National Health Service

HL Deb 01 April 1987 vol 486 cc576-88

2.59 p.m.

Lord Ennals rose to call attention to the state of the National Health Service, and to move for Papers.

The noble Lord said: My Lords, I am delighted that so many noble Lords have indicated their wish to speak in this debate and also that the noble Lord, Lord Peston, has decided to make his maiden speech today.

I shall start with what I call a short health of the nation statement. In spite of the National Health Service the United Kingdom has become one of the most unhealthy societies in the world. Is that sensational talk? No, it is not. First, the latest World Health Organisation figures show that Britain has the worst rates in the world for deaths from lung cancer, breast cancer and heart disease.

Secondly, the incidence of chronic illness in the United Kingdom is steadily rising. The latest available figures reveal that the percentages are 30 per cent. for males and 32 per cent. for females. That is a very substantial rise as compared with 10 years ago. Bluntly stated, it indicates that at any one time almost one-third of the adult population has a long-standing illness.

Thirdly, in Britain the expectation of further life at the age of 45 is among the worst in the developed world. Fourthly, cigarette smoking is still responsible for at least 100,000 deaths each year in the United Kingdom and for the additional burden to society from associated heart and lung diseases.

This debate on the National Health Service, and the essential services that go with it, comes at a time when the Prime Minister and other leading Ministers have been making what I believe to be exaggerated claims about the strength of our economy and while the Chancellor of the Exchequer has been distributing largesse in tax cuts largely benefiting those in the community who are fit and upwardly mobile. The health service received nothing from his Budget. The decision to give away £3 billion in tax cuts will, I believe, fuel the consumer boom and worsen the balance of payments. Prescription charges are increased while the real price of drink and cigarettes, left at the present level, is falling in relation to inflation. These are decisions taken in the run-up to an election when the Government will no doubt seek to defend the Prime Minister's statement that the National Health Service, which she and most other Ministers can afford, and prefer, not to use, is safe in Conservative hands. That tattered claim is not accepted by the public, who in every opinion poll about issues put the National Health Service very high on their list of concerns. The public say constantly that they would prefer more funding for the National Health Service and indicate their support for Labour policies as opposed to those of the Government.

As we are all aware, the National Health Service suffers from an acute lack of resources. I accept that this is not a new phenomenon; I accept that demands can never be totally met. However, as a result of the Budget, the Government can no longer defend themselves, as they have in the past, by the plea of shortage of resources. Their decision to deny the money needed by the National Health Service and to give it away to those in work who do not need it, was, in my view, deliberately anti-social and gravely damaging to the health service today and in years to come. It jeopardises the future of the National Health Service and the future health of our people.

In this respect, the Government's policies are cynical and uncaring, and I intend to spend most of my time seeking to prove it. I have sympathy for the Minister who has been put up to defend what I believe is the indefensible. I am very disappointed that the noble Baroness will not be replying the debate: she has an appointment overseas. I believe that her first responsibility is to your Lordships' House. I deeply regret that even though she knew about this debate three weeks ago, she did not feel it important enough to be present tonight to reply to the debate. I gave her warning that I would say this.

The Minister's brief will say that the Government are spending more on the National Health Service than ever before. That is quite true. Not once in 40 years has there actually been a cash cut. But it has been clearly proved by the House of Commons Select Committee on Social Services, based on figures given by the Government, and from a series of independent studies, that after taking account of the historic growth in the number of elderly people, with their increasingly heavy demands on the National Health Service, advances in medical technology, which we all welcome, the much higher inflation rate in the National Health Service and the Government's habit of paying for only part of staff salary increases, NHS spending in England has actually fallen by 5 per cent. over the past four years.

Examples are to be found on all sides and from all parts of the country. Rochdale has a £15 million overspend and has been warned that if it does not find ways of cutting that amount, commissioners will be sent in to run the health service for it. Salford has a £2 million overspend; Merton and Sutton a £1.25 million overspend; Mid-Glamorgan a £2.5 million overspend; and Shropshire a £2 million overspend. They are all technically bankrupt and are told to slash their already strained services or to go.

