National Health Service

HL Deb 01 April 1987 vol 486 cc599-658

4.27 p.m.

Debate resumed.

The Lord Bishop of Manchester

My Lords, I begin by apologising to the noble Lord, Lord Hesketh; owing to the length of the Statement I may not be in my place at the end of the evening.

I thank the noble Lord, Lord Ennals, for introducing this debate. Even if the subject has been discussed on many previous occasions, the National Health Service is of such great importance to the life of our country that it is right that it should be under review in your Lordships' House from time to time.

Some of your Lordships may have noticed in The Times a review of the new biography of Aneurin Bevan, who was one of the chief architects of the National Health Service, in which the writer, John Grigg, said: For all its faults it has remained so popular that even fanatical anti-collectivists have felt bound to proclaim themselves its champions". I believe that to be true of its popularity, and many polls have shown this.

However, popularity is not enough. It is said that the price of liberty is eternal vigilance and so surely is the price of maintaining an adequate National Health Service, especially in view of the great pressures on it which have been outlined already this afternoon. There are the great problems of an ageing population and the development of costly hi-tech medicines, to which the noble Lord, Lord Winstanley, referred. It is vital that the National Health Service does not simply become a political football between the parties. The NHS is far too important to us all.

The main protection for the National Health Service must be a deep-seated conviction in this country that health care is vital and worth paying for by the nation; that such care should not be dependent on the ability of people to pay; that charges, if any, should be minimal; and that the principle of its being free at the point of use should be maintained. Therefore, the task facing us is to maintain the popularity of the NHS and the willingness of people to contribute to it a substantial proportion of our national income in face of the growing problems to which reference has been made.

The Churches, weaker though they are than in the past, perhaps still have some influence on the thinking of people about society. However, I believe that we have not done nearly enough over the years to give the backing to the health service that has been needed.

Yet there have been some efforts in this direction to encourage people to think about the philosophical and indeed the theological basis of the health service, and one such has come recently in the report from the Board for Social Responsibility of the Church of England entitled Not Just for the Poor—Christian Perspectives on the Welfare State. I should like to quote just one paragraph from that report because it gives a line on its approach: The social character of our human life and the responsibilities and duties which attach to it are consistently and persistently set out in biblical thought and in the development of Christian belief. Human beings are made for each other. We can find our vocation in relationships with others, in the service of others, and in community with others. The ordering of society should give expression to these basic truths about what it means to be human". The report is emphatic in pointing to the dangers of having a divided society so far as concerns social benefits and indeed health care. It states: Our Christian understanding is that, not just within the Christian community but within society as a whole, 'we are members one of another'. In the light of this, welfare provision should not just be about directing benefits to the very poor. It should be concerned with justice for all citizens and any tendency to allow the development of a socially disenfranchised sub-class of those receiving benefit is unacceptable.". I believe that the creation of the National Health Service owed not a little to the part played by those ideas in the life of our country in times past. It would be quite wrong to say that the inspiration came entirely from those who would confess that they were believing or practising Christians. That is quite untrue. Nor would it be true to say that it came from any one particular party, because its inception was widely supported by people from all parties. There was broad agreement on the ideas behind the National Health Service.

Today, while we welcome—and it is a welcome given by all parties—the National Health Service, we must ensure that this concept is not eroded in the years ahead. I believe that there is a grave danger that it is likely to be eroded unless action is speedily taken on certain fronts.

Reference has already been made to the important report some years ago about inequalities in health care—the Black Report: I think it is worth listening once again in your Lordships' House to what the Black Report said about inequalities: present social inequalities in health in a country with substantial resources like Britain are unacceptable and deserve to be so declared by every section of public opinion … we have no doubt that greater equality of health must remain one of our foremost national objectives". That has been underlined by the row that has recently broken out over the report entitled The Health Divide. I could not help noticing the remarks of Dr. David Player, the Director General of the Health Education Council, which were headlined—again, I believe, in The Times—" I was signing my death warrant". Why, my Lords'? It was because he sent copies to 10 Downing Street. It would be very sad if a report that was underlining the serious situation that faces us over inequalities in health care was felt to be politically unacceptable in any one side of the political life of our country.

The noble Lord, Lord Winstanley, referred to Salford. As some of your Lordships know, I live in Salford, and I am often present in church congregations and other groups there. In the city of Salford the inequalities in health care hit me in the eye very hard indeed. I think that what must first be given attention in the years ahead is the very serious problem of basic inequalities in health care. I am not suggesting that nothing is being done. We have heard this afternoon from the noble Baroness about some of the things that are being done. However, it is not nearly enough to meet this major challenge in our national life at the present time.

There is also the question of the effect of private practice on the National Health Service. I do not want to say too much about that topic because your Lordships recently had a debate on this very matter; but I look back to the speech made by the Prime Minister in October 1982 when she said: Of course we welcome the growth of private health insurance. There is no contradiction between that and supporting the National Health Service. It brings in more money, helps to reduce waiting lists and stimulates new treatments and techniques.". I do not believe that that observation is true. On the contrary I believe that the very rapid growth in private health care and insurance has diverted resources and increased disparities. Staff have been siphoned off; influential patients, who themselves would press for better provision and the ironing-out of inequalities, have been taken out of the National Health Service; and doctors and consultants have often been tempted away from what should be their proper duties. We should all appreciate the personal choice of those who opt for private health care for themselves and their families. I can readily appreciate that people have responsibilities; hut that is a different issue from public policy commitment. There should be no encouragement to the further growth of private health care. It damages the National Health Service and exacerbates some of the problems with which we are faced.

The other issue that I should like to raise concerns the question of how to achieve greater efficiency in the National Health Service. Surely that is something with which we are all concerned in such a vast organisation, and it is a problem that always faces us. We all ought to be agreed on the need to promote more efficiency. Yet there is the other side of that question, which is the care of those who work for the National Health Service—not only nurses (to whom reference has rightly and properly already been made this afternoon), doctors and medical staff, but also those who maintain its basic services. I believe that to go down the road of privatisation is not necessarily to take the right road at all so far as concerns basic services such as cleaning, laundering and catering. Those tasks represent work of constant volume in hospitals. The morale and pay of those who work in those services are a very important part of our National Health Service these days. The last thing we should be doing is exploiting the very low paid in a service that is meant to maintain basic health in the life of our country.

Of course the National Health Service cannot bear the whole burden of trying to achieve greater equality in health care. As we all know, it covers many different areas such as housing, unemployment and so on. Yet the conduct of the National Health Service, the way it is organised and the way in which its resources are distributed, are vital to the health care of many people in our country. Our people are our wealth. This is very closely related to productivity and concerns our ability as a nation to earn a high standard of living. I believe that in the years ahead the National Health Service, far from being a political football between the parties, ought to be something for which we all care and whose improvement we wish to see.

4.37 p.m.

Lord Peston

My Lords, I have just been experiencing the acute tension of waiting to make my maiden speech coupled with the extreme frustration of not being able to join in the previous item of discussion on higher education. The result is that I may become a burden on the National Health Service sooner than I had anticipated.

In speaking to your Lordships on the subject of the National Health Service, as a matter of courtesy I ought to declare an interest—indeed, a multiplicity of interests. My wife's career has largely been in the National Health Service: as a speech therapist, as the secretary of one of the first community health councils, and now as a part of the administration of one of London's major teaching hospitals. Like many other academics, I have sat on research committees of the MRC and the DHSS. I was also a member of the Nuffield Foundation inquiry into pharmacy and am now a lay member of the Council of the Pharmacy Society of Great Britain. I am proud to say that I was a founder member of ASH (Action on Smoking and Health) and I continue to support that body.

I am not here to boast of my credentials however. In my maiden speech I want to emphasise a commitment to the National Health Service as such, the principles and values of care and concern with fellow human beings and the devotion to duty that lay behind the setting up of the service. Those are values which I believe continue to permeate the health care profession despite the occasional cynical dissenting voice to the contrary.

Let me mention what seem to me to be the key principles, the first of which is universality. The NHS is available to all citizens; it is not limited to those with the ability to pay. Therefore, ipso facto, it is redistributive. On this occasion again I must refrain from entering the debate on inequality and health, fascinating though it is.

The second principle is that the health care offered should be that which is most appropriate to the patient; if you like, the best. Even though in this case a private alternative is available, in fact in health care one cannot buy a better treatment than is offered by the National Health Service. Of course, one can purchase more privacy, luxury or immediacy, but that is another matter.

On waiting lists, the present position is not good. One can even say that it is intolerable, especially for what one might call straightforward or bread-and-butter surgery which can so enhance the quality of life. I for one, would give the highest priority to the use of additional resources for that purpose. Unless I misunderstood the Minister, she was taking the same view in her contribution to this debate.

To me, most importantly, the health service offers to the patient and to his or her family a kind of certainty—given the anxiety that illness causes, together with economic worries arising from loss of time at work—that doctors, nurses and most other health care professionals are accessible without direct charge. All this involves vast resources. No one is or ever has been ignorant of that. Indeed, the whole purpose of having a system of taxation is to finance activities for which charging at the point of service is inappropriate. It is economic nonsense to suggest otherwise. Moreover, since we all require health care at some time in our lives, and benefit from the treatment which others receive as well, public finance—which one can interpret as a form of insurance system—is the best way of paying for it all.

Nonetheless, resources are not unlimited. The economist must emphasise his dismal science and say that he is aware, as I am aware, that no matter how rich we become, there is no limit to our demand. In the case of the NHS I would go further. I would expect the demand for health care to rise more rapidly than income. I would also expect technical advance to be more rapid. In addition, the expectation of life has risen, and I would hope to see it continuing to rise.

Putting all these factors together, there can be little doubt that there must be some tendency for health's share of public expenditure to rise, and indeed for the share of health expenditure in gross domestic product to rise. I agree with the right reverend Prelate the Bishop of Manchester that it is undesirable for those who work in the NHS to go on subsidising the rest of us. It is surely reasonable for them to wish to participate in whatever national prosperity there is available.

On resources, there are no easy ways out. Those who place their faith in new forms of finance are chasing a chimera. Paying for things is always difficult. The pursuit of efficiency is highly important. Some of us have been pressing this for years. But while it is a duty to use available resources as effectively as possible in the interests of a patient, it is impossible to ignore the fact that in too many areas there are simply not enough resources in the first place.

I am aware that I have been moving too close to controversy and must start to draw back. However, I must raise the topic of prescription charges which others have mentioned. I give my support to what my noble friend Lord Ennals has said. As an economist I am never doctrinaire on sources of funds. If prescription charges are a source of finance without adverse side-effects, why not use them? The problem today is that they have risen so much in real terms that they may, and indeed in my view must, be harmful. It is entirely right that the medical profession should be aware of the expense of items and should not prescribe what is dearer when what is cheaper is just as good.

I supported the introduction of the limited list and will continue to support greater rationality in prescribing. But high prescription charges—and there is some argument about the exact figures—even though they fall on only half of all patients, go further than that. They may cause the doctor to prescribe too much at a time and the patient not to purchase what the doctor regards as necessary, therefore adding to the so-called problem of non-compliance.

The Nuffield Foundation report was surely right to recommend an enhanced advisory and counselling role for the pharmacist. But that was to help and not to get in the way of the general practitioner. There is now a growing tendency for patients to ask the pharmacist for advice because the total cost of all the items on the prescription form is more than can be afforded. This places the pharmacist in the impossible position of having to respond to the question, "What does the doctor want me to have?" Following on from that, in some cases prescription charges may cost the service more than it says. It seems to me therefore that the time has come to look at them again in a dispassionate and open-minded way.

If Ministers ask the usual question, "Where will the money come from?", for once there is an easy answer. Let me suggest that they raise—or advise their right honourable and honourable friends to raise—the excise duty. That is a financial policy which has clear health benefits.

Those of us who were brought up in the liberal —with a small "I"—tradition of western civilisation believe most strongly in the value of debate and criticism. But we sometimes forget that we need on occasions to support and praise our institutions. My purpose in intervening today has been to do precisely that. Those who claim that nothing radical or progressive can be achieved by parliamentary democracy can be rebutted in many ways, not least by the foundation of the National Health Service.

In conclusion, I offer my support and thanks to all those in the health service—the doctors, nurses, ambulance drivers, speech therapists, pharmacists, auxiliaries of all kinds, porters, clerks and, not least, the administrators. Together, they comprise a health care team of which we can be proud.

4.47 p.m.

Lord Nugent of Guildford

My Lords, perhaps I may begin by thanking the noble Lord, Lord Ennals, for raising this debate this afternoon and for limiting it in time. I am afraid that I have to make an apology; I also have to leave before the debate concludes. I hope that I may be excused.

My first pleasure is to congratulate the noble Lord, Lord Peston, on his maiden speech which, he will have observed, was much enjoyed by all sides of the House. He contrived the right balance between expressing some of his views—which are obviousy strongly held—without being controversial. If I may say so, we all felt that he made a most valuable contribution to the debate. We look forward to hearing him on many occasions in the future.

The noble Lord, Lord Ennals, made a wholesale condemnation of the Government's record in the health service in every aspect of its work, referring to shortfalls of all kinds. My reply to that is yes, of course, it is not perfect; and, yes, of course, much remains to be done. However, I would say—and with his ministerial experience the noble Lord well knows this—that in judging this Government's record on the health service we must have regard to the reality of the position from which the Government started.

Over the past eight years the achievements are impressive. If we look at the record since 1978, the last full year of the Labour Government, there are 4 million more patients being treated every year. They comprise in-patients, day patients and out-patients in hospitals. It is a very substantial number. But that is what the health service is all about. There are 12,000 more doctors and dentists—a quite substantial figure. There are 63,000 more nurses and midwives. There is more cash to the tune of 26 per cent. plus in real terms. I ask the noble Lord, Lord Ennals, to take note because he rubbed our noses in the fact that the EC had observed that we needed an extra 3 per cent. per annum in real terms in order to achieve the health service that we should like. This 26 per cent. in eight years, unless my arithmetic is wrong, is more than that figure; so we are doing something. I agree that there is much more to be done. This is as good a record as any government have achieved.

I should like to congratulate my noble friends Lady Trumpington and Lord Hesketh, and in particular my right honourable friend Mr. Norman Fowler, on what they have done. In particular I join with the noble Lord, Lord Peston, in thanking and congratulating the 800,000 dedicated health service workers who make this tremendous service possible. Of course, there are still complaints and delays.

It is interesting to look at the whole picture. I should like to pick up two points made by the noble Lord, Lord Peston. I was going to make precisely the same points. There are two major factors which will always ensure that demand exceeds supply. We are a longer-lived population; our expectation of longevity grows and grows. I become 80 this year and I confidently expect, the Lord willing, I might even get to 90. Who would have expected this 50 years ago? This is the same for everyone.

As the noble Lord quite rightly said, the older we get the more support services we need, which makes greater and greater demands. Alongside that there is the continuous stream of improvements in surgical and medical skill, not to mention anaesthetics, radiology and ever more ingenious drugs. Yesterday's incurable is today's curable. What wonderful news that is for everybody, and it is a great credit to the National Health Service.

I have had the interest in Guildford of seeing on my doorstep the development of one such scheme. Guildford and Edinburgh were chosen as the two pilot scheme sites for mammography screening following the success of the scheme in Sweden. The team in Guildford consisted of a surgeon with an international reputation, Mr. Boulter, who is an old friend of mine, a similar star radiologist, Professor John Price, a pathologist and an administrator.

The team spent two years making its plans on paper and it went into action about eight years ago to call up all women in its area between the ages of 45 and 55. It won an excellent response. The administrative work of call and recall is formidable, but it was successfully coped with. Patients with incipient lesions were treated with radiotherapy and success achieved with—what is even better news—ever-decreasing doses of treatment. As the noble Lord, Lord Ennals, will know, often in the past radiotherapy did more damage than benefit. But the team had the most valuable experience in that respect.

