has started from scratch again. Therefore it would have been very unfair to give the increase to some but not to others, and we took our decision on that matter in the fairest way that we could.

My noble friend Lord Boyd-Carpenter touched on a matter that is very near and dear to my heart as Minister for war pensioners. He spoke about the elderly war widows. This issue has irked me ever since I was appoointed. The situation was not caused by the war pension scheme administered by the DHSS, because the rate of war pension is the same for those widowed before and after 1973. The difference is due to the occupational pension scheme introduced in 1973 by the Ministry of Defence for servicemen and women. It is simply not possible to make retrospective payments under the occupational scheme.

However, the point about elderly widows is heartbreaking to me—especially as I am getting older myself. The older I get, the colder I get, and the more money I shall need to keep me warm. I am trying desperately hard to find a way around the problem. The war pensioners' organisations are well aware of my efforts in this direction. However, I will plough on and hope that I achieve success before I am put out to grass.

The noble Lord, Lord Pitt, said that renal dialysis should be added to supra-regional specialties. If supra-regional specialties are designated by agreement among regional chairmen the essential point is that these specialties are genuinely supra-regional, that they are best provided by one or two centres for the whole country and that money for them is allocated from within the total resources available. Renal dialysis, as the noble Lord knows very well, is more widespread than might justify designating it a supra-regional specialty. We have made clear that renal services are one of the key priorities for service development.

I fear that I will have to write to the noble Lord, Lord Pitt, about ward closures in Bloomsbury. With regard to child benefit, which was spoken about by several noble Lords and particularly the noble Lord, Lord Ennals, my noble friend Lady Faithfull and the noble Baroness Lady Ewart-Biggs, increases in child benefit cannot be viewed in isolation. Child benefit is, by its nature, expensive. It costs about £4.4 billion in a financial year. There is a need to direct resources effectively, and in determining future levels of child benefit we cannot ignore the need to concentrate resources on those families in greatest need.

The proposed family credit scheme will allow help to be directed to where it is most needed; but as the Green Paper makes clear, we are committed to keeping child benefit as a universal benefit for children, payable primarily to mothers, not means-tested, and tax-free. I think that my noble friend Lady Faithfull has misunderstood the Green Paper. Family credit is not replacing child benefit. It is paid in addition to it. Child benefit will continue to be paid primarily to mothers.

My noble friend Lady Faithfull referred to staff in local offices, and I welcome her tribute to the staff. I should like to associate myself wholeheartedly with what she said. Staff do get the training supervision they need but many of the present problems stem from the complexity of our present schemes. That is why we want to reform the service.

As regards counselling services, when they come in we shall have specially trained staff to administer the social fund and we will be encouraging social links between officers and social workers. I must write to my noble friend Lady Faithfull with regard to social fund loans, because the answer is too long. The same applies to her question about implementation of the Acheson and Court Reports.

The noble Lord, Lord Bottomley, spoke about private medicine, and so on. He made two points about privatisation and private medicine. He said, first, that the Government saw privatisation as a way of reducing the cost of the NHS. That is not so. Our policy is one of competitive tendering to achieve the most cost-effective support services whether provided in-house or by a contractor. The savings made make a valuable contribution to the resources available for patient care. They do not reduce the cost of the service. Savings from tendering so far are expected to yield £28 million in a full year and still some 85 per cent. of services are to go to tender. That money can be used to improve patient care.

Secondly, the noble Lord suggested that private medicine is somehow detracting from the NHS. I do not agree. We are committed to the NHS as the backbone of the nation's health care but we recognise the important complementary contribution that the private sector can make to the totality of health care in this country.

The noble Lord, Lord Lovell-Davis, spoke about the Government's sense of unreality. I fear that his speech left me with a similar sense. The noble Lord, Lord Prys-Davies, suggested that the views of some managers in the health service were not reaching Ministers. I can assure the noble Lord that we and our officials keep in touch as closely as possible with views in the health service. For every example I hear of a manager carping about lack of resources and opportunity in the health service, I hear very many more from those who see great opportunities and challenges in the health service today. I must reassure the noble Lord, Lord Prys-Davies, that we have the highest sense of priority about the elderly and all those other people who need care and about whom he spoke.