Bearing in mind that the position of Britain in the OECD league tables of percentage of national income is slipping year by year, it is quite clear that the National Health Service suffers from a grave shortage of funds. In the view of the Labour Party, the National Health Service in its current circumstances needs not less than a 3 per cent. real terms increase in order to fulfil our modest commmitment to improve standards of patient care, to step up the programme of health education, prevention and limitation of disease, and to raise the standard of living of health workers.

What is the situation today? Even with 3 per cent. annual real terms growth, we should still be almost bottom of the European league of percentages of GNP spent on health care. Ours is approximately half the figure for Germany and France. Let us look at some of the facts. Roughly 10,000 beds have been closed since 1979. That fact was given to me by the Minister herself. However, she says that more patients have been treated. Frankly, she does not know: her statistics only tell her how many patients are admitted and discharged. Let me tell the noble Baroness while she is present that, according to the most reliable evidence, the efficiency drive has too often led to patients being discharged too early and consequently often having to be re-admitted. On re-admission, the statistics record another new patient. My Lords, that is not efficiency. There are some cases of patients being discharged and re-admitted on the same day. But it helps the statistics.

Secondly, according to the British Medical Association, the cut in beds now means that 40 per cent. of acute beds are occupied by patients over the age of 65, thereby blocking beds for younger, acutely ill patients. Thirdly, in spite of all that has been said about waiting lists by the Secretary of State, and repeated by the noble Baroness, according to the latest figures, they are at an all-time high. Leaving aside the peaks during industrial action in the periods of both governments, the latest figure issued by the department shows that waiting lists stand at 673,000. That is 1.8 per cent. higher than six months previously and roughly 100,000 more than the average during the period of Labour Government. These are not just figures; they are men, women and children waiting in pain for hospital treatment, often in circumstances where their condition is getting worse and the chances of total recovery getting less.

Moreover, the waiting time for emergency cases—for emergency cases!—is also rising. The BMA reported 12 months ago that 63.5 per cent. of urgent cases had been on the list for more than a month and 25.8 per cent. of non-urgent cases had been waiting for more than a year. Quite frankly, this is appalling.

Health authorities are saving money by making hospital doctors work even longer hours. Up to 3,000 hard-pressed junior doctors are working more than the stipulated maximum of 101 hours a week. In my view it is sheer exploitation of dedicated and skilled men and women which, at the same time, increases the risk that they may commit an error. It should be stopped.

There is a nursing crisis. Nursing really is in crisis. It is nothing to do with the dispute. It is a profession of 509,000—that is more than half the staff of the National Health Service—who have greatly earned the respect of the nation and of anyone who has ever been into hospital. Today there are grave shortages, with wards and theatres being closed for no reason other than the shortage of nurses. The NHS needs 30,000 additional nursing staff each year. On present estimates we face a shortfall of 10,000 qualified staff, and that may be as high as 16,000 by 1995.

It is not just the demographic factors. There are fewer young people reaching the age at which they would go into training for nursing, but it is not just that. It is pay and conditions. We need to keep those who have been trained and induce others to return. In 1981–82, 30,046 nurses entered training. By 1985–86 it was down to little more than 22,000. It is serious for the future.

In February 1987 the United Kingdom Central Council for Nursing, Midwifery and Health Visitors published Project 2000; crucially important proposals. I look forward to the Government's response to that document when the Minister replies. The document is called No Nurses, No Future. At the present time nurses are voting with their feet and have little confidence in the Government's commitment to them.