The experiment was completed, and it was critically structured with some areas where there was no such treatment to see what mortality was in those areas. The experiment proved that early diagnosis and treatment save much mortality and very much suffering. Hence the report of Sir Patrick Forrest and the health service adoption of the policy for the national scheme for the whole country as rapidly as possible. I should like to make the point to my noble friend Lord Hesketh (I am sure he will take it away) that the training of the teams for the 100 centres to he set up will be formidable. It will be a major undertaking which will need the greatest possible attention.

This is a wonderful story. Many such things are happening today. Each one makes greater demands on the health service and gives rise to greater cost. I have mentioned the scheme in Guildford because I was lucky enough to see it. However, when we think of the cost and the burden of the research work and the treatment for AIDS, which are bound to grow and grow, we must make the point that this demand will continue and continue. There will always be some delays and shortages. Even with the present Government, who have a very good economic record whatever noble Lords opposite may say, it is possible only to increase the funding of the health service by a certain amount year by year. Therefore, there will always be shortages somewhere. To go at a faster rate is to court disaster and leads to overspending; you end up not only without an increased health service but a sharply reduced one.

The experience of 10 years ago, which the noble Lord, Lord Ennals, so painfully had himself as the Secretary of State, confirms that this is what happens. He actually had to cut the health service in order to bring it within the economic requirements of the day. These are the harsh realities of life and good intentions do not alone provide the health service of our dreams. We have to watch all the time how we manage to provide the money for such a service.

In my contribution to this debate I should like to say that by comparison with the record of any government of the past, and especially the government of noble Lords opposite, the record of this Goveernment in relation to the health service has been a good one. Not everything has been done; masses more remains to be done. However, I believe that this Government deserve a major measure of congratulation on what they have achieved.

4.55 p.m.

Baroness Seear

My Lords, I should like first to apologise to your Lordships' House for the fact that, owing to an engagement which I had accepted long before I knew that this debate was to be held, I shall not be able to be here for the reply from the Government Benches later this evening.

It gives me more than usual pleasure to congratulate the noble Lord, Lord Peston, on a well-informed and balanced maiden speech. We look forward to hearing from him on very many occasions. He is a necessary addition to his party's strength in this House. It gives me special pleasure because he was a colleague of mine from the London School of Economics before he left us to go to other places. Indeed, we are almost reaching the point when we need, or can justify an ex-LSE House of Lords society—something which once upon a time would have been considered a contradiction in terms.

In the brief time allowed to me I should like to say something about the paper, The Health Divide, referred to earlier this week and to which passing references have already been made. We cannot pass a debate of this kind without making further comment on this very important paper. It shows beyond a doubt the growing social inequalities in health and the extent to which these inequalities are due to not only failures in the health service (perhaps inevitable failures in the health service) but also to a whole range of social issues which require attention on the preventive side.

We have to remember that although the National Health Service spends most of its time curing people, it is far better to prevent than to cure. If some of the advice given in this report was followed up, prevention would be a great deal more effective and would in turn save resources. It is highly important that this report should be properly followed up. It is well-documented; the evidence is beyond question, and the picture that it shows is of quite unnecessary ill-health and early death arising from a whole variety of causes, some of them preventable. In a debate of this kind this is a matter which we cannot possibly ignore.

Having said that I must also say that we on these Benches deeply regret the fact that the Government have seen fit to change from the Health Education Council to the newly appointed Health Education Authority. We ask them to give the true reasons why they have seen fit to make this change. We are also much concerned about the change in the nature of the work to be done by the new authority. The Health Education Council had the duty not only to educate but also to promote good health. In the light of the information contained in the report, there can be no shadow of doubt that health promotion, as well as health education, is urgently needed.

Health promotion is part and parcel of the preventive work which I am sure all noble Lords agree needs to be done. Why then have the Government said that the new health authority will not have a promotional function but only a much more limited educational function? This would appear to be a step backwards and a step which we greatly deplore. We also deplore the fact that the new authority is to be a limb of the DHSS and is not to be an independent body. Surely in a matter with the ramifications for health that the National Health Service has, serving so many people across the country, it is extremely important that there should be an independent body able to speak its mind based on the information that it collects—a body which is seen to be separate from the DHSS. To have moved this body into the DHSS, or rather to have moved it directly under the DHSS, is surely a retrogressive step. We should very much like the Minister to explain why the Government thought that it was necessary to take this step.

It seems to me that this is yet another example of this Government's extraordinary determination to centralise wherever possible. That is a most extraordinary development for a Conservative government. Whatever the demerits of previous Conservative governments, nobody could have said that they were centralisers, but this Government seem to wish to centralise everything they can lay their hands on. They have now centralised this council. We deeply regret that and we should like to know what the justification for that was and to say that we believe that a powerful independent body which could voice its findings about the state of health in this country is a very necessary part of the whole machinery for making the National Health Service and society as a whole work properly.

The question of machinery is a big question which in the tail-end of a Parliament, as this can now presumably be described, probably must be a matter to be discussed in the future. However, looking at the problems of the NHS, is it really sensible to have the great variety of things which are covered by it at the present time in one department, one huge DHSS? Surely there should be a Minister for the National Health Service who could concentrate on the problems of prevention, cure and health. Surely that is job enough for one man. Why cannot it be under one person? Why does it have to be dealt with by a department which handles such complex matters as pensions and the payment of benefits and general social services? Surely the NHS is a job in itself which a Minister should do? Those of us who try to deal with government departments know what a very great advantage it is if one can deal with a Minister whose attention is entirely focused on one particular field of work.

In the two or three minutes left to me I wish to pick up some things which have already been said about community care. Moving people from institutions to community care is generally approved of. I urge the Government to look at this very carefully indeed. I suspect—and I am not qualified to say this with any authority—that there are some people, especially the mentally handicapped, for whom moving out of an institution may be very difficult indeed. They may have been there for a very long time and have come to terms with the institution and have made a world for themselves inside that institution which they can understand.

While I and my noble friends on these Benches are entirely in favour of the general thrust towards community care, we should like to state a reservation that there should be careful examination of that residue of people for whom it surely will not be suitable. Consideration should be given to how their needs will be met.

For those who come under community care there must be community care, not just a pushing of people out of institutions back into society, into bed and breakfast accommodation from where they wander around during the day trying to find somewhere to go and something to do. That is not community care. Nor is it community care to expect families, however devoted, to take on the total caring of people who come out of institutions.

For 20 years I have been chairman of the National Council for Carers and the Elderly Dependants and I know that the problems of the carers are acute, unless they are very well supported. It is hypocrisy to talk about community care unless the Government are prepared to provide a far larger home-help service, a far better local nursing service, day centres, respite centres and respite opportunities so that people can put those for whom they are caring into some kind of home for two or three weeks in order that they can get away. Help should be available with sitting-in. Indeed, a whole range of things are necessary. We need a charter for carers if community care is not to create almost more problems than it solves.

5.5 p.m.

Lord Hunter of Newington

My Lords, may I first add my congratulations to the noble Lord, Lord Peston, on his maiden speech. Preventive medicine, which has been coming to the fore in this debate, if successful saves lives and prevents ill-health. It also saves resources, but what is distinctive about it is that in order to be successful it requires the co-operation of individuals and often requires the support of the community.

Sometimes success depends on one thing; for example, inoculation. Sometimes it depends on a combination of inoculation, public health measures and thereapy. I shall give a number of examples. Fluoride prevents dental caries. A poll conducted in February this year by the National Association of Health Authorities found that 76 per cent. of people thought that fluoride should be added to the water supply and 15 per cent. were against it. What do we do? If there is a decrease in dental caries in the young, there will be more dental capacity to look after the increasing number of old people, perhaps at no additional cost. Will the Minister please tell us how many local authorities at the present time add fluoride to the water supply?

The virtual elimination of tuberculosis required the combination of preventive inoculation, public health measures and drug treatment. The result is that there has been a massive redeployment of staff and hospital resources which were previously committed to the treatment of tuberculosis. This made more room for the long-term sick and many others. However, in order to maintain this situation there must be constant vigilance and preventive measures, urgently applied if necessary; and this means public co-operation.

Inoculation is very effective in preventing whooping cough and measles. With whooping cough there has been some damage in the past. As your Lordships know, the resultant campaign, conducted because of sympathy for the sufferers, has had a devastating effect, lowering the whooping cough inoculation rate and influencing the measles inoculation rate which at the moment is perhaps about 40 per cent. The children who are not inoculated are exposed to risk, particularly when they go to school. The risk is serious, the worst complication being meningitis. Should we require inoculation against measles of all children before they go to school? In the United States this has virtually controlled the disease. However, this is a matter for the expression of public opinion. The means to do it are available and can be provided by the National Health Service. Perhaps I may ask the Minister for the present inoculation rate for measles.

In recent weeks the noble Baroness, Lady Trumpington, has made a number of announcements about funding. These have been referred to. The most recent were announcements about research into AIDS and screening for breast cancer. Additional sums have been made available for cardiac surgery and screening for cancer of the cervix. In these days of patient awareness, the demand to see patient records and the desire of any patients to make their own decisions about treatment, and also the increasing threat of litigation, I thought it might be helpful to analyse these situations just a little further, remembering perhaps that one is talking about guidelines and evidence and that the diagnosis and treatment of individual patients requires very specialised skills. This is the kind of evidence that is taken into account by courts of law concerned with claims for negligence.

Regarding AIDS, the substantial sums mentioned by the noble Baroness, Lady Trumpington, were for research to try to find a vaccine. Additional sums were also provided for the care of sufferers. There is no treatment—only prevention by individual decision.

With regard to carcinoma of the cervix, it took 50 years from the time that Marie Curie discovered radium until an effective safe treatment was developed which did not cause damage to patients or doctors. Here the emphasis is on early diagnosis because an effective safe treatment is available. The substantial sums mentioned by the noble Baroness and the noble Lord, Lord Nugent of Guildford, for screening for carcinoma of the breast are again given for different reasons.

In 1971 the first results were published in the United States showing that the early detection of breast cancer had a mortality one-third lower than undetected cases. These results have now been confirmed in Sweden, the United Kingdom and Canada; but the importance of this finding and why it is being strongly supported is because radical excision has not been shown to be of greater benefit than simple excision, and radiotherapy in some cases is disappointing. Expert advice is required in individual cases; but this investment in screening by mamography is of great importance. Again, it requires co-operation. As we recognised, the sums voted so far are modest—one centre for each region. What of the future? How rapidly can this be spread? They are matters of public concern and public opinion.

Hepatitis B presents a different problem again, and I suspect that it would have been very much in the public concern if AIDS had not happened when it did. The virus is known, the diagnostic tests are available and vaccines prepared from antigens in the blood are already on the market. The antigen which is now licensed in Britain is perfectly safe for infants. If we could immunise the entire world population, and immunise babies born to carrier mothers at birth, all cases would disappear in two generations.

In practice, what can be done? Ideally in Britain we should screen all mothers and immunise the babies of carriers at birth. That would be ideal, but it seems absolutely essential that all mothers of Chinese, African, Indian and Asian origin should be tested. What responsibilities do we have? Is this a health-promoting exercise which should have a high priority? Will the Minister say what is the Government's policy as regards this serious matter?

Additional sums have been set aside for coronary by-pass operations. But the sums became available for a different reason again. Controlled clinical trials were started and then abandoned, such was the immediate success of the operation.

Thinking of these matters which are examples of health measures, where informed public opinion is necessary to influence the Government on the expenditure of limited resources, one is considerably distressed by the changes that are taking place in public opinion in relation to medicine.

As the noble Lord, Lord Pitt, said in the debate of the noble Lord, Lord Hacking, on civil liability, the United Kingdom is following the American pattern in many fields and solicitors are advertising for dissatisfied patients to consult them on a non-fee basis. I agree with his view and those of the British Medical Association on the need for no-fault compensation.

We in Britain are fortunate in having general practitioners available as a gateway to the health service, and it is hoped as a guide, counsellor and friend to the patients. The importance of this cannot be exaggerated. When this is absent, patients may choose their own doctors perhaps for the wrong reasons, and they are often actually aware that the meeting has a financial basis. As a result of this, relationships can be clouded and doctors tend to do many tests to cover themselves because of the possibility of litigation, perhaps when such tests are not strictly necessary. The results are further increases of costs. I sincerely hope that that spiral does not happen here.

There are two vitally important areas for all members of the public to have an active interest. First the positive approach to their own health and measures about their lifestyle; and secondly, an opinion about matters of the kind that I have referred to earlier in my speech where public opinion can make the difference between success or failure.

5.14 p.m.

Lord Soper

My Lords, I begin with congratulations on my own part on the maiden speech of the noble Lord, Lord Peston. It was admirable and, if I may say so, one of erudition and warmth, and I am sure that the House will be in his debt on many occasions in the future.

I have said often and say again that in my experience the welfare state is the most Christian thing that has happened in my lifetime. The older I become the more convinced I am that that is not untrue. It is for that reason that I am more concerned by the kind of erosion of its principles and the occasions of default in its practice which were enumerated in a bristling catalogue of information about the welfare state and the National Health Service in the opening speech of the noble Lord, Lord Ennals, and for which I was extremely grateful. The accusations have not been met.

I presume to take what I have to say from an experience which is mine. I was instrumental in founding the West London Day Centre some 15 years ago. I have looked into the experiences of that day centre for the kind of evidence which I presume to present before your Lordships in the realm of the National Health Service, and in particular in the difficulties which it faces and the omissions for which I believe there must be a speedy remedy.

The first is the question of prescription charges. Your Lordships have been told this afternoon that since the last Labour Government the charges have risen from 20 pence to £2.40. The British Medical Association and British Dental Association have passed comment which I think is worth repeating. The British Medical Association states that there is a large measure of deterrence as prescription charges increase, and that more and more people who ought to be treated are making the choice—however silly and economic it may be—to refuse or not to accept the responsibility of doing what the doctor says when it will cost them something to do it.

The British Dental Association has been more specific. Only the other day it said that the prescription charges are excessive and socially divisive. I found that to be the experience of many people in the day centre. I believe that that fact has been enlarged and established in speeches which have been made in your Lordships' House this afternoon. I believe that the whole concept of the welfare state is imperilled by the prescription charges.

Secondly, as I looked into the experiences of those who come into the welfare centre, I was impressed by the long delay, accompanied by much suffering and pain, which is the accompaniment to the kind of problem about which your Lordships have heard a great deal today. There are 600,000 or more people who need relief from pain and who are denied access to the opportunities of that relief.

Representation of fact by the St. Thomas's Hospital implies that of the 10 health authorities in London and the South-West the cut in beds will be by 15 per cent. to 36 per cent. before 1993. I am a little allergic to statistics; one can prove almost anything by them. However, I suggest that the evidence is incontrovertible: that the absence of opportunities at the emergency state has been increased and is constantly being increased.

I have a simple comment to make about that. Pain is a sufferable but sometimes an almost insufferable condition. Noble Lords will not think that I am sentimental if I remind myself that there are a great many people who are in considerable pain every day of their lives and in a society which could afford, if it was only conscious enough of its moral responsibility, to do more for them than to say, "You will be postponed in your treatment for so long". That time seems to become longer as their pain increases. This is, I believe, an experience in that the microcosm of the West London Day Centre is represented in the macrocosm of society as a whole.

There is an even more serious element. It will not surprise your Lordships that quite a number of people, when you mention in this day centre the welfare state or the national health condition, regard it as a rather sick joke. They feel that they have no part in it, that they have no access to it; and in particular this is true of the homeless. I shall read to your Lordships, if I may, a short excerpt from a publication by UNLEASH, which is the United London Ecumenical Action on Single Homelessness, an imposing statement of participation. There is an even more significant statement in the publication itself: To be single and homeless for any period of time is to endanger one's own health to a far greater degree than normal; yet normal health care is precisely what is commonly denied to single homeless people. Numerous studies have shown that homeless people not only suffer from higher levels of illness and handicap, but also are likely to have much greater difficulty in gaining access to health services.". That is the experience that we have undergone in the centre to which I refer.