The noble Countess, Lady Mar, raised the question of patients in rural areas being removed from their doctor's dispensing list, and she suggested that FPCs are dealing harshly with patients living on the limit—the one mile Clothier rule. She has also suggested that the rule of serious difficulty should be interpreted more liberally. I listened with great interest and some concern to her comments, but I am bound to say that I am afraid I cannot actually give her the answers this evening, so I shall write to her.

In a wide-ranging speech the noble Baroness, Lady Masham, had too many points for me to answer now and I shall write to her. However, in answer to her question about annual reports from hospital kitchens (I think I am right in saying that she asked me that question), my right honourable friend in another place liked her idea, but so far as I know no firm plans are yet in hand. I shall be happy to answer some more of her questions; really, it is up to your Lordships. I shall write to her, and I fear that the same answer applies to my noble friend Lady Macleod.

The noble Lord, Lord Winstanley, in his refreshing and on the whole highly palatable speech, touched on the social security system. The single, most effective way of removing uncertainty among claimants and staff alike is to simplify the social security system, and that is precisely at what our proposals for reform are aimed.

I am very conscious that I have only touched on this debate. It would have been very difficult for me to do otherwise. I am also conscious of the fact that work in the health service is carried out not just by the staff about whom we have been talking; it is also carried out by other people whose work is largely unrecognised. I hope it will not be taken amiss if I mention in particular a service which rarely obtains public recognition, and that is the ambulance service. Behind the scenes, in central posts and training schools, as well as on the road, it is staffed by conscientious men and women, many of whom are now training in highly sophisticated resuscitation techniques, so that they can help to improve even further the quality of care available to the people in this country.

Of course there are many others whom we have not mentioned and I feel badly about that; but I hope that they realise that they are appreciated in every way by the whole of the country wherever their care is needed by members of the public. Not for a moment would I pretend that our health service and social security systems are perfect. We do not live in a perfect world. I recognise the genuine concern expressed by your Lordships today in the debate. The complexities and difficulties in the way in which social security operates are a prime reason why we are undertaking such a thorough review, and much remains to be done in the health service. Under this Government we have secured some major improvements and more are on the way. The Government are proud of their record and the people of this country have services which they value greatly. We shall ensure that the progress continues.

9.44 p.m.

Lord Ennals

My Lords, I am sure that your Lordships will be delighted to know that I shall be extremely brief. I want, first, to thank all those who have taken part in this wide-ranging debate and especially to thank the noble Baroness for the large number of questions that she answered. I am one of her greatest fans. I think that she is absolutely marvellous. She is marvellous when she answers questions and she is marvellous when she does not. It was typical of her charm to send me flowers when I was in hospital, and her little note, "Get better slowly", was perhaps typical of her sense of humour! I wish to thank her. I am running a campaign for "Trumpers for Secretary of State". I hope that many noble Lords on all sides of the House will wish to join me.

To be serious, it might have been preferable to have had a narrower Motion. As has been shown, there was a case for a debate on the health service alone, and also on social security. We chose social security and health as this was the last opportunity for this House to express its views to Ministers before the White Paper is published. I was quite delighted that the noble Baroness said that the points that had been made—and made forcefully—would be taken into consideration. In spite of the difficulty, it was worth while having this particular Motion.

Having thanked everyone for taking part, I make this last point. In the final operation of producing the White Paper, and after that the Bill, I ask the noble Baroness and her right honourable friend to seek consensus. They should try to ensure that, at the end of the day when the Bill has gone through another place and through this House, we have agreement and are not kicking around pensioners, disabled people, single parent mothers and all the other disadvantaged people in society. If we cannot achieve consensus, there is something wrong with all of us. I am certain that on all sides of the House we want to achieve it.

With those words, I beg leave to withdraw the Motion for Papers.

Motion for Papers, by leave, withdrawn.

House adjourned at thirteen minutes before ten o'clock.