Hardly less important is the growing shortage of occupational therapists, and 19.2 per cent. of funded posts cannot be filled; of speech therapists; and of chiropodists, especially needed for our elderly folk. It is not just an immediate problem, although it is urgent, especially for the growing number of the elderly. But future prospects are horrific. Looking at the period up to 1994 the required growth rate is for chiropodists 30.6 per cent.; for dieticians, 25.8 per cent.; and for physiotherapists, 28.4 per cent. Occupational therapists, who mainly work with the elderly and the disabled—and I am interested because I am president of the College of Occupational Therapists—have a massive need for an increase of 73 per cent. What are the Government doing about it? That is the question that must be answered so far as these essential professions are concerned.

As president of the College of Occupational Therapists I have had countless meetings with Ministers in the DHSS and the Department of Education and Science. I hate to say it, but they do not seem to know, and nor do they seem to care, about the prospect that is facing us. As for speech therapists, it was only two weeks ago that it was revealed that only 25 per cent. of district health authorities had achieved the target of one speech therapist for every 5,000 children. Why is this? It is partly because they are paid less than a typist gets paid in London. You cannot expect people to go into significant and important professions which require great dedication, commitment and training and then pay them salaries that are simply not worth the challenge.

Let me continue with this sad saga. Prescription charges have risen twelvefold since 1979. I repeat that, twelvefold. Of course the Minister will say that 75 per cent. do not have to pay, so she can cross that out of her speech since her time is so short. But of the 80 million prescriptions that are paid for, about 32 per cent. are for items that cost less than £2.40, which is the prescription charge, according to the Prescriptions Research Centre, and it should know.

They are not allowed to pay less for prescriptions-only medicines, which means that the Government are making a profit out of any prescription which is less than £2.40. Talk about penalising the sick! It is an extraordinary situation that we face, and there is no point in the noble Baroness saying that I had to face it. In my day prescription charges were 20p and not £2.40.

There are two other consequences of the Government's money-making prescription charges. According to the Pharmaceutical Services Negotiating Committee there are about 100,000 patients a year who cannot afford to have all that is prescribed. That means they go without medicines that the doctors think necessary. Secondly, doctors are writing prescriptions for longer periods to save money for their poor patients. This leads to a great deal of waste with patients who for some reason or another do not use their medication.

Sharp increases in charges for dental treatment have had serious consequences. According to the Government's Dental Estimates Board the 25 per cent. increase in dental charges led to a 5 per cent. fall in treatment the following year. That is a substantial fall in root treatments; a 15 per cent. fall in extractions. Treatment of gum diseases which can save teeth in the long-term has fallen by 38 per cent. I had hoped that I would hear from the noble Lord, Lord Colwyn, and the noble Baroness, Lady Gardner, what they thought about this problem.

Only last week the Royal National Institute for the Blind expressed deep concern at the consequences of the Government's decision not to increase the value of spectacle vouchers for blind people on low incomes as from today, April Fools' Day. Honestly, how can they take such action when we know of the fantastic sums being earned by many in the City? It is a total discounting of priorities in our society. I find myself angered by such decisions. At a time when we are all supposed to be well off—except the National Health Service, which cannot afford to provide a decent service—health authorities in England have just written off £640,000 from bad debts by private patients.

I have time only for a brief conclusion. I am deeply worried about community care—the policy of the Government and their predecessor in respect of the mentally ill, the mentally handicapped and the disabled to close, so far as it is reasonable to do so, the big long-stay hospitals and to provide service in the community. Frankly it is not happening because the extra money is not there.

That is why the manifesto which has ben issued jointly by Dr. Barnardo's, Royal MenCap, MIND and the Spastics Society specifically calls for a central bridging fund to be established as a matter of priority to supplement joint finance in the transition from hospital to community care. I believe that it is absolutely vital that that should be done. I know that other noble friends will deal with some of the points which came up in the report from Sir Douglas Black. I shall not deal with those today.

My indictment of the Government's handling of the nation's health is fundamental. I believe it strikes at the root of the deep divide between the approach of our two parties in terms of health and social security. The time is past when the Government can meet the targets set out in our carefully documented programme. The people themselves must decide on the future of the National Health Service. I believe that they will do just that. I beg to move for Papers.