One of John Wesley's injunctions to his followers was in a document called Twelve Rules for a Helper. One of those rules which was impressed on me when I was a student was: Go to those who need you, and specially to those who need you most". I believe the homeless are those who are in the greatest need. Remember, if you will, that a great many of these homeless are not destitute in the old-fashioned Dickensian sense. They are without a house to live in or an accommodation in which they can lay their heads, and they find it increasingly difficult to believe that the National Health Service really is concerned with the overall well-being of the community as a whole.

I do not say that with any rancour. I say it because it is an increasing experience of those who are not particularly susceptible to all the statistics of the increasing amount of money that is given to the health service; whereas there seems to be an ever-increasing divide between those who have, and have the opportunity of having more, and those who are impoverished and find very little access to those means of the welfare state which are often trumpeted as their opportunity.

I believe in the welfare state because I believe that it is substantially the only way in which you can create and maintain community. I deplore the invasion of privatisation which is a thoroughly un-Christian word, and the invasion of what is called caring capitalism, which in my judgment is a contradiction in terms.

I therefore press the House, if I may, that we take much more seriously our opportunity of doing two things: of spending more money in ways which have been academically set forth in your Lordships' House this afternoon by which we could immensely improve the whole working of the health system if more money were centrally offered to those projects which are now in decay; secondly, to rededicate ourselves to the concept of the welfare state, which is the only way to rescue the health service as it is now from an increasing polarisation and the decreasing sense of its commitment to one of the prime requirements of a civilised society—to care for all, and to expect from all that which they can contribute to that care.

It is in that respect that I offer these comments. I hope that out of the conversation this afternoon there may be more caring, and in that caring a new dispensation for the welfare of those who are our brothers and sisters and to whom we owe, and should continue to owe, the duty of comradeship.

5.25 p.m.

Baroness Cox

My Lords, I too congratulate the noble Lord, Lord Ennals, for initiating a debate which covers so many matters of great and urgent concern. I also congratulate the noble Lord, Lord Peston, on his excellent maiden speech. I must apologise if I have to leave just before the end of the debate due to a longstanding commitment to chair a meeting which cannot take place in my absence. I apologise.

While this debate gives my noble friend the Minister a most welcome opportunity to emphasise the very real achievements of the Government, it also provides an opportunity for other issues to be raised for consideration and, hopefully, for reassurance by my noble friend. I shall confine my contribution to just two issues: community care, and my own profession of nursing.

The principles behind the policy of community care are commendable. Of course in appropriate circumstances it is preferable for people to enjoy the greater freedom and independence of life in the community rather than to become dependent and institutionalised in long-stay residential care. In many places arrangements for transition from residential institutions to life in the community are imaginative, sensitive and finely tuned to the needs of each person. Where this is happening, this is good news.

However, sadly there are also many reports of real suffering due to unsatisfactory transfer to community care. The people involved are very vulnerable: they include the mentally ill, the mentally handicapped, and the elderly. Many have been residents for years, even for decades, in places which often had the good characteristics of the term "asylum"—institutions offering refuge, security and care in a protected environment. For thousands of residents their residential institution has been home; it has been their world. For them, to be moved out into the community can be a dislocation of their entire way of life and of all the human relationships which make life meaningful.

There is no shortage of evidence of concern for real suffering. Organisations such as RESCARE, the National Society of Mentally Handicapped People in Residential Care, and the National Schizophrenia Fellowship have been urgent in their pleas to rethink the massive shift to the community, or at least to slow it down until really adequate alternatives are available. Also, the Audit Commission report Making a Reality of Community Care, and the report published by MIND, When the Talking has to Stop: Community Care in Crisis, both discuss problems for those who have already been discharged into the community—problems caused by indadequate funding and staffing, fragmentation of responsibility and poor communication.

In the temperate words of the Audit Commission report: It is not surprising that joint planning and community care policies are in some dissaray.". The MIND report claims rather more graphically: Community care is not dumping all responsibility onto informal carers, in the vast majority of cases women; it is not pushing people into bedsit poverty and isolation; it is not hostels which, rain or shine, turf people out at eight in the morning until five at night; it is not homelessness and destitution … scandalously, this is what it means to so many people at present.". I am aware that the Government have set up an inquiry into community care to be chaired by Sir Roy Griffiths, but can my noble friend the Minister indicate what steps are being taken now to alleviate the anxieties and sufferings of people such as these?

This leads into my second topic, nursing. A part of the solution to some of those problems could lie in the development of neighbourhood nursing services as proposed by the Cumberlege report, and endorsed by the report of the Social Services Select Committee on Primary Health Care. Perhaps 1 may ask my noble friend the Minister whether the Government will at least consider setting up some pilot or experimental schemes embodying some of their recommendations, such as the establishment of community nursing services in smaller units; or the establishment of some nurse practitioner posts with specified powers of prescription; or the development of some schemes with appropriately trained nurse practitioners working with GPs to provide a complementary service for elderly people; or, finally, a manpower planning exercise on the training and supply of community nurses. Such measures could not only involve improvement in community care but could also lead to more effective nursing, which would enhance professional job satisfaction. I think some reassurance from the Government on those lines would mean a great deal to the morale of the nursing profession.

It is urgent, because nursing in general is in a state of crisis, as the noble Lord, Lord Ennals, emphasised. It is in a crisis of recruitment and a crisis of training. One-third of students fail to complete their training. There is a crisis of retention of trained staff and a crisis of shortages of staff in many parts of the country, shortages so extreme that wards have had to be closed. Morale is at an all-time low in many places. That is not surprising, especially given the pay and conditions of service. A qualified staff nurse, after over three years of training, earns a mere £6,475 a year—now much less than the new scales for non-graduate teachers.

Conditions of service involve work which is inherently stressful. For example, research has shown that student nurses, caring for patients who are in severe pain or who are dying, experience stress levels comparable to those occurring during major personal tragedies, such as bereavement. There is the unremitting responsibility of being in the front line of patient contact, where errors may mean serious physical harm and even death.

I ask my noble friend what reassurances the Government can give to the nursing profession. Recent pay awards recommended by the pay review body were not given immediately in full. They were staged in a way which appeared churlish and resulted in a real loss of salary of several hundred pounds for each nurse.

My noble friend may respond by pointing to an increase of over 50,000 in the numbers of nurses and midwives. But those figures cannot be taken at face value. Nearly half of that increase was needed to compensate for the reduction in the working week, and the remaining real increase of about 27,000 also needs to be put into context. For example, those figures include untrained staff, and also much of that increase had already taken place by 1983, since when there has not been much growth.

However, as we have heard, there is great and justifiable pride in the increase in the number of patients treated. For example, in-patients have increased by 18 per cent. and day patients by a staggering 71 per cent. But that quicker and more cost-effective throughput means that patients are in hospital for a much shorter time, during which they are much more dependent and require much more intensive nursing care. The increase of around 7 per cent. of qualified nursing staff between 1978 and the present has to care for far greater increases in patient numbers and needs. This is often associated with great stress for the nurses and what is in technical jargon often called "burn-out".

It is not surprising that nurses are leaving in droves. Even more worrying perhaps is the decline in new entrants, with a drop in the number of school-leavers, but also, sadly and significantly, fewer of those choose to go into nursing. There is a real danger that if the Government do not respond appropriately to these crises in the nursing profession there just will not be enough nurses left to staff the NHS. The National Health Service itself could then face a crisis of unprecedented proportions.

I appreciate the reassurances given earlier this afternoon by my noble friend, but I also urge him to consider very carefully the questions which I have raised, so that not only can nurses be encouraged but also those for whom they are responsible can benefit from the highest possible standards of health care which we as a nation would wish them to receive and which the National Health Service was established to provide.

5.34 p.m.

Lord Porritt

My Lords, thanks to the initiative of the noble, and perhaps this afternoon slightly bellicose, Lord, Lord Ennals, we are again discussing the state of the National Health Service. Medically speaking I feel that that state is such as to give rise to acute anxiety. The NHS seems to be suffering from an extensive number of serious diseases.

There comes immediately to mind a severe lack of financial sustenance; repeated and continuing attacks of acute wasting disease; painful disability from increasing rigidity; an apparently unlimited degree of giantism as evidenced by overmanning in excelsis and overbuilding in extenso—big is not always beautiful—plus excessive doses of misplaced and blinkered enthusiasm derived from short-sighted estimates and contorted values. Add to this psychologically an insidious growth of material and monetary motivation which has been steadily eroding those idealistic and humane characteristics with which the service was endowed when it was born. All this being so, I cannot help feeling that there is an urgent case for emergency surgery, followed by prolonged intensive care and after that a long rehabilitation.

I trust that your Lordships will not feel that it is in any way a frivolous contribution with which I have started my words in a serious debate. I can assure the House that the words I have used are not lighthearted. In fact it was with rather a heavy heart that I finally decided to take part in today's proceedings and risk once again skillful brickwall treatment in an attempt to get beyond the hotchpotch of piecemeal and hand-to-mouth methods by which the affairs of this colossal organisation that we call the NHS is managed today. We should get back to and get down to an unbiased, wide-ranging, long-term strategy for the future. Only by such a non-partisan, non-party and, I humbly suggest, non-political approach can we hope to save the best of this fine idealistic concept which is both financially and administratively slowly strangling itself in front of our very eyes.

One of the advantages of growing older—I am pretty well ahead of the noble Lord, Lord Nugent—is that to some degree one can see things more clearly in perspective. Some 40 years ago, admittedly on the outskirts, I was involved indirectly and to a very minor degree in the early days of the NHS. I met socially, got to know, admired and liked Aneurin Bevan. His Welsh oratory, his shrewd political sense, his opportunism and almost evangelistic enthusiasm, singled him out as a very special individual. His Achilles' heel was his quite rigid socialist idealism. His health for all given free (so-called) at the point of delivery was simply against human nature. Financial stringency did not take long to make its unwelcome appearance and early charges for spectacles and dentures led to Bevan's resignation—a loss that must always leave, to my mind anyway, an historical query.

Ten years passed. The National Health Service seemed to prosper, largely owing to the loyalty of a not originally very approving army of general practitioners. The profession decided to see how it could improve the service after this initial experimental period and so the Medical Services Review Committee was set up. I was now very directly concerned as its chairman. That report, representing the views of the totality of the medical profession at the time, was constructive, comprehensive and practical. It was shelved by the Government.

The committee made three major proposals, among some 50 altogether. The first was agreed to soon after the publication of the report: namely, that the original three parts of the NHS—general practice, hospital practice and public health (what we now call community medicine and community care)—should be united to effect economies in administration and personnel. The remaining two, another 30 years on, still remain unsolved or unconsidered; namely, that the capitation system of remuneration of doctors is inferior to other methods. No other country in the world has followed our lead in this respect.

Secondly, the detailed administration of the service must be at the periphery, where doctor and patient, supplier and consumer meet. This is where detailed methodology should be dealt with: not at the one colossal monolithic centrepiece of the NHS as it stands at the moment.

So here we are now, with vastly increased commitments in responsibilities, buildings, equipment and staff of all sorts, struggling on with roughly the same old organisation, concerned chiefly with financing a system that has grown out of all recognition and improved to an almost magical degree over the intervening years. Why must the health service be a party concern? No party owns the national health. I must admit to being embarrassed and often disappointed when I hear able Ministers beating a party drum, metaphorically, to drown out the querulous and petty criticisms of an equally able opposition, as if the only solution to all the ills that beset the National Health Service is more, more and more taxpayers' money.

As I have pointed out on previous occasions, there are many other ways of raising money for such a vital matter as the National Health Service if only these could be considered in an open-minded, unbiased and long-term manner. Money, essential as it is, is far from being the only problem to be faced in dealing with a human clientele and a humane profession. The problems are important enough to require—even, I would say, to demand—wholehearted co-operation on the part of all concerned.

Why is it beyond the power of government—any government—to set up an independent group, preferably of people with a philosophical outlook, to advise medically and economically, to investigate the whole infinitely complex scenario, to be courageous enough to dismantle machinery where necessary and to plan a fresh start from basic principles?

Purely as tentative suggestions, I would envisage, as mentioned by the noble Baroness, Lady Seear, the study in depth of certain simple and fundamental questions. For instance, why must pensions be linked with health? There should be a more precise definition of health and illness: that is to say, preventive measures and therapeutic methods. Is the capitation system the best means of remunerating doctors? Is the technologically and scientifically trained doctor of today best suited to serve the better informed and more demanding patient of today? Why, in hospital management, administration and so on are 10 people required today to do the work of one 30 or 40 years ago?

Why do highly trained nurses have to become business managers in an office in order to gain promotion? Should the large modern hospital entirely take the place of the hostel-type of hospital, which deals so well with the geriatric and the mentally handicapped, and of the small urban and suburban hospital? As selective medicines become necessary, thanks to the amazing developments of modern therapy, how and by whom is the selection process to be managed? Also, is today's patient happier, either in the hospital or in the doctor's surgery, than his counterpart of 30 or 40 years ago?

These are simple questions. These simple questions and a hundred more that are pertinent beg for answers. Perhaps it is already too late. Ingrained habit is notoriously difficult to eradicate; but I would suggest that these sorts of questions fairly represent the state of the NHS today. I would not want to appear to be a prophet of doom—perhaps just a prophet in his own country—and I assure your Lordships that I maintain an unquenchable optimism that ultimately a great and historical profession will win its way through all its present difficulties and dilemmas.

5.44 p.m.

Lord Bottomley

My Lords, I should like to join with others in thanking my noble friend Lord Ennals for raising this subject for debate today. He spoke with his usual skill and knowledge. I should like also to congratulate my noble friend Lord Peston on a model maiden speech. He will be a very worthy addition to Her Majesty's loyal Opposition and we look forward to hearing from him often in the future. It is a pleasure to follow the noble Lord, Lord Porritt. When I was Secretary of State for Commonwealth Relations, he was the distinguished Governor-General of New Zealand.

As Commonwealth Secretary of State and earlier as Secretary for Overseas Trade in the Attlee Administration, I had an opportunity for considerable travel overseas. It was with pride and pleasure that I learned how highly regarded was our National Health Service. The service was also admired and respected by the British public. I regret to say that this is not so today, as the standards of the service have fallen. In many other countries the provision of health services is superior to our own.

The creation of the National Health Service in 1948 was probably the greatest social advance of this century. During the post-war years it encouraged values of equity, social duty and solidarity. That the service was available to all through financing by the national exchequer brought security to millions who in earlier years had feared the cost of ill-health. It is the duty of the Secretary of State for Social Services, as laid down by the National Health Service Act 1977, to continue the promotion of a comprehensive health service, designed to secure improvements in the physical and mental health of the community and the prevention, diagnosis and treatment of disease.

Standards fall far short of these requirements today. Less is being spent as a proportion of the gross domestic product, and per head of the population, than in other comparable developed countries. The lack of public resources available to the National Health Service will mean a recurrent problem in providing the necessary health care for our people.

Since the early 1960s the proportion of the nation's wealth spent on public health programmes has fallen. Spending on the National Health Service has failed to match the rapid increase in the numbers of very old people in the population and the extra inflationary costs of medical technology. The National Health Service has been damaged by the growth of powerful commercial interests such as the new contract-cleaning companies, the private clinics, health maintenance organisations and private hospitals.

A Consumers' Association report has said that private hospitals will not necessarily give access to the best facilities. Private hospitals could be less able to cope if unexpected complications arise. National Health Service hospitals are much better equipped to deal with emergencies and complex operations than most private hospitals.