Lord Harmar-Nicholls

My Lords, before the noble Lord sits down—

Noble Lords

No. Order!

Lord Harmar-Nicholls

My Lords, before the noble Lord sits down, is he aware that in this Wednesday debate his speech had little to do with the National Health Service?

Noble Lords

Order! Sit down!

Lord Harmar-Nicholls

My Lords, it was nothing but a naked Labour Party propaganda attack.

Lord Hesketh

Order!

3.22 p.m.

Baroness Trumpington

My Lords, I must begin by offering your Lordships my most sincere apologies. Months before I knew of the existence of this debate I had accepted an invitation to visit West Germany on official business. I know that my noble friend Lord Hesketh will respond admirably to the points raised in the debate, but I deeply regret that I shall miss your Lordships' speeches,

The noble Lord, Lord Ennals, to my knowledge did not give me warning of his opening remarks. I am, however, grateful to the noble Lord, Lord Ennals, for giving us an opportunity to discuss the health service. It was not so long ago that he was the Secretary of State, so presumably a part of today's health picture follows his period in office.

When someone first comes into contact with the NHS, whatever the circumstances, they must above all feel they are being treated as an individual, not as a patient and certainly not as a statistic. As I have only 10 minutes, I should like to say a little about three major areas.

I begin with services for elderly people. In particular, I should like to remind your Lordships of the developments which have occurred in the health service's ability to treat older people. We all know people who have recently benefited from hip replacement operations at an age when even five or ten years ago they would have been considered too old to undergo surgery of any kind. We are focusing on hip replacements and on cataract operations and have set health authorities targets to be achieved by 1990 in both these fields. Such operations can restore mobility, independence, hope and dignity to elderly people.

The provision of community care services for elderly, and particularly very elderly, people is also vital to improving the quality of service which they receive. We aim to provide services that enable elderly people to live at home for as long as possible. There are many successes to report, such as an increase in the number of elderly people treated by district nurses. These successes must be sustained in the future.

Community care also has a vital role to play in the provision of better services for mentally ill people. This is a subject which I know is dear to the heart of the noble Lord, Lord Ennals, and it is certainly dear to mine. Though the newspapers mainly record bad news—and no doubt the same was true during the noble Lord's own time as Minister—progress in this area continues. There is a gradual shift of beds for elderly demented people from large district hospitals to pleasant local units. The work done by consultant psychiatrists at general practitioners' premises is increasing. And groups of well-trained social workers with a real involvement with mentally ill people are increasingly common.

Community care for mentally ill people is the preferred option in the majority of cases because it prevents the danger of institutionalisation. But this cannot happen without adequate professional support. This support is now being put in place. The number of community psychiatric nurses has far more than doubled. There are 480 day hospitals, well over two per district on average, and 155 district general hospitals. And by 1986 only seven health authorities had no psychiatric beds of their own.

I have talked so far about how the health service cares for those who already need help. But the health service is not just about treating disease; it is also about preventing disease and promoting good health. This will be a key theme in the future, and I believe that it is a theme whose time has come. It involves work on healthy eating and healthy lifestyle, and public education on how to avoid the greatest risks to health. All of these issues will be addressed by the new Health Education Authority which comes into being today and will be focusing particularly on coronary heart disease as its first major campaign and will of course be responsible for the AIDS public education programme.

Prevention is also linked to another theme which has assumed greater significance in recent years: it is that of women's health and how the service can meet the special needs of women. There are a whole range of issues here, but I will focus on the need to reduce the number of deaths from breast and cervical cancer. The Government are determined to reduce deaths from this type of cancer. On 25th February we announced our decision to implement a national breast cancer screening service. An extra £6 million will be provided in 1987–88 to set up a least one centre in each region. Four of these centres will be funded to provide a national training facility. The screening service will be extended over the next three years to cover all women in the age groups concerned.