The private hospitals cream off the lucrative surgical work, leaving the care of the old, the chronically ill, the mentally sick and the handicapped to the state. They poach the nurses trained by the National Health Service. The role of health service consultants with part-time private practices is questionable, particularly with their use of NHS facilities. The government auditors' reports show that there have been substantial losses of revenue through non-payment for national health services.

Priority is given to private patients causing NHS waiting lists to be kept long, while instant treatment is available privately from the same consultant. The situation is aggravated by the government policy of cutting social expenditure and shifting the balance between public and private sectors and constructing a permanent unemployment economy. We now need to restate that the resources of medical skill and healing should be placed at the disposal of the individual when he or she needs them, that medical care should be a community responsibility, available to rich and poor alike in accordance with medical need.

The financial restraints placed upon the National Health Service have meant the postponing of essential services, cutbacks in research and the placing of obstacles in the way of improving training for nurses and professions supplementary to medicine. The NHS is still relatively efficient, in spite of the old, badly equipped hospitals. Hospital staffs are stretched to the limit and are among the poorest-paid workers in the country. The Government have neglected the NHS by their encouragement of the commercial sector. By their enforced privatisation programme and their inappropriate application of business principles to the managment of illness, distress and death they emphasise the need for a public service, free and available at the time of need.

The report Inequalities in Health is the most important document on health since the Beveridge report in 1942. It sets out an analysis of ill-health in contemporary Britain and strategies for the prevention of disease, and the encouragement of health. Its principal finding was that ill-health was strongly class-related and that the causes were to be found in the economic and social structure. Key factors such as accidents at work, overcrowding, a dangerous environment and poor nutrition have to be tackled. The National Health Service has to operate within a society dominated by powerful commercial interests. Its success in meeting the health needs of the population has been restricted by the conflicting demands of the market. The result has been an erosion of the National Health Service by government cuts in services and jobs, low wages, privatisation and charges for national health services.

There is an increasing neglect and despair of the very old and the mentally ill. For all the major advances in eliminating the old killer diseases and development of powerful therapies, the general health of the population is improving less rapidly than in other European countries.

The regional and district health authorities are undemocratic; they are not elected; many of those who serve on the committees are appointed and they do not live or work in the area for which they are responsible. Among the community there is a strong sense of an imposed and alien authority. As an illustration, an admiral who was partly responsible for the privatisation of the Royal Naval dockyards is now the chairman of the regional health authority. There must be more political awareness of the need for the resources of the community to be used in the service of the people and not for managerial staff to control and operate.

5.55 p.m.

Lord Hastings

My Lords, I shall not enter into the political debate going to and fro across the House. I rather agree with the view which has been expressed that if we can keep politics out of health, so much the better.

I happen to know two groups of disabled and handicapped people which I want to talk about because I am sure the House will agree that that at least is a non-political issue. One of them has been mentioned: that is, the mentally handicapped. I see a lot of mentally handicapped children much of the time and many young mentally handicapped adults in the working villages of the CARE organisation, in the Camphil organisation, and in the Gateway clubs for young adults run by MENCAP. These are nice people, fully capable and fully deserving of a good life, enjoying and appreciating it.

When we talk about care in the community, I think the noble Baroness, Lady Seear, gave a warning note with which I entirely agree. The noble Baroness, Lady Cox, very effectively enlarged upon this issue and I agree with every single word said by both noble Baronesses. Having listened to the noble Baroness, Lady Trumpington, making this one of the main issues of her speech and stating that a lot of money is being spent on providing extra social psychiatric workers as well as extra day centres, I find that this is good news, but she failed to mention accommodation.

I should like to know where these people are living. Arc they in council houses? Are they in rented flats? Are they in hostels? Where are they and what are they doing during the daytime? What sort of supervision is being given to them? They cannot just be left to get on with things by themselves. The accommodation issue is one which I would ask the Government most sincerely to investigate thoroughly. I should like to be told whether they even know—we should all like to know whether they know—the answers to those questions, because it is a very serious matter indeed.

I have heard of schemes where instead of selling off hospitals, or at least not selling off all their grounds, the outbuildings can be adapted, new ones can be built and a little village can be created within the grounds which is not far removed from the general community, because many of these hospitals are right in the middle of it. Yet they would still have a small clinic for their daily care which they will need. Have the Government heard of such a scheme? Have they examined such a possibility? Are the Government selling all the hospitals, and if so, where is the money going? I think we should like to know.

I am afraid that some of these mentally handicapped people—I am not talking about the mentally ill but the mentally handicapped—will end up in trouble if we are not careful, because they are innocents abroad. Instead of ending up back in hospital where they came from, some of them may unfortunately end up in prison, a place where they should never—I repeat "never"—in any circumstances be sent. This is the danger.

Now I should like to turn to an even smaller minority group, the mass of the people who suffer from epilepsy. Some of your Lordships may remember that I said on another occasion that I had been the president of the British Epilepsy Association for well over 20 years; and I declare my interest again. Over the last 30 years, there have been several reports on this subject. There was the Cohen Committee in the late 'fifties, then the Reid Committee which reported in 1969—when something actually was done—and then the Bennett investigation into the results of the Reid report. Finally, there was this document, the report of the Working Group on Services for People with Epilepsy, which was asked for by the DHSS itself and produced in 1984, but not, strangely enough, sent out and made available to those interested until July, 1986.

Then a circular was sent out by the DHSS saying: It is not however the DHSS's intention that the report should be treated as a 'blueprint' for the provision of services by all authorities. It is hoped that the report will stimulate discussion on the scope for improvement.". Then later, on the question of funding—and I have had correspondence with the department on this matter—I was told that the responsibility for funding lands firmly upon health authorities and depends entirely on the extra funds made available to them by the Government. But the decisions are the health authorities' own according to their priorities and the resources available. That is a classic formula for doing absolutely nothing. I know it, everybody else knows it, and I am quite sure that the Government know it. I think that this is not quite fair and not quite good enough.

The main recommendations are simply that, in addition to the three special assessment centres—one at Oxford, one at Chalfont and one in York set up after the Reid Committee—there should be two more, one in the Midlands and one in the South-West. They should have supra-regional funding, which means that the Government have to pay, and that, I am afraid, is what the DHSS does not like about it.

The other important recommendation is that there should be special epilepsy centres attached to neurological units in as many general hospitals as possible. There are diabetic centres and it is not very difficult to have epilepsy centres, yet this has not been pushed at all. I ask the Government simply whether they have followed up that circular. It went to health authorities, social workers, local authorities, district councils, county councils and a whole lot of people who ought to be able to get together and do something.

This is a small but important group. These people suffer and there is no reason why they should. They are perfectly capable of having a very good life. Lots of other people do not even know that they have epilepsy, but if it is known it is still a local stigma and the Government, with very little money, could do an awful lot. I simply ask them, please, to follow up this report, not let it gather dust, ask all these authorities what they are doing and say, "Please, even if we, the Government, do not have to pay, find the money for it".

6.3 p.m.

Baroness Robson of Kiddington

My Lords, I should like to join other noble Lords in thanking the noble Lord, Lord Ennals, for raising this issue yet again. I should also like to join in the congratulations to the noble Lord, Lord Peston. My noble friend Lord Winstanley referred to the fact that this is the third time that he has had to listen to the noble Lord, Lord Ennals, making more or less the same speech—

Lord Ennals

No.

Baroness Robson of Kiddington

He did.

Lord Ennals

He did, but he was wrong.

Baroness Robson of Kiddington

But, my Lords, I have been present on at least two of those occasions and I have been staggered by the similarity of what has been said. On every occasion we have heard from the Government that they have put a lot more money into the health service. From this side of the House we refute that argument, or try to.

As a former regional chairman, I thought that I would look at the regional cash allocation for the year 1987–88 and what it means for the regions to try to solve this problem. Is the extra money really extra money? There is built into the 1987–88 allocation 3.75 per cent. for increases in pay and prices. All inflation above that figure will have to be met by the health authorities out of the total budget.

Much has been said in this debate already—and there has been no disagreement on nurses' pay—about the loss of nurses to the health service. I wonder whether anybody in this House believes that the review bodies for both doctors and nurses are likely to recommend pay rises within that limit if they want to stop the drift of nurses out of the service. I do not believe that they can. The inflation of prices is immaterial compared with what we ought to pay the people who serve us in the National Health Service for lost ground within recent years. I should be very surprised if the Government, in an election year, even attempted to keep the pay increase to below 3.75 per cent. On the basis of the inflation allowance to the regional health authorities there is a very bleak outlook.

Additionally, over quite a number of years the NHS has been under pressure to produce extra cash through compulsory efficiency programmes. I am not against saving money through efficiency programmes. It started even before I left the health service, but it was always understood that that saving should be for developing the service. It should not be for topping up the inflation charge that the Government are not allowing to the health service, and, in practice, almost all of the savings have gone towards meeting the costs of pay awards.

In addition, I must grant the Government, in this year's allocation the NHS is receiving a 1 per cent. growth in real terms, presumably for development. This 1 per cent. has to cover all extra costs associated with the increase in the elderly population and technological advances based on extremely expensive equipment. As well as that, the Secretary of State is now setting targets for various types of care which he wants to see improved, such as renal services, cardiothoracic services and hip replacements. We all want to see those services improved, but they have to be paid for out of the 1 per cent. growth money, plus the savings achieved through efficiency programmes.

Thus we are asked in the NHS to use all our savings twice over. We are asked to use them to top up the pay awards over 3.75 per cent. and we are asked to cover increased charges, because the population pattern has changed and technological advance asks us to invest more money. I have never heard anyone adequately dispute that the figure necessary to cover both demographic change and technological change is at least 2½ per cent. per annum. It follows that the future is grim so far as any improvement in the service is concerned, and we may be approaching a time when rationing will be the order of the day.

If we add to that in certain regions, such as metropolitan regions, the additional problems of RAWP, then the picture becomes even bleaker. The four inner London regions were asked to cut £109 million in acute service spending between 1983–84 and 1993–94. In the years 1983 to 1985, they have achieved 74 per cent. of the planned 10-year bed reductions. However, they saved only £30.9 million or 34.5 per cent. of the projected revenue reductions. One does not need much imagination to visualise the deterioration in services which will result from a further compulsory saving of £78 million.

I should therefore say that the picture is in line with that painted on this side of the House. The increased moneys which, according to the Government, have been given to the health service have been more than spent by the changes that are necessary. Improvement is therefore minimal.

I was also in agreement with the noble Lord, Lord Ennals, and was very concerned when he referred to the excessive hours worked by junior doctors. It is a frightening thought that a junior doctor who has been on duty over a weekend should not be allowed off duty until the end of Monday. I do not believe that one can ask people to make reasonable judgments after working such excessively long hours. Long before I retired as a regional chairman, and as long ago as 1980, there was a plan to increase consultant cover in order to deal with this problem. I should like to ask the Government how many new consultant posts have been created and how many regions have been able to afford to take up the possibility of appointing new consultants. I can remember in my day that two consultant posts were granted and the districts in my region could not afford to take them up. I should therefore like to know how many consultants have been appointed.

I was going to speak for some time about the Health Service Commissioner, which was what I really wanted to speak about. However, I see that my time has run out and I therefore hope that on the next occasion when the National Health Service is discussed I shall be able to make my point.

6.15 p.m.

Lord Dean of Beswick

My Lords, along with previous speakers in your Lordships' House I wish to express my appreciation to my noble friend Lord Ennals for giving us the opportunity to debate what is probably the most important personal service that we as a nation provide. I also congratulate my new colleague, my noble friend Lord Peston, on his maiden speech. Knowing his reputation, we expected a high standard and I think that that was achieved. I have no doubt that we shall hear from him on numerous occasions in the future.

For part of my contribution, I wish to deal with a specific problem in an area of Manchester. Much has already been said about the National Health Service in a national context. We are sometimes a bit repetitive in highlighting the same problems. However, I was interested to hear the contribution of the right reverend Prelate the Bishop of Manchester with his knowledge of Manchester and Salford. Those who do not know the geography of that particular area may not realise that Manchester city centre and Salford actually meet. They are separated by the River Irwell.

Manchester and Salford are very much interlinked in terms of needs and wants. In speaking of that particular area, we are referring to one of the most deprived areas in the United Kingdom. Previous speakers have mentioned London and what I shall say could be applied to many of the major conurbations. A short time ago we discussed these matters in a debate concerning inner cities. Those areas need—I do not say demand—a higher proportion of care in dealing with their problems than the more affluent areas. I shall not go into many statistics. However, it is a fact that in the major city areas and certainly in the Manchester area there is a far higher incidence of death through heart failure. People die much younger on average, a high proportion of people die due to various forms of carcinoma and a child born in the centre of such cities has, as I understand it, four times more chance of dying before it is 12 months' old than a child born in one of the better areas.

Manchester has three area health authorities: the Central Health Authority, the South Health Authority and the North Health Authority. Most of my remarks will concern Central Manchester Health Authority. However, they are indicative of what is taking place in most areas. There is an increasing workload and a diminution of resources to deal with the situation. Like the noble Baroness, Lady Robson, I intended to make one speech and I find that I must make another in order to get my points over. However, the fact is that between 1982 and 1986 Central Manchester Health Authority lost, in terms of financial support, nearly £3 million. That is a lot of money. At the same time, between 1st April 1982 and 31st March 1985, there was an increase in workload. In-patient workload increased by nearly 9 per cent., district specialties increased by 22 per cent. and day cases increased by 29 per cent.

The more mundane part of what I wish to say concerns the fact that there has been a further load increase placed on Central Manchester Health Authority, whose main hospital is Manchester Royal Infirmary, by the closure of the emergency and casualty department of Ancoats Hospital. Anyone who comes from that side of Manchester, as I do, will know that Ancoats Hospital was a small hospital which dealt with many local cases. It had mystique and many people in that area literally did not know of any other hospital. That was their hospital and it flourished in the past, very often because the local people donated generously in a charitable way to keep the hospital going. What has happened is that the accident and emergency services have had to close.

A few weeks ago there was a debate in another place in which the Member for central Manchester and the Member for north Manchester highlighted the difficulties raised by the closing of these accident and emergency services in that hospital and what was happening. I should like to give briefly some of the statistics which have been quoted concerning the burdens which will fall on the Manchester Royal Infirmary, without, as I understand it, additional funding. A document I have states: In 1986, the MRI Accident and Emergency Department treated 43,286 new patients and 7,071 follow up patients. Total: 50,357". The document continues: It is impossible to quantify the effect the daily short closures of Withington Hospital Accident and Emergency Department will have on the MRI". That is a hospital in south Manchester where facilities have also been withdrawn. It places an additional workload on Manchester Royal Infirmary. The document then states: In 1986, Ancoats Accident and Emergency Department treated 25,656 new patients and 11,611 follow up patients. Total: 37.267". If the situation continues, those patients will have to be dealt with by Manchester Royal Infirmary which is already dealing with an increased load on a diminishing supply of money. The hospital is almost at breaking point. I think it has had to use capital resources, as have other hospitals, which should have been used on the hospital's fabric and maintenance, in order to keep those services ticking over. That type of thing was featured last year in reports on the nation's housing, education and health service establishments. They are seriously deteriorating and in some cases they are in a dangerous condition. That cannot be allowed to go on.

Manchester Royal Infirmary says that it will require an extra £189,000 to deal with the additional load which has been placed upon it. No one can deny that it makes out a genuine case for that additional funding.

I wish to return to the subject of Ancoats Hospital. As I said, the subject was raised in another place. I make no criticism, but the Minister was unaware of the hospital and what it meant to the area. I know that it will be difficult to reply to a small point like this in a major debate, but will the Minister ask his right honourable friend in another place whether he will consider the future of Ancoats Hospital as a matter of urgency? I am not trying to simplify the matter and say that it is easy to make a decision to restore the emergency and accident services. It is not a simple matter, but I do not have time to go into the details. All I ask is that the Minister give an undertaking to look at the matter to see whether it is possible to comply with the requests of the local people, and the staff of that hospital who throughout its history have performed a marvellous service.

In 1940, when we were waiting for the blitz in Manchester, I was (I will not say that it was a privilege) one of only two patients in a ward in that hospital. I had been knocked down by a hit-and-run car during the blackout. I do not know whether it was lucky or unlucky that I survived, but that hospital has been like a beacon in the area. Will the Minister please look at the situation to see whether something can be done about the cuts and whether services can be restored in that densely populated and underprivileged area?

6.23 p.m.

Lord Ferrier

My Lords, in his programme "The Week in the Lords" on Saturday, Christopher Jones said that this debate was a forerunner to the election.

I think it is safe to say that there has been a minimum of political give and take across the Chamber. We have had a remarkably informed debate despite the fact that over 40 minutes have been cut from it by a mini-debate on higher education.

To my mind, the outstanding speech was that of the noble Lord, Lord Porritt, who could remember the early days of the National Health Service. I remember that in my maiden speech I made a remark which led to the substitution of the words "supplementary benefit" for "national assistance". That was greatly to advantage in the distribution of assistance.

The noble Baroness, Lady Cox, made a well-informed speech which contained an up-to-the-minute approach to the problems which face the DHSS. A debate which has 28 speakers and lasts five hours epitomises the position referred to by the noble Baroness, Lady Seear, and to some extent by the noble Lord, Lord Porritt. Mixing health problems and social security leads to a great deal of overlapping everywhere. If it is correct to say that old men dream dreams, one of my dreams is that the time will come when the two departments will be separated.

I do not know whether it is correct, but someone has said that National Health Service morale is going down. The lack of a Minister responsible for health contributes to any weakness of morale in this wonderful service and the thousands of people who make their careers in it. I find it to be a marvellous success story (I think we all should) despite the difficulties which have arisen and which were mentioned by my noble friend Lord Nugent.

The large number of speakers taking part in this short debate shows how important the service is felt to be. We have talked about this matter before. It was talked about years ago, but the longer we put off separating the two departments and having two Ministers, one responsible for health and one for social services, the more difficult the division will be. That is the first of my dreams that I wish to put to your Lordships.

My next point is a simple one, which I have mentioned in the House before. The time has come for manipulative therapy to be accepted by the National Health Service as part of the services it makes available. It is all very well having views about whether or not it is good, but we know that there could be an enormous financial saving if surgery, drugs and beds were replaced by the modern practices of osteopathy and chiropractic. I hope that that will come our way. It is a task which can be faced by the next government, whoever they are.

I come next to the subject of social security. The most important social security problem which has been considered in your Lordships' House in the past year or so has been that of aged and handicapped people in cold weather, and insulation, draught exclusion and other ways of ensuring that next winter old folk and handicapped people will be better treated and given more assistance.

I say that because, years ago, I was promoting the use of night stored electricity—off-peak electricity. I believe that in the years that have gone by we have reached a stage where there have been enormous advantages in the actual materials used for the storage of heat. One of the tasks that I have set myself, and one of the dreams that I dream, is that by next winter it will be possible to have small night storage heaters available for off-peak electricity.

In the debate on heaters in this House some months ago it was said that the night storage heater is a failure. It is not the heater which is a failure; it is the switchgear. What goes wrong with them today is that if there is a power failure the switchgear stops and the heater goes on at the wrong time of the day. I urge the Department of Health and Social Security to help me in tackling the whole question of off-peak tariffs.

I believe that our electricity is far too expensive. When I first came home from India and set up house in Scotland in 1952, the off-peak tariff was one halfpenny (in old money) per unit. Today it is 2.3 new pence; in other words, it is seven times more expensive than in 1952. One reason for that was because we had a hydro-electric base in the Clyde Valley. However, I believe we should have a real attempt to do something and I am going to see Sir Philip Jones of the Electricity Council in the next week or so to press for a revision of the approach to off-peak tariffs and the use of night storage heaters for relieving the difficulties of heating for old and infirm people during the winter.

I could go on and on, but I shall not do so—which will be a relief to your Lordships. However, I feel that we should be pleased that this House has given this subject some attention. We have had most informative speeches by senior medical people such as the noble Baroness, Lady Cox, and so on. I hope that the Government will take note of one or two of the points that have been raised.

6.33 p.m.

Lord Dunleath

My Lords, I hope that the noble Lord, Lord Ennals, to whom we are grateful for having initiated this debate, will not consider me unduly opportunist in making use of the occasion to draw to the attention of Her Majesty's Government what is an apparent and notable gap in the coverage of the National Health Service and one that is peculiar to Northern Ireland.

I should like to refer to homeopathy, which is a subject on which I have no special knowledge and in which I have no personal interest: Indeed, I had hardly heard of it until the subject was debated in the Northern Ireland Assembly on 14th March 1964. I remember the occasion clearly, because I was unable to participate in the debate due to the fact that Mr. Speaker was otherwise engaged and I was stuck in the Chair for most of the afternoon.

However, I recall that we were told that there was a distinct difference in the coverage of homeopathy in the National Health Service in Northern Ireland as opposed to the rest of the United Kingdom. In Great Britain there are five hospitals which specialise in homeopathy and which give National Health Service treatment to patients. However, that is not the case in Northern Ireland where there are just eight doctors who specialise in the discipline and anyone who requires treatment has to go to them as a private patient.

I was not alone in being surprised and concerned at that information given to the Assembly on that occasion. Such was the concern that the Health and Social Services Committee of the Assembly took evidence on the subject and produced a report to the Assembly on 4th March 1985. It was most comprehensive and was widely acclaimed. It was approved by the Assembly and sent to the Secretary of State on 20th March 1985.

The main recommendations of the report were, first, that a referral clinic should be established and that patients should be allowed to be referred to such a clinic by their doctors, where they would receive homeopathic treatment on the National Health Service rather than having to pay for treatment as private patients. The second recommendation was that a clinical research facility should be established to ascertain precisely the efficacy of homeopathic treatment. The implications of that are that for the research facility an estimated £25,000 a year for two years would be required. Thereafter it would have to be reviewed. In the case of the clinic the cost would be that of the National Health Service personnel providing the services.

Some 10 months later, on 16th January 1986, the Secretary of State replied, conveying the Government's response, to the effect that further research would be inappropriate until the research presently taking place in Great Britain had been completed. The second response in respect of the clinic was that there would be no justification in establishing such a referral clinic until the demand for homeopathic treatment was known and proven.

Since then two developments have occurred. First, the fairly limited research which took place in Great Britain—I understand in Glasgow—revealed that homeopathy is not a matter of giving placebos. Homeopathy must be taken seriously. It was also revealed that further and much more scientific study is required; and that is what the Northern Ireland report advocated. Indeed, one of the witnesses who gave evidence was Professor P. F. D'Arcy, the Dean of the Faculty of Science at Queen's University, Belfast, and Professor of Pharmacy. Professor D'Arcy said that he would be prepared to carry out such a research programme and confirmed that he had the expertise among his staff and the equipment with which to do it if he was given the funds. I should add, with respect, that Professor D'Arcy is a self-confessed agnostic as regards homeopathy. He does not know, but he would like to know. I am in the same position and so are a great many people; but the difference is that Professor D'Arcy is in a position to find out because he is a scientist. He is not the sort of man to listen to hearsay or anecdotes. As a scientist he wants facts and it is only facts that will convince the rest of us.

In answer to the second response, the Northern Ireland Homeopathic Society surveyed province-wide all the general practitioners in Northern Ireland to inquire whether, if a referral clinic were to be made available, they would actually make use of it and refer their patients to it. Just over 20 per cent. said that they would. That does not mean that 80 per cent. said that they would not. Some practitioners did not reply and some were equivocal, but over 20 per cent. said that they definitely would use it.

The Northern Ireland Homeopathic Society also consulted Price Waterhouse about the possibility of doing a feasibility study on setting up a clinic, and it found that it would cost £11,000. In September last a delegation was sent to the DHSS Department of Community Health to see whether grant aid could be obtained towards the cost of the feasibility study, but it was refused. However, the Department of Community Health suggested that the society make application under the clinical research grants scheme, and it duly did so, requesting £10,000 per annum for three years to research the subject of "Homeopathy, the Answer to Childhood Respiratory Disorders", which it felt would be a particularly appropriate and relevant topic to test the efficacy of homeopathy. Again it was turned down.

Meanwhile the same society raised £3,000 by voluntary effort to provide funds for patients who wanted such treatment but who could not afford it as private patients, and so assisted them in that way. In the absence of public funds, self-help has been tried as an interim measure. Having said that, I emphasise that I myself am not a member of the Northern Ireland Homeopathic Society.

In the light of that situation and in view of what has happened since the Assembly report was delivered, I respectfully ask Her Majesty's Government, first, whether they will now provide £25,000 for two years to undertake a preliminary study on the efficacy and scientific basis of homeopathy; secondly, whether they will be prepared to set up a referral clinic linked with that research unit whereby National Health treatment can be provided for patients. In advocating that Her Majesty's Government should follow that course, perhaps I may conclude by summarising three points.

First, the research that has already been carried out reveals that homeopathy is not to be dismissed. It works—we know that—but we do not know how it works. That is why more research is needed. Indeed, the London faculty of homeopathy has recommended Northern Ireland with its compact community as being an ideal situation in which to carry out such an exercise. Secondly, a referral clinic would not just bring parity with Great Britain, which is only fair: it would also meet an increasing demand that has now been quantified. That is unlike the previous position. Thirdly and finally, in the context of the National Health Service budget, the outlay would be insignificant, particularly in the context of the bill for drugs and prescriptions. In Northern Ireland alone in 1970 the cost was £8.1 million and in 1983 it was £56.9 million. In that context the outlay would be insignificant. It would not be money well spent; it would be money well invested and I believe that it would be one of the best investments that the National Health Service could make.

I commend this proposal to Her Majesty's Government. I do not expect an answer immediately from the noble Lord since he has not had notice of this point but I should he grateful for a reply as soon as he has had an opportunity to ask his staff to look into the matter.

6.45 p.m.

Lord Taylor of Blackburn

My Lords, I too should like to thank my noble friend Lord Ennals for initiating the debate and for drawing attention to this matter. I should also like to congratulate my noble friend Lord Peston on his excellent, non-partisan speech. My noble friend will not, I believe, take that line again in the House. I expect that he will be more partisan in future and I look forward to listening to him when he is perhaps in better form in that respect.

At Question Time one hears many requests to Ministers concerning various aspects of the National Health Service, and one notes the replies of Ministers concerning the amounts of money that are spent and the quality of the service. However, I am in the position of a Back-Bencher. And from the Back-Benches, I often think of what my next door neighbour might say if he heard the answers that are given. I recall that when I was a child, the boy next door suffered from tonsilitis and had trouble with adenoids. He had to wait for 15 months—perhaps it was much longer—to go into hospital for treatment, and during that time he was constantly off school.

One wonders not only what my neighbour would say but also what a woman who has already been waiting two years for a gynaecological operation and who has been constantly in pain would say. Or what about a man who is waiting for a hernia operation and frequently has to take time off work? So it goes on.

I think about such things when I sit on these Benches and hear statistics bandied about in the way that they are. What does the man in the street think? He or she is not interested in the amount of additional money provided; he and she are more concerned about the time they have waited to go into hospital. They cannot see any improvement as a result of the additional moneys. They find the waiting lists just as long as they were years ago. We must get over the message that the waiting lists have to be reduced. This must be brought again and again to the attention of hospital authorities. The first priority is to treat people who are waiting for treatment.

My second point is that I want the Government to realise the amount of voluntary contribution that is made towards the health service. I do not think that this aspect has been followed up today, although it has been casually mentioned by one or two noble Lords. I want to say thank you to those people who give their time most generously working in hospital wards, not performing professional tasks but relieving nurses in ways such as arranging flowers and writing letters for, or comforting, patients and running errands for them. We should remember those people who are working hard and keeping the National Health Service going.

Another group of people contribute by paying heavy taxes through their weekly stamps and so on. Some are going deeper into their pockets to provide for hospices, scanners and so on. In my particular area of East Lancashire—in Blackburn and the Ribble Valley—we have a very proud record of that sort of service. We do not rely on the state to provide everything for us. We are prepared to help. Those efforts are co-ordinated by the local newspaper which is doing a tremendous job in encouraging the community to dip into its pocket.

There is a scheme at the moment for a scanner which requires a tremendous amount of money. I am sure however that in the next 12 months we shall provide that scanner for one of our hospitals. If the community is prepared to dip into its pocket in that way, surely the Government can encourage such people, not by putting the money into ordinary allowances for the DHSS but by giving something extra where they find a community that is prepared to provide certain amenities out of its own resources.

Perhaps the Government will consider this position. If the community can make this effort, then the Government can match it pound for pound, or by some other means. I am sure that this would encourage a great response throughout the country from the man in the street. We know that we are a very generous nation when there is a call for contributions to be made. We should therefore use the facilities and resources which exist to be tapped by the state.

6.50 p.m.

Lord Auckland

My Lords, the noble Lord, Lord Ennals, must be very gratified that this debate has inspired nearly 30 speakers to take part. It has given us an opportunity to hear the inspiring maiden speech of the noble Lord, Lord Peston. I am particularly interested, although not financially or professionally, in the pharmaceutical industry, and his speech was of much interest on that aspect. If we debate that aspect of our lives I hope that we shall hear from him again, and on other subjects.

There are two areas where expenditure is essential. I believe that one is defence and the other is health. To be a strong country we must be defended. To be a strong country we must also be healthy. It is a matter for great regret, and this has been mentioned by a number of Members in your Lordships' House this afternoon, that party politics seem to be seeping more and more deeply into the National Health Service. To some extent this may be unavoidable.

I have taken part in a few election campaigns for colleagues in another place. Come the election, Party X says, "I am spending Y amount of money on the health service". The other party says, "I am spending Z amount". For those who are on waiting lists and for those who are working in the health service, very often on inadequate pay, it is little consolation to hear politicians trying to score points off one another. I believe that this is one of the most important aspects of the debate.

I have served for some 30 years on hospital committees, both mental and long-stay hospitals. Currently I am president of the friends of our local district hospital in Surrey. I was a patient there 18 months ago having a gall bladder operation. I was in hospital for only nine days. Ten years ago for an operation like that one was in hospital a good deal longer. Recently my wife was in the same hospital having an operation on the veins in her leg, a frequently performed operation. She was in for three days. We were both extremely well treated.

In this connection I should like to pay tribute to the Leagues of Friends of various hospitals. I declare a non-financial interest as president of the friends of our local district hospital. I know something of what goes on there. It is not a party matter, but under all governments, if it were not for the friends facilities for some of our hospitals would be very much less adequate than they now are. At our local hospital the friends raised about £6,000 towards equipment for the intensive care unit. That is not a lot of money for the equipment which may be needed but it is a very fine contribution.

I should like to say a word about the pay and conditions of nurses. My noble friend Lady Cox, who has much experience in this field, made a speech which was acclaimed on all sides of your Lordships' House. Special pleading must play some part here. We have a younger daughter with a young family who, if she were to return to nursing—which she wished to do—would be earning about £6,400 a year gross, plus about £900 a year in London weighting. Having small children she needs a creche. She told me the other day—I have checked these facts—that she has to pay about £30 a week for a crèche, or £3.50 per session. On a salary like that how can any government expect experienced nurses—she has her SRN—to return to nursing? I hope that the Minister will bear this point in mind. The situation has probably existed under all governments.