Because we are determined that the service will be introduced as efficiently and as quickly as possible, we are today announcing that Sir Roy Griffiths has been asked to lead a small team to oversee the implementation of the Government's policy on cervical and breast cancer screening. Sir Roy and his team will be working with health authorities and family practitioner committees to make sure that they have viable plans, not only for installing computerised call and recall systems but also to improve take-up of screening and to follow up when women do not respond after being called for screening. Sir Roy will be making regular reports, and I will keep your Lordships informed, particularly about progress towards the target date of 31st March 1988 for the cervical cancer screening service throughout England.

I have spent much of my valuable time this afternoon speaking about what our achievements in the health service will mean for patients, because I believe that that really is the bottom line. I should now like to take a few moments to say something about the role of nurses.

I know that the nursing profession is facing a period of change and development. There are major proposals for a new system of education and training and wide-ranging discussions, largely under the banner of the Project 2000 recommendations about the nursing role in the future. I cannot comment at the moment on the Project 2000 proposals themselves as they are still out for consultation, but I should like to record our appreciation of the work which has gone into their development. I should also like to restate the Government's real appreciation of the work done by nursing and midwifery staff, and of the dedication which they bring to that work. We have done our best to show our appreciation of that work. The nurses' working week has been reduced from 40 to 37½ hours.

We have established the Nurses and Midwives Review body. The review body is currently considering the evidence for 1987–88 and will report to the Prime Minister shortly. We remain committed to the review body system. In April last year we published the Cumberlege report on neighbourhood nursing. We encouraged wide public debate on the report and are now considering all the views expressed. We shall want to build on the areas of agreement that emerged during consultation.

Last week, my right honourable friend the Secretary of State announced that he was funding a fellowship in each of the 14 health regions for a nurse to study and formulate ideas for the nursing practice for those who are infected or who have AIDS but are not in hospital. They will be tenable for three months, awarded centrally and open to any nurse in England with an interest in a community approach to the care and treatment of AIDS patients. The reports of these studies will be published as a set of collected papers.

He has also doubled the allocation to the English National Board for nurse training on Aids in 1987–88. This will enable them to develop and expand their AIDS course. We will also, in consultation with the board, fund workshops in each of the health regions to offer training to community nurses on AIDS management. The chief nursing officer will shortly be writing to regional nursing advisers about this.

This subject is so wide and so much that has happened and is happening is so exciting that I feel terribly frustrated at having to merely skim the surface of just a few of the many innovations and improvements I could have talked about. I have not even mentioned the primary care review—the first of its kind for 40 years—and the steps we have taken to improve the position of disabled people, the waiting lists initiative or, of course, AIDS. During the past two years (to the day) since I have had the honour to hold my present job, I have had the chance to see something of the results of our policies. Let me give the noble Lord, Lord Ennals, some figures. There have been 1 million more in-patient cases treated; 3.5 million additional out-patient attendances; 400,000 additional day cases; double the number of kidney patients being treated and more than three times as many coronary artery bypass graft operations performed. These are just a few of the figures. And these are not just dry figures; they represent millions of people helped by the health service.

I have met some of the people whose stories are hidden under the statistics of extra patients treated, fewer babies dying, and so on. I have talked to them and I know how much they appreciate the National Health Service. Those people are loud in their praise of the care they have received. They represent lives saved, pain eased and hope restored. I contend that our record on the health service speaks for itself.

3.32 p.m.

Lord Winstanley

My Lords, may I say at once that I greatly enjoyed and indeed agreed with the speech of the noble Lord, Lord Ennals, every bit to the extent to which I have agreed with his speech on the previous three occasions on which he has made it. I do not for a moment say that in any sense of criticism. I say it merely in order to underline a point which is clearly apparent—that debates on the state of the National Health Service have now become frequent and regular events in your Lordships' House and they have done so for the very good reason that they are necessary. Indeed, it is necessary to say the things that the noble Lord, Lord Ennals, has said, and in fact it is necessary for them to be said over and over again. Perhaps I have reminded your Lordships before of the lines from Lewis Carroll in, I think, The Hunting of the Snark, where he said: What I say three times is true". What the noble Lord, Lord Ennals, has said three times is true and what I shall now say for the fourth time is also true.