We pay a great deal of money for various people to stay in bed-and-breakfast hotels on social security. I do not wish to comment on the rights or wrongs of that. But is it rational or logical that £30 a week should have to come out of the earnings of experienced nurses who have been through their training, who have a young family and therefore need a crêche? I believe that this is a fair point.

Another matter that has not yet been raised is our service hospitals. The report by the Comptroller and Auditor-General on the Ministry of Defence hospitals mentions, for example, Aldershot. The military hospital there had a surplus of 91 nurses over a complement of 236 in 1986. The Royal Air Force hospital at Ealing had a surplus of 48 nurses over a complement of 148. Are facilities at these hospitals available for national health patients? If our service hospitals are not full, if the beds are not being used, here is a way in which waiting lists could be cut. All governments want to cut waiting lists in hospitals. It is not a monopoly of any political party. How it is accomplished is a much more difficult matter.

I should like to say one word about private hospitals, which have been touched upon. It is fair to say that St. Thomas's Hospital in 1985 was provided by private hospital funds with a lithiotripter for crushing kidney stones. Two thousand patients have used it, many of them from the National Health Service. I mention that point not to cast favour or otherwise on private medicine. I believe in an ideal society. Having recently read Mr. Bevan's speech on the Second Reading of the National Health Service Bill it is my interpretation that he did not wish completely to abolish private medicine. I believe that there is a place for private medicine and the National Health Service to work side by side. Every country has a certain amount of private medicine—even in Eastern Europe. I go around a number of countries and I see this working.

To conclude the plea, we have a National Health Service which is composed of thousands and thousands of dedicated workers. Let politicians remember that.

7 p.m.

Baroness Turner of Camden

My Lords, I too should like to commence by thanking my noble friend Lord Ennals for the opportunity afforded by this debate. I should also like to congratulate my noble friend Lord Peston on an admirable maiden speech. I am sure we all look forward to hearing a great deal more from him.

Like the noble Lord, I wish to commence by declaring an interest. I am a union official. My union, ASTMS, organises extensively in the National Health Service. In the public mind, although not, I am sure, in your Lordships' House, the National Health Service consists mainly of doctors and nurses. However, it has to be appreciated that it employs many thousands of highly skilled people in other professions.

There are about 26 professions in the National Health Service where the people concerned are members of my union. There are scientific officers, medical laboratory technicians, radiographers, clinical psychologists, pharmacists, therapists of various kinds, and so on, and fairly recently your Lordships' House has debated the problems that face speech therapists. These are not professions which people join if they are out to become rich or even moderately well off. Although the work is often highly skilled and requires a great deal of training, as has already been indicated in the debate, the pay is pretty low. You have to be dedicated to do this work and most of the people who do it are dedicated.

A medical laboratory technician, for example, working on cancer screening or on AIDS would have a commencing salary of £6,000 a year, rising in a number of stages to the princely level of £8,000. A principal medical laboratory scientific officer, with many years of experience and a staff of around 60 working under him, can expect to get about £16,000 per annum. This is hardly a fortune for the type of work and responsibilities undertaken.

Since 1979 the real disposable income of these people has gone down by about 16 per cent., yet arguably the work has become more skilled and more demanding. We have heard on several occasions during the debate that there is a shortage of nursing staff. This point has been dealt with in some detail by the noble Baroness, Lady Cox, and by the noble Lord, Lord Auckland, and I do not wish to add to what has been said. Poor pay and working conditions have combined to produce a shortage of highly trained people. The gap between National Health Service pay and the rest of the workforce is exacerbating the difficulties and quite clearly is creating problems that have to be overcome.

However, I do not intend to use the opportunity afforded by this debate simply to air the problems of poor pay, except to say that these are a symptom of general underfunding and inadequacy of resources. We are—and I believe that this is true of most of us in your Lordships' House—very proud of our National Health Service. It was founded in 1948 to provide, as other noble Lords have said, a comprehensive service available to all on the basis of medical need and free at the point of use. That was a very high ideal. These principles have been the guiding light of the service since the beginning. However, the continued effectiveness of the service depends on matching needs with resources.

There is a growing gap between needs and resources. This continues to widen, despite an increase in total care expenditure. The Government have repeatedly said that they are spending more than ever on the National Health Service—and they are. However, as other speakers in this debate have said, we are having to meet the pressures of an ageing population, the advance of medical technology which leads to greater expectations on the part of people generally and added issues such as drug abuse and AIDS.

Compared with our competitors in the industrialised West, the UK fares badly in terms of expenditure on health care. The United States spent 10.8 per cent. of national income on health care in 1983, France spent 9.3 per cent. and Italy 7.4 per cent., compared with our expenditure of 6.2 per cent.

I know that it is claimed that spending on the National Health Service has risen by over 20 per cent. in real terms between 1978 and 1985–86. However, a large part of this increase was absorbed by the pay settlement for medical and nursing staff. Clearly this was absolutely necessary because there had been years when salaries had fallen behind. Nevertheless, despite the fact that it is proposed, I believe, to spend more for the next three years, it is questionable whether this will be enough to meet the needs.

A major problem is that real growth in spending is absorbed by increasing demands made upon the National Health Service by the changing demography in the United Kingdom. As has been mentioned a number of times in the debate, and I think it is a highly important point, this is instanced by the rising number of people over the age of 75 who use the hospital service. Over half the average daily hospital in-patient population is concentrated in the demanding areas of geriatrics and psychiatric medicine.

As has been referred to previously, there has been a policy of developing community care for certain patient groups since 1976. The aim of the policy, as we know, is to transfer appropriate elderly, mentally ill or mentally handicapped patients from hospital into the community, often in their own homes. The principle of care in the community is a good one, but comprehensive community support must be developed if these very vulnerable groups are not to suffer. At present there is an insistence that funding for these developments must come from existing resources. We have an obligation to see that these vulnerable groups are not forced into an unprepared community because in-patient facilities are closed before alternative facilities have been developed. Indeed, a worrying feature of inadequate hospital funding is the growing list of hospital closures.

Between 1979 and August 1986 a total of 205 hospitals were approved for complete closure. There may have been good reasons in some cases but, as has been mentioned, waiting lists have been growing. Between 1981 and 1985 waiting lists rose by 66,000 to 802,000, with nearly 20 per cent. of the patients queueing for orthopaedic surgery. Wards have been closed and, as already indicated, there are staff shortages. We have reports reaching us at the union office of concern expressed by staff about the decline in standards of the fabric of the hospitals in which they are working and the need for money to be spent on supporting those structures and improving the environment generally.

New developments in medical care and technology also need increased spending. In 1985 a third heart transplant programme was established at the Freeman hospital in Newcastle to supplement the work of Papworth and Harefield. Up to 1986 a total of 348 heart transplant operations have been performed, including 57 heart/lung transplants. Operations such as coronary artery by-passes help prolong the life of people with heart disease, and these operations are increasing. The number of liver and kidney transplants is increasing but such operations are extremely expensive. A liver transplant costs about £19,000 for an adult and about £75,000 for a child, with £5,000 per patient per year in subsequent costs. Kidney transplants cost around £8,000, with £2,700 in subsequent therapy.

The publicity that such achievements receive has led to advances in public expectation, but there is a shortfall in the number of such operations that can be undertaken. Therefore, any real spending increase has to cope with growing and, for example, in the case of AIDS, with entirely new demands. AIDS is being tackled as a central initiative. But it also has considerable implications for the regional health authorities. As the incidence of AIDS increases and the disease spreads—although one hopes that it will not, the indications are that it could—a significant increase in resources will be called for. Drug abuse is a further area that calls for centralised help and this should essentially be long term.

There has been a decline in deaths from certain diseases. On the other hand, as with AIDS, there are less encouraging signs. Deaths from heart disease among women fell by only 1 per cent. in the years 1979 to 1984, while deaths from lung cancer among women rose by 20 per cent. That is an indication perhaps that far more women are smoking and are not being prevailed upon to give it up.

Despite the publicity accorded to the campaign for screening to identify cervical and breast cancer at an early enough stage and thus take steps to deal with it, there is still not enough being done to monitor and to check on the women at risk. A disturbing development has been the introduction of a commercial service in the screening area. We have information which would seem to indicate that National Health Service staff are working on commercial projects concerned with screening and testing smears, and so on. We think that that development should be watched. In any event in this area we still believe that there are too many preventable deaths.

Nevertheless, improvements in the quality and length of life since the Second World War owe much to the existence of the National Health Service. It promised security to millions who in earlier years feared the costs and consequences of illness. Peri-natal mortality has been falling for years. Life expectancy across all classes has been improved. Children born in the years 1982 to 1984 can expect a life span two years longer than those born 10 years before.

The NHS was designed to meet the health needs of all citizens without regard to income. It has been able to respond to an ever-widening range of health care needs thanks to the developments in care and the treatment, devotion and dedication of its staff. But, as has been said during the course of this debate, there are problems because the resources are simply not keeping pace with demand. The suggestion has been made that my noble friend Lord Ennals was bellicose in his attack upon these issues. I fully support his comments and I prefer to say that he made a passionate demand for further resources, and that that is a demand which we all should support.

7.12 p.m.

Baroness Lane-Fox

My Lords, I should like first to thank the noble Lord, Lord Ennals, for initiating this debate and to congratulate the maiden speaker the noble Lord, Lord Peston. Many who, like me, have been the recipients of clever and good treatment under the NHS consider it deserves all the help it can get. Equally, there are employees of the NHS who, after giving so much effort and expertise, sometimes think that their services are not fully appreciated.

In 1987–88 no less a sum than nearly £20 billion is to be spent on the NHS. That must go part way to meet both the views that I have given. As my noble friend Lord Auckland said, considerable individual sums are raised voluntarily all over the country for separate parts of the service. For instance, last week I addressed the AGM of St. Stephen's Hospital League of Friends. In just one year it had contributed £30,000 for vital hospital equipment and other invaluable service in their hospital. With effort like that, who could deny the strong pulses beating throughout the service?

The Phipps Respiratory Unit Patients' Association, to which I am attached, so far has raised £650,000 of the £1 million it needs to equip the unit's future in new purpose-built surroundings. This has been achieved through the work and devotion of ex-patients. Some, like me, are timid about raising funds and tend to be lured by voices saying, "Why is this not done by the NHS?" But most of us appreciate the crying other needs to rebuild so many out-dated hospitals, the ones whose crumbling conditions were overlooked in the past. Now, the biggest hospital building programme in NHS history has been embarked on by the Government. This includes over 170 schemes, each worth more than £1 million, which have been started and completed since 1979, with 400 schemes in the pipeline, 100 to be completed in the next three years. Wonderful doctors and nurses deserve to work in the best hospital surroundings. It is incredible that this unwritten rule was abandoned by the previous government.

The large increase in patient treatment and the success of new sophisticated methods employed is a tribute to all concerned. It would not be possible without an overall increase in provision and of course without the skill and proficiency of hospital staffs. Medical science is so diverse and progressive that it can take on and defeat so many illnesses and conditions that would be fatal or crippling if left alone. Although there are economies to be made to public expenditure when people are restored to look after themselves, medicine overall essentially is an extremely costly programme.

It appears to me that the only way to keep the cost ceiling in place is to encourage everyone to understand good health education. Towards this end we have the new Health Education Authority. I am hoping that this will see the message of good health instilled into everyone and especially into the student teachers for they can have a great influence on the common sense of their pupils in this. Many teachers could be amazed to find just how much good posture and good example affects the future health of children, as of adults.

I am told by a very knowing Scandinavian physiotherapist that the teaching of physical education needs to include a degree of anatomy, physiology and psychology just to show the reasons for care and a smattering of kinetics to show the relation between movements and the forces acting against them. This is needed particularly to help in lifting methods.

If the message of health discipline gets across it can I believe cut the numbers of slipped discs and hernias for a start, let alone coronaries, arthritis and the rest. While on this subject, I implore every hospital ward to have not only an efficient hoist for lifting patients but also nurses who know how it works. I do not say this only for the increased comfort of patients but also in order to protect nurses' backs. If, like me, you happen to measure nearly six feet and to be of ample proportions to match, it is rotten luck for patient and nurse if for six days you have to be manually lifted up the bed several times a day on a hospital ward. When you are discharged your conscience very rightly worries you about all the damage that you have left behind.

Other countries admire the Government's campaign about the scourge of the 1980s—AIDS. Of course there were some who sought to deride the campaign, yet who could possibly deny that it has made known the grim facts more widely than could ever have been hoped? Government funds have encouraged charities to prepare to take part of the strain and to raise necessary funds to help with care for cases in the community. I am attached to one such organisation and I am aware of the heavy programme and workload that is expected. Joint finance and other flexible plans are welcome in community care, but I, like several other speakers, should like that to be expanded. There are patchy conditions of care in the community, even in London. The back-up support of charities such as Crossroads Care Schemes and CSV deserve funding even more than they are at present.

District nurses do such wonderful work, yet I am amazed to find that, unless they own a car or a bike, in some districts they have to walk. In my area their patients can be as far apart as Knightsbridge and Earl's Court. With the new potential load I ask my noble friend to agree that every area should have its own car.

I particularly want to refer to RAWP because to my mind it is a ghastly trouble to London hospitals. It is particularly bad in that there are RAWP losers and RAWP gainers. However, what I believe to be wonderful, and a real step in the right direction is the fact that there has lately been a recognition of that. There has been a total grant of £30 million towards the hospitals which were in real trouble, with £10.6 million allocated to the Thames regions. Many of us see this as a small amount, but the hope is that it is a first step and that it will lead to more recognition that our heritage of hospital centres of excellence does not fall back and fall hostage to the RAWP theory.

It should be remembered that it was not this Government that initiated this uncomfortable scheme: it was thought out before, and particularly when noble Lords opposite were in government. I think that RAWP is particularly difficult for London because it ties the money to the people. It means that when somebody moves to live in the country then decides to commute back to London and use London hospitals, the money is not there to pay for them.

I cannot end my speech without reference to the most welcome establishment from July of a special health authority for the artificial limb and appliance services. Being an old client of the appliance centres, I applaud this and especially the selection of the noble Lord, Lord Holderness, as chairman, and Professor McColl as vice-chairman. I should humbly like to thank the Secretary of State on those appointments and for the attention paid to the McColl Report.

7.22 p.m.

Lord Rea

My Lords, I should like to spend about five minutes talking about the state of the nation's health, and about five minutes on the direction in which I feel that the National Health Service should be moving in order to cope with our major problems.

Just over four years ago I was in the same position as the noble Lord, Lord Peston, when I made a maiden speech, though not such a good speech. It was directed to what is again a topical issue: inequalities in health. My text was the Black report, which, incidentally, has never been fully debated in your Lordships' House. For me the most significant implication of that excellent report was that our health record could be equal to the best in the world—for example, that of Scandinavia, Holland or Japan—if the health of our least well off people could be improved to match that of the best off. The good state of health of the professional classes in the United Kingdom has been achieved by some whole nations. The higher mortality rates in this country of manual workers and their wives and children are more characteristic of less well developed nations, despite the fact that we are still a comparatively rich country with a long tradition of public health.

The report re-emphasised that the differences in health between the social classes were only partly dependent on health services as such, and were more related to long-term environmental influences such as housing, nutrition, education, smoking habits and conditions at work. It made 37 recommendations, 20 of which would have cost little or nothing to implement. Others, particularly those relating to child health and nutrition, had cost implications—£2 billion was one estimate. The suggestions of the report were therefore dismissed as being far too expensive and out of the question.

That now seems to be rather ironic considering the fact that £2 billion is the sum which has just been handed back to income tax payers at the better end of the pay scale, let alone all the money that has been received by the Government from the family silver auctions over the last five years. I believe that there is more to come from the nice furniture in the sitting-room, if I remember the words of the late Lord Stockton. In fact, only a few even of the cost-free recommendations of the Black report were carried out. Those were usually done by the district health authorities or the local health authorities rather than from central government initiative. As regards school meals, an exactly converse policy to the report's recommendations has been carried out.

We now have an update of that report called The Health Divide, compiled by Margaret Whitehead and published by the Health Education Council. Unlike some noble Lords, I have had a chance to read this fascinating and well-written document. It is a worthy successor to the Black report, with some 300 references to work done in the intervening seven years. It is an objective account. It does not question, for instance, the fact that overall our statistics have improved. It points out one example where social class differences have actually narrowed—in post neonatal deaths—illustrating that the class differential is not inevitable and can be reduced provided that resources are properly mobilised.

However, many more examples are given of the converse where the gap between the social classes has actually widened. In the case of coronary heart disease, not only has the gap widened but the actual rate of mortality has increased in manual workers and their wives, and deaths from carcinoma of the lung have also increased in the wives of manual workers. As has been pointed out, these differences can be largely attributed to the fact that smoking is more widely prevalent at the lower end of the social scale. The Government's decision not to increase the excise taxes on cigarettes and alcohol in the last Budget should be condemned.

However, recent research has shown that coronary heart disease in adult men is not only related to smoking but is also associated with a deprived childhood. Almost certainly a nutritional factor was involved in the childhood of those men, backing up the Black report's emphasis on the importance of child nutrition in improving the nation's health. One social class, if one can call it that—the unemployed—has become much more numerous since the Black report. Clear evidence is presented to show that their health experience, for both physical and mental illness, is much worse even than that of unskilled labourers in work.

A section of the report which looks at international comparisons describes the reduction of health differentials in Finland as a result of government policy. An important part of that was a concentration on primary care in the areas with the highest mortality. I quote: Building costs were switched from hospital to health centre buildings. By 1981 the community and hospitals sector were taking equal shares of the building budget (formerly the hospital sector took the major share)". At the same time: Differences between cities and rural areas in mortality rates of men aged 35–75 are said to have disappeared". That leads me on to a brief look at primary care services in the United Kingdom and last year's Green Paper. Now that the consultation period is over, we should be interested to know whether the Government's plans for primary care will be announced soon; or must we wait until after the election? If we do, we may be in a position to make proposals from this side of the House, though we shall be on the other side of the House by then.

One of the most important commentaries on the Green Paper is that of the Social Services Committee of another place, which has been mentioned by the noble Baroness, Lady Cox. I entirely agree with her speech and the points that she made: exactly the converse of her speeches when she is talking about education.

The Select Committee report is a distillation of much evidence both from the concerned professions and from the consumers. I find myself in agreement with most of their 55 recommendations. In fact, I should be pleased if the Government took them over lock, stock and barrel and incorporated them.

There is little doubt that good primary care is the key to an efficient health service, particularly with regard to reducing health inequalities. To increase hospital spending in deprived areas may be fair if it reflects the increased demand for acute care made by a less healthy population, but by itself it will do little to improve the poor health of the population. It may even deflect scarce resources away from the preventive and promotive activities which are an integral part of good primary care.

I would suggest that the Government take seriously the suggestions of the BMA and the Royal College of General Practitioners (my own college; and here I declare an interest) that the good practice allowance suggested in the Green Paper be dropped as such and replaced by performance linked contracts which could be entered into voluntarily by GPs prepared to provide an improved range of services. They could contract to provide these services to an agreed standard, taking appropriate training if need be. Such services include, for instance, computerised call and recall services for cervical screening or high blood pressure screening, child health surveillance, minor surgery, and special clinics for the surveillance of chronic diseases. There are other needs, and new priorities may well arise.

Additional costs for providing these services would need to be recognised. Recommendation 5 states: we recommend that the Government enter into negotiations with the medical profession about alternative ways of remunerating GPs to include a range of separate allowances related to the type of service offered". In this way GPs will be encouraged to provide help to those who need it most but who do not come forward until too late as things are.

As there is still a little time to run, I should like to add a further recommendation to those in the Green Paper. It is one which seems to have been omitted. Individual GPs vary enormously in the frequency with which they refer patients to hospital. One study has shown that the costs of the hospital care of their patients per doctor ranges from £100,000 to £500,000 per annum.

A recent study in Manchester was unable to determine whether high or low users were practising the best medicine. I suggest that GPs may make more rational use of expensive National Health Service facilities if they are each sent confidential statistics of their referral patterns compared with national and local averages. This was an important point made by the Green Paper which seems to have been omitted by the Select Committee report. There are many other recommendations in the report that I should like to describe to your Lordships, but time is short. I commend the report to the Government, and I hope they will be guided by its very wise suggestions.

7.35 p.m.

Baroness Masham of Ilton

My Lords, my life was thrown into confusion this week. The BA aircraft on which I was due to return from holiday broke down. There was a delay of 17 hours. This meant I was unable to ask a supplementary question on Monday about the future funding and management of the Portman and Tavistock clinics. The answer given by the Government makes clear that they are still deferring a decision. The insecurity and lack of decision is not good for staff morale.

These clinics try to help some of the most complicated and difficult cases in society. They deal with the sexually abused and those who do the abusing. They train social workers and other staff throughout the country. Recently they have had an application from the health district of Hull to train 400 staff. This illustrates how wide is the need. It seems sensible to create a special health authority to deal with the growing problems of sexual abuse and the horrendous outcome.

Many noble Lords have mentioned the crucial problem of nurse recruitment. A sister at the Westminster Hospital told me only yesterday that recruitment was at rock bottom. I was recently a patient at Stoke Mandeville Hospital which has recruited nurses and auxiliaries from the north of England, many of them splendid people ready to learn. But the accommodation offered them within the hospital was very poor and they could not afford to live out.

Several staff left because the pay was so bad. An auxiliary receives between £3,000 and £4,000 a year. One day a doctor stormed into my room, his face white with fury. A government Minister had made a statement that 90 per cent. of nurses had their own accommodation. The doctor said, "It is not true. In Oxford, if they can get accommodation, they cannot pay for it. In Aylesbury, it is the same".

Today, one of your Lordships' staff told me that his local hospital has had to close wards and the casualty department because of lack of staff. This is the West Middlesex Hospital. I hasten to add that among nurses there are some glowing stars of first-class efficiency and dedication. Many of them come from southern Ireland.

Last night, I went through 122 job applications for a director of our North Yorkshire Red Cross. Several were senior nurses in post in the National Health Service. While pleased that they are applying to the Red Cross, I am worried that they are not content to stay within the health service. What has gone wrong? Is it job satisfaction or frustration within the administration? In this case, it is not money, as the Red Cross cannot afford high wages.

The regional health authority of Yorkshire is losing its general manager, an excellent person with a good wage, but the appointment is only for three years. Do not even general managers need security? Even someone of that calibre who comes into the National Health Service from outside takes time to learn about the vastness of, and the complexities within, the service. It is sad when they leave after two years.

A few weeks ago I attended an interesting conference organised by the DHSS on incontinence. The message from the conference, attended by health managers from throughout the country, was that incontinence is a matter which needs specialised treatment and support, especially in the community nursing service. Many of the specialists working in the community were overwhelmed by the amount of work. They felt isolated and in need of support. Many National Health Service staff working with emotional and difficult health problems need support and a good supply of equipment to deal with those problems. It would be serious if incontinence aids were not readily available because of cost.

One of the frustrations for some staff working within the hospital service is outdated and inadequate equipment. I have had letters about a three-year-old child who is on a ventilator. The correct ventilator was not available. Her parents were devastated with worry. Voluntary contributions to hospitals are most important, but it seems that every health district needs a Jimmy Savile, who has a gift for fund raising.

Having recently been a patient in a National Health Service hospital, I found the food in the spinal unit of Stoke Mandeville Hospital monotonous, with hardly any fresh vegetables, and badly presented. For patient morale and wellbeing, this is serious. One pound and eight pence is allocated per day per patient for food, and this includes drinks. Many patients send out for take-away food, which is delivered by taxi. Patients who cannot afford this borrow money from other patients, and I wonder whether they ever pay it back. I feel that if food was better and more imaginative, patients might get out of hospital quicker.

With the increase in alcohol abuse and illegal drug taking, violence in casualty departments is increasing. We must find ways of protecting our hardworking hospital staff. Not only are they at risk from infection; they are at risk from violent assaults.

I have a few minutes in which to thank the noble Lord, Lord Ennals, for instigating this debate. I hope that he will do so on many more occasions. I also congratulate the maiden speaker, who is not in his place, and say that I hope we shall often hear from him. It is always good in your Lordships' House to have new supporters for the National Health Service. They are greatly needed. I was hidden behind Bar but I listened to every word said. By concluding my remarks now, I am able to provide a few extra minutes to other speakers.

7.41 p.m.

Lord Cullen of Ashbourne

My Lords, I shall be very brief. It had been my intention to make two points only. Fortunately one of these has become unnecessary owing to the speeches of the noble Lords, Lord Ennals and Lord Winstanley. I had intended to endeavour to bring to an end the endless accusations of Opposition speakers and the media about cuts in the National Health Service, but both noble Lords were refreshingly realistic on this score. They appreciate that National Health Service spending rises annually in real terms. In fact, I understand that since 1978–79 it has risen by 26 per cent. in real terms, which is a very large increase.

Now that the two noble Lords have acknowledged that former accusations of tax cuts are completely wide of the mark, I trust and hope that the media will follow suit. It has been tedious and highly misleading to the public to continue year after year and month after month with these false accusations. Now at last the criticism that the Government are not spending enough on the NHS is quite fair. It may even be right, though I feel sure that my noble friend Lord Hesketh will come forward with a robust argument to refute it.

Secondly, I should like to draw to the attention of any noble Lords who have not seen it a very interesting document issued by the Institute of Directors entitled The Business Leaders' Manifesto. This is its manifesto for the incoming government, whoever and whenever it will be. It is easy to read. It explains the poor performance of this country since 1945 against that of our competitors and makes radical recommendations over a wide front and over a long timescale.

The noble Lord, Lord Porritt, in an extremely interesting speech pleaded that the whole structure of the NHS should be re-examined. That is what the Institute of Directors has done. Many noble Lords have observed that whatever government are in power the National Health Service never has sufficient resources to cope with demand. The institute is well aware of this; hence its wish radically to change the structure that exists today and to reconstruct it on the lines originally envisaged. It is probable that unless we do this we shall never overcome the difficulty.

Among other things, the institute proposes, first: a return to the principle of Beveridge in the financial structures of health and social security spending, making them honest, open and transparent to the individuals who pay for them". Secondly: introducing tax reliefs for private health and welfare insurance and eventually introducing financing based on compulsory insurance provision with the State paying the premiums for the small group unable to meet them". It is not possible for me to do other than point your Lordships in the direction of this manifesto. It covers a whole range of other issues: social security, taxation, local government, employment, and so on. It all hangs together.

I believe that all of us must be equally concerned over the huge and mounting costs of our welfare state. I for one am grateful to the institute for putting forward solutions to that pressing and escalating problem, among others. I commend them to your Lordships.

7.45 p.m.

Lord Kilmarnock

My Lords, a commentator suggested recently that after the Royal Family the National Health Service was our most popular national institution. The number of speakers this afternoon has given some credence to that point of view. The right reverend Prelate the Bishop of Manchester said that it was popular even with fanatical anti-collectivists.

I shall not go into all the statistical wrangles, claims and counterclaims on expenditure. The noble Lord, Lord Ennals, said that the service needs a 3 per cent. increase in real terms per annum and the Labour Party is pledged to that. The Government claim 26 per cent. since they came to power, though my noble friend Lady Robson has given indications as to why that does not quite work out in practice and the Alliance is pledged to 2 per cent., with a substantial development fund. I want rather to spend my few minutes dealing with the receiving end of the service where the claims of politicians meet their real test.

The Health Education Council's swansong, The health Divide, which one might call a successor to the Black Report, has been mentioned this evening particularly by my noble friend Lady Seear. It is indeed a remarkable document, not least because it is scrupulously fair about the difficulties of evaluating some research data. But its central message is not open to challenge; namely, the results of these studies taken together, give convincing evidence of widening health inequalities between social groups in recent decades especially in adults". I was surprised to hear the noble Baroness, Lady Trumpington, counter this on Monday by repeating that, overall, health in the United Kingdom is improving steadily, with rising life expectancy and reduced infant mortality. Of course it is: the report recognises that. The noble Baroness, Lady Turner, recognised that in her speech, but it is not the point. The point is that: In general, death rates have declined more rapidly in the higher than in the lower occupational classes, contributing to the widening gap. Indeed, in some respects, the health of the lower occupational classes has actually deteriorated against a background of general improvement in the population.". Frankly I do not find that surprising. Inequalities are seldom isolated phenomena.

Just as the gap between the richest and the poorest has increased within an overall increased national income—and the plight of the homeless has become worse within an overall pattern of increased home ownership—so health inequalities have increased. It is all part of the same pattern. Indeed shortcomings in other spheres of policy such as housing and employment feed through into health, just as one would have expected and as my noble friend Lady Seear said in her speech.

This being so I want to ask the noble Lord my first question. How does this trend accord with the Goverment's commitment in 1980, renewed, I believe, in 1984 together with the 33 other members of the European Region of the World Health Organisation to ensure that: By the year 2000, the actual difference in health status between the countries and between groups within countries should be reduced by at least 25% by improving the health of the disadvantaged nations and groups."? Can the Government say in the light of this report how these aims are to be advanced, because all the evidence is that the trend is moving in the opposite direction at an accelerated rate? That is my first question.

I turn to the subject of waiting lists. They have already been discussed but they constitute one of the major flaws in the whole system. The last figures available, which are the Government's figures, show a total of 717,761. The noble Lord, Lord Ennals, gave a smaller figure but I believe that that referred only to England while this is the most recent figure available for England and Wales. It represents a 3 per cent. increase over the year ended September 1985. It is particularly disappointing when all health authorities have been asked to prune the lists of those no longer requiring an operation or of those who have moved away from the district.

We are going to have a debate on the crisis in nursing and there will be other occasions to go into this in more detail. But it is interesting to note that the situation is so bad that the College of Health now publishes a guide to hospital waiting lists, an advance copy of which I hold in my hand. It analyses the background to the waiting lists and gives valuable advice to those who are able and willing to shop around and seek treatment in another district.

As your Lordships will know, there is already a system of cross-boundary flow payments, and the patient's general practitioner may be prepared to co-operate. But it all requires a lot of homework in ringing around and consulting one's community health council, etc. Even if you have the time and the initiative, there are problems with this DIY approach, such as the cost of travel to another district and difficulties for your relatives in visiting you, and so on. Basically you are trying to beat a system which is no longer user-friendly.

Why should the system not be user-friendly? As I said, cross-boundary flows are already rather reluctantly recognised. We on these Benches would go further and suggest that DHAs should adopt a deliberate policy of buying in some services from other districts and selling their own specialties on a much wider scale than at present. This could benefit authorities with strong specialties which lose money under RAWP, as was mentioned by the noble Baroness, Lady Lane-Fox, and allow them to use to the full their manpower and facilities. That is far better than sacking staff, closing wings and maintaining empty beds. I gather that Guy's and St. Thomas's have been trading in this way for some time, and the system could be extended much more widely. If accompanied by a right for the patient to be treated within a certain time, it would give a tremendous boost to the reduction of waiting lists.

What have the Government proposed? Last July the Secretary of State announced a new drive to reduce waiting lists. It was to continue over three years and the intention was to treat an additional 100,000 patients a year. He allocated £50 million for two years. On 17th February last it was confirmed that £25 million would be available for the present year and that the extra funding would allow for at least 5,000 extra hip replacements. But at £2,500 a time, these will cost £12.5 million, leaving only an equivalent amount of £12.5 million for the remaining 95,000 operations.