I accept the truth of everything the noble Baroness, Lady Trumpington, has said to us and I am absolutely sure that she herself is dedicated to the principle of an effective, efficient and humane National Health Service. I accept of course that the figures she has given us are true. We all know that the Government have put more money into the National Health Service; but we also know that this is a field in which we have to run extremely quickly if we are going to stay in the same place.

Modern medicine is such that, were it allowed to do so, it could consume all the resources that there are. As we learn to keep people alive and continuing to require treatment—people who would formerly have died and been no expense to anybody—and as we learn to treat conditions for which formerly we could do nothing, as we learn new methods (highly expensive technological methods) of investigation, so we increase the burdens borne by the National Health Service and of course we have to increase the resources in order to meet those burdens.

The noble Baroness constantly comes to us with good news. Let me mention just one little piece. Not very long ago she gave us a Statement which reported that the Government had decided to put a lot more money into AIDS research. That is very necessary, and from these Benches I welcome that. The noble Baroness told us that every penny the Medical Research Council had asked for had been given. I welcome that; but of course what was not said was that most of the research being done into AIDS is being done by academic staff, the cost of which is borne by the University Grants Committee; and we heard nothing about extra funds for them. So sometimes the good news that we hear is not perhaps quite as good as it sounds.

The adequacy of the National Health Service depends on four factors. These are: the number and quality of the people who do the work (doctors, nurses, chiropodists and all the rest); the adequacy of the places in which they work (the hospitals, the surgeries, the clinics, and so on); the tools with which they work (the drugs, the instruments and the highly advanced technological equipment); and, finally, the administration whereby those other three are brought together and delivered to the patients. It is my belief that the National Health Service at present is deficient in all four respects. I will take them one by one and as briefly as I can.

First, as regards the people who do the work, I do not think we should say anything adverse about the quality of those people. We have doctors, nurses and other workers in different disciplines of medicine of the highest possible standard in Britain. I think there are certain anxieties about the training of them. Some of the training seems to me to be based on work in an institutional environment, whereas so many of them actually are now required—by government policy; and rightly so—to work in the community. That is rather different and perhaps that is a matter which could be dealt with at greater length in another debate.

There are shortages, which have been referred to by the noble Lord, Lord Ennals; and some shortages are acute. The noble Lord referred to nursing. I have seen nothing more illuminating and perhaps more worrying than the paper sent to all of us by the Royal College of Nursing. I think most noble Lords have seen that and I will not weary the House by going through it but I would ask your Lordships to consider one particular fact from the information sent to us which I think shows the predicament that we are in.

The Royal College of Nursing says that in 1982 there were 1 million 18 year-olds to recruit from and by 1992 that figure will have dropped to 600,000. More importantly, the Royal College says that the number within that figure who have between five 0-levels and two A-levels, from which the nursing services recruit at present, will also fall. Nursing takes 25 per cent. of all young women in that cohort at present. As the Royal College says, there is a demographic time-bomb under nurses which will cut off its supply of recruits unless the system is reformed. It is really a very worrying situation, and words which sooth us are not really helpful. We have to recognise that there is a real problem.

I have just mentioned that the community is the place where so many work. Talking of the people and the shortages, the noble Lord referred to Salford. It so happens that I have had a letter from the secretary of the Salford local medical committee, a copy of which has also been sent to Ministers. I do not have the letter with me but I have made some notes of what I recall having been said in it. The Salford local medical committee has written to Ministers to say that Salford people can no longer be considered as having a safe and efficient health service. The letter goes on to say that long waiting times for hospital services of various kinds have resulted in a situation which can no longer be regarded as safe. I am told by the Salford local medical committee that 80 acute hospital beds will have to close unless adequate staff are provided to man them.