In a press release on the same day, 17th February, the DHSS said that these operations would include 22,000 general surgery operations, 20,000 orthopaedic, 14,000 ophthalmic, 14,000 gynaecological, 8,000 ear, nose and throat and 6,000 concerned with plastic surgery. That is marvellous news if it can happen, but can the noble Lord tell me how on earth all those operations are going to come out of the remaining £12.5 million in this year's allocation? To put it the other way round, will the Government pledge themselves to those 100,000 additional operations and pay whatever is necessary to deliver them—or are we to be sceptical in the future of the department's press releases? I very much hope that the noble Lord will assure me that that is not the case.

Finally—and I do not want to trespass on the generosity of the noble Baroness in having given us a minute or two more, as other speakers are to follow—I turn to an area in which the Government have a relatively good record; namely, the treatment of AIDS. I want to ask the noble Lord two questions, of which I have given him notice. I hope that he received my note. A community care conference was held on Wednesday, 25th March, chaired by the Secretary of State, which considered among other things care in the community for AIDs victims. I believe that the Secretary of State was much impressed by what he saw in San Francisco. Can the noble Lord say what money the Government will put into a similar system of hospices in this country? Is he aware that the London Lighthouse Project has enough money for only another three months of its building programme? Is any help at hand?

I am still not clear—indeed I think none of us is entirely clear on this matter—how every district health authority in the country is to comply with the Secretary of State's direction to draw up an AIDS plan, to appoint an AIDS prevention officer, to instruct its own professionals in AIDS detection and so on within its normal budget. I am aware that it is the Government's intention to finance AIDS expenditure through the usual channels. There is something to be said for not having a whole separate system which might seem to relegate the disease to the category of a plague or to give it some kind of ghetto status.

Even so, additional sums have been made available to some regions and they will become increasingly necessary. AIDS care is labour-intensive. Existing teams are in danger of burning out. There is a lack of junior doctors because training posts are not available and they cannot count work in this field as a career credit. In short, there is a host of problems which cannot be solved by inadequate central subsidies plucked out of the sky in an emergency. Would it not make more sense to set up a central AIDS fund to which districts could make bids for sums specifically related to their own plans and requirements, and indeed to the incidence of the disease in their own areas? All these vary very much up and down the country. Would the noble Lord discuss this suggestion with his honourable friend the Minister for Health? He cannot give me an answer now but I throw this into the pool for discussion and I very much hope that it will receive serious consideration. Otherwise I think we shall run into trouble in that area, despite the Government's excellent efforts to date.

In contradistinction to some of the other areas we have discussed this evening, I think the Government's approach to AIDS has obtained widespread general support. It would be a pity if this essential element of public confidence was to be eroded by an inadequate funding mechanism. I hope very much that the noble Lord will be able to reassure me on these points.

7.57 p.m.

Lord Prys-Davies

My Lords, for over four hours we have been debating a subject of vital interest to the people of the four countries of the United Kingdom, because we are all patients or potential patients. We are grateful to my noble friend Lord Ennals for the opportunity to focus attention on the National Health Service.

We have listened to a series of important speeches, often based on considerable experience of the NHS. According to my account, the issues which have dominated the debate are the inequalities in health which have been referred to by some eight or nine speakers, the underfunding of the NHS, the inadequacy of the community care facilities, the crisis in the nursing profession and the growing waiting lists. Those are the issues which have dominated the debate, and many searching questions have been asked. They are begging for an answer, and we await with interest the Minister's replies. Of course I join with other speakers in thanking my noble friend Lord Peston for his well-informed and reflective speech.

The subject is wide, but I propose to exercise a little discipline and go straight away to the Government's central theme in relation to the NHS. It has been the Government's case for some time that the NHS has been prospering since 1979. This case rests on four assertions, and they were advanced last Monday during Question Time by the noble Baroness, Lady Trumpington. They are recorded in col. 360 of Hansard for 30th March. The four main assertions are these: the increased resources which the Government have put into the health service since 1979; the increasing number of patients who are being cared for; the improved treatment which is being offered; and, finally, the assertion that the overall health in the United Kingdom has improved steadily. That is the Government's case.

It is our case that these assertions or arguments are sometimes misleading because they are not based on the whole truth or because they are taken out of their true perspective. I shall analyse them very quickly. My noble friend Lord Ennals, the noble Baroness, Lady Robson of Kiddington, as well as several other noble Lords have brought the increased budget into its true perspective by reminding the House that the increased funding—and certainly we do not deny that there has been increased funding—has failed at least since 1982–83 to keep pace with additional demands being made by the growing number of elderly, the increase in costs of medical technology and the increase in NHS pay and prices.

That is the main reason, though not the only reason, why we read all too frequently about wards and operating theatres being closed permanently or temporarily because of shortage of funds for that particular service or shortage of nurses in key specialties such as intensive care units and theatres.

Then the Government go on to call in aid the increased number of in-patients who have been cared for in our hospitals since 1979. But increased productivity is not new; it has been improving ever since the first day of the NHS. Of course we are immensely grateful for that, and this gives me the opportunity to express our appreciation of the skills and care of all the members of the health team who work in hospitals and in the community.

It must be noted that the improved productivity since 1979 has been achieved notwithstanding a reduction of about 36,000 or 37,000 hospital beds. It will be our case that further improved productivity is no longer a risk-free policy because it inevitably reduces sharply the period of convalescence in hospital, and if reduced too far this could lead to premature discharge. Is this already happening? Will the Minister, when he comes to reply, enlighten the House as to how many patients were re-admitted to hospital once or twice within 12 months of their discharge in 1986?

We cannot leave the question of productivity without drawing attention to the very long waiting lists. This has dominated the debate. They have grown, according to my account, by about 2 per cent. to 673,000 in the last six months. This would have been the highest ever recorded if the lists were currently being calculated on the same basis as before 1979. In the 1983 debate in your Lordships' House on the state of the NHS, the Minister could bracket the figures of improved productivity with the steady progress in reducing the waiting lists. But this is something which the Minister can no longer do. I noticed that when opening the debate the Minister was silent on the question of the waiting lists. I submit again that this is the price we pay for closed wards and the shortage of nurses in the key specialties.

One could demonstrate how the long waiting lists can lead to unfairness. For example, three weeks ago I heard of a woman patient in my parish who had a lump in her breast but could not obtain an NHS consultant appointment in under six months. Worried, she agreed to pay the fee for private consultation and was seen within five days. But this option is not available to all patients. We say that it is unfair and unjust that patients in a priority category such as this should have to wait six months or more for an urgent consultation. I am sure that this lady in my parish is not an isolated figure.

I move onto the third assertion; namely, the improved treatment which is being given. Of course we are immensely grateful for improved treatment, wherever it is on offer; and it has been on offer since 1948. But let it be remembered that the improved treatment of today often rests on a long line of research and also on the level of excellence in our teaching hospitals. I think this point was touched upon by my noble friend Lord Bottomley and it may have been elaborated on by the noble Lord, Lord Nugent. This is a subject which your Lordships' House discussed on 26th November 1986 when we drew attention to the fact that medical research is now in jeopardy and that the country has lost, since 1979, the equivalent of one medical school. If we are today denying the Medical Research Council and the medical schools adequate funds, where will the medical miracles of tomorrow come from? I should therefore be grateful if the Minister would tell the House what level of support the MRC and the medical schools and teaching hospitals can expect to receive from this Government.

To return to the question of improved treatment. perhaps I may say that it is patchy. For example, has the treatment improved for those suffering from chronic bronchitis? We have heard that the Government are setting targets for so many extra hip replacements, so many extra coronary bypass operations, so many bone marrow operations, so many extra cataract operations, as well as the list to which the noble Lord, Lord Kilmarnock, referred. We gather that the Government are setting targets for additional operations, but this is some acknowledgement, nevertheless, of an unmet demand.

What about the care received by the mentally handicapped, the mentally ill and the elderly in the community? Has their treatment improved? Organisations such as the National Schizophrenia Fellowship and the newly-founded RESCARE are by now actively campaigning for the retention of many of the hospitals scheduled for closure until such time as improved facilities are available outside the hospital. Indeed, they are holding a meeting here in Westminster in a few weeks' time, because experience tells them—and I think this is the point that has been made already this evening—that in general, life in the warmth and within the community of the hospital is far better than existence in many bed and breakfast lodgings which have mushroomed since 1982 and which are financed by the DHSS.

The testimony of these two voluntary organisations can be coupled with the illuminating evidence of the Audit Commission published last December which has been referred to. The commission found that there are today at least 25,000 fewer long-stay hospital beds than there were 10 years ago, but there are only an additional 9,000 day-care places. As has been said, very little is known of the whereabouts of the 17,000 or 20,000—it could be even more—who would have been in hospital 10 years ago. The noble Lord, Lord Hastings, asked a number of searching questions: where are the missing 17,000 or 20,000! What care are they receiving or not receiving? Is it true, as has been reported to RESCARE and has been suggested by the noble Lord, Lord Hastings, that a small number of mentally handicapped persons may even be in prison? If that is true, what on earth is being achieved by sending these unfortunate people to prison?

Forty-eight long-stay hospitals are due to close in the next eight years with the loss of 10,000 more places. Yet I have been told that the DHSS or the regional boards or both are pressing the district authorities to accelerate this planned rundown. Will the Minister take heed of the warnings of the voluntary organisations and the warnings that have been issued in the Chamber this afternoon? Can he therefore confirm whether or not the regional boards are pressing the district authorities to accelerate the planned rundown? Indeed, will the Minister tell the House which of the Audit Commission's recommendations have been accepted by the Government?

Finally, I come to the Government's fourth assertion—that overall health in the United Kingdom has improved steadily. Of course TB is not the plague that it was and people are not dying from diphtheria, but then we have the evidence of The Health Divide which has dominated the debate today. This document published last week shows that all the major killer diseases now affect the poor more than the rich, and confirms that the inequalities in health between the social groups are widening.

I can only ask the Minister whether this report, like its predecessor the Black report, is to be shelved or ignored. Unless the Government can demolish the Black report and The Health Divide report—and we on this side of the House do not believe that they can be demolished—the noble Baroness and the Minister cannot assert that overall health in the United Kingdom has improved steadily since 1979.

I must now conclude. The Government's case that the NHS is flourishing rests on the four assertions which we have examined, and it is our submission that those assertions are misleading. But it is rather interesting that no one has attacked the concept of the NHS, the principles of the NHS, which is after all one of the outstanding creations of the post-war Labour Government; and its principles are for the vast majority of people every bit as relevant as they were in 1948. That has been suggested by the noble Lord, Lord Soper, and by the right reverend Prelate the Bishop of Manchester. So when we talk of the failure of the hospitals to tackle the waiting lists, or the failure to provide adequate community care facilities, we are talking in the main but not exclusively about the shortcomings of a government who seek to run the NHS on the cheap.

8.12 p.m.

Lord Hesketh

My Lords, I have a very heavy right arm with the many questions raised in this afternoon's debate, and a great debate it has been. But before I say anything I should like to congratulate the noble Lord, Lord Peston, on a remarkably good maiden speech. I thought he summed up extremely well part of the whole problem that lies before us today. I hope he will forgive me if I slightly paraphrase him. He said that no matter how rich we become, we shall never be able to exceed demand. That is true.

I would also, before answering as many of the questions as I can, like to reply to the noble Lord, Lord Ennals. He suggested that Ministers do not use the National Health Service. This Minister, be he very junior, was for four days an in-patient of the National Health Service quite recently and is very grateful for the fine service which he received.

I think we all agree on both sides of the House about our wholehearted support for the very fine work that everyone in the health service has done for the service. The noble Lord, Lord Taylor of Blackburn, the noble Lord, Lord Auckland, the noble Baroness, Lady Lane-Fox, and many others paid great tribute to the voluntary sector and I wholeheartedly support the tribute paid to those who undertake voluntary work in the health field. It is hard to overstate the value which we place on this and I shall take the suggestions on board, particularly those of the noble Lord, Lord Taylor of Blackburn, and draw them to the attention of my noble friend the Minister. I believe that the noble Lord, Lord Porritt, spoke for all of us in this debate, as did the noble Lord, Lord Prys-Davies, at the end, in saying that no one questioned the National Health Service and he hoped very much that its future could be discussed without politics. I for one wholeheartedly agree with that.

The noble Lord, Lord Ennals, felt that the Government claimed that we were spending more money on fewer hospital beds. It is true that there are fewer hospital beds, but those which we have are being used more intensively and effectively than ever before. Sometimes the increased levels of activity run ahead of the resources available, and temporary reductions in services have to be made if authorities are to remain within their cash limits.

It will always be difficult, if not impossible, to explain the rationale behind such decisions to those who are still waiting their turn. But I know that your Lordships will recognise the underlying significance and the advantages to the National Health Service and its patients of higher productivity and lower unit costs, which the noble Lord, Lord Prys-Davies, also mentioned.

The noble Lord, Lord Ennals, and the noble Baroness, Lady Turner of Camden, referred to spending on health in this country compared with overseas. International comparisons of this kind are notoriously unreliable because of differences in the definition and range of services provided. For example, what we classify as personal social services others may include in health service provision. Nevertheless. I hope your Lordships will recognise as significant the fact that health spending per head of population grew in real terms in the United Kingdom by 21 per cent. between 1978 and 1983—well above the average for Western countries.

The noble Baroness, Lady Robson of Kiddington, felt that the cash allocations to regional health authorities would not enable nurses to be awarded the pay rise that they deserve. She will surely recognise that planned cost improvements, amounting to savings of as much as £150 million, will be retained by health authorities to the benefit of their local services.

The noble Lord, Lord Ennals, and the noble Baroness, Lady Lane-Fox, drew our attention to the need for more money for community care. The latest estimates we have of expenditure by local authorities on personal social services indicate an increase of almost 30 per cent. in real terms nationally between 1978–79 and 1986–87—substantially more than is required to keep pace with demographic pressures. For 1987–88, the rate support grant settlement allows for a 3½ per cent. increase.

The noble Baroness, Lady Seear, the noble Baroness, Lady Cox, and the noble Lord, Lord Hastings, drew our attention to the importance of real care for those who need community care. I refer them to my noble friend's speech with regard to the position of those discharged from long-stay care. We have consistently said that no long-stay patient should be discharged until appropriate care is available to support him or her outside the hospital.

The noble Lords, Lord Ennals, Lord Winstanley and Lord Soper, drew our attention to prescription charge increases. The recent increase in prescription charges of around 9 per cent. is broadly in line with rising costs of medicines. We believe that people who can afford to do so should contribute. I remind your Lordships that 75 per cent. of all prescriptions are dispensed free. There was a further point raised by certain noble Lords that the cost of 30 per cent. of prescriptions was beneath the charge for the prescriptions themselves. But the remaining 70 per cent. cost rather more than the prescription charge.

The noble Baronesses, Lady Cox and Lady Robson, spoke about the low morale and low pay of nurses. Pay is a matter for the independent Pay Review Body, which is expected to report to the Prime Minister shortly. Members will not expect me to anticipate the review body's recommendations, other than to say that it will be carefully considered by the Government when it reports. I take this opportunity to remind your Lordships that the basic pay rates for nurses have risen by 10 per cent. in real terms since 1983 and 23 per cent. since 1979.

The noble Lord, Lord Ennals, referred to the shortage of nurses. In the country as a whole the picture is less gloomy than some anecdotes might suggest, but there is evidence of shortage in key specialities in London and the South-East, particularly in the inner-city areas. Basic pay, which is a matter for the independent Pay Review Body, does not appear to be a major factor affecting recruitment, though the high cost of housing in the South-East is a major source of difficulty. The National Health Service Management Board is now discussing with the regional health authority chairmen what action might be taken in conjunction with local management to overcome problems.

The noble