The committee clearly maintains—and the family practitioner committee in Salford also maintains—that the resources, such as they are, have been efficiently managed locally. The problem has been resources coming from the centre. Members of the committee believe that they manage the local resources entirely satisfactorily. Having mentioned Salford, I think that underlines the North-South divide in terms of health. Noble Lords have heard much about Sir Douglas Black's report Inequalities in Health and we have had a further report recently which has underlined the fact that people living in poor housing and underprivileged circumstances are undoubtedly penalised and disadvantaged from the point of view of health. Those are the areas. The news which I have had from the doctors in Salford shows that there is insufficient recognition of the special needs of special areas if the health opportunities are to be equalised. That is the real problem there.

Having mentioned the North-South divide, let me touch on it once again in another connection. There is an extent to which the South-East and London in particular, which we blame as being privileged, suffer from the North-South divide, because the London teaching hospitals can no longer recruit nurses of adequate standard because those nurses, if recruited, cannot find anywhere in which they can afford to live. The question I should like to put to the noble Baroness or the Minister when answering is: what is left of the old nurses homes? It is my impression that most of the living accommodation for nurses in London has been sold off or has been diverted to other purposes so that it is no longer possible to recruit within the National Health Service in London staff of an adequate capacity because having recruited them there is nowhere for them to live.

Let me move on. We have a shortage of consultants in certain specialties, particularly those specialties which do not require English. An anaesthetist who does not have to talk to patients can disappear and get a job at a much higher salary in the EC. Many are doing so; many operating theatres are lying idle, not because of a shortage of nurses but perhaps because of a shortage of anaesthetists, sometimes of radiologists to do the X-rays in rheumatic conditions, and so on. That is a big problem. There is no doubt that GPs are often in the wrong places. As the noble Lord said, we have a shortage of chiropodists and speech therapists, and overall there is a big shortage of community workers.

I must conclude. I shall merely say how wise your Lordships' House was to remove crown immunity from National Health Service hospitals. We have recently seen a case of a London hospital where the wisdom of our decision has been underlined. However, the main place in which people now work is the community, not the hospitals. The Government are right in switching to an increased involvement in community health care, but you cannot have community health care unless you have the organisations within the communities to carry out the services. We do not have those.

Moving on quickly, it is difficult to have to dismiss the universe in a few easy phrases since it is an immense subject, but there are the tools with which people work. Drugs, of course, are the principal tool and I agree wholeheartedly with the noble Lord, Lord Ennals, that there are thousands of people every week going to the chemists and saying, "Which of these items must I have?" That is a deplorable situation. I have said before and will say again that if charges have to be made, the prescription charge is an unreasonable one. Why level a charge on the random need for a prescription and the random question of whether it contains several items rather than just one? If there must be a charge, it should be a charge for the use of the service, which would be more equitable. I should prefer no charge at all.

With regard to other tools, not a week passes when noble Lords do not get requests for funds, for donations for buying brain scanners and mammography X-ray machines or renal dialysis machines. There is a real shortage of technological equipment and that shortage must somehow be remedied.

Finally, as regards administration, we moved to a situation of management, and I thought that was good. With the Griffiths report we moved to a business system. We then found that the manager left because there was so much interference centrally and we now have the Minister for Health sitting as chairman of the National Health Service Management Board. At the moment we have the most centralising Government we have had in my lifetime; power in the National Health Service is being concentrated centrally instead of being diffused out to the regions.

To end, I merely repeat what I said at the beginning—that there is a gap to bridge. It must in part be bridged by health education. My noble friend Lady Seear will deal further with that. It must partly be bridged by better use of the resources we have. I hope we now begin to move back to the original concept of a comprehensive National Health Service, free at the time of use; not free, but free at the time of use to every man, woman and child in this country. It will not be easy, but I hope I live long enough to see it achieved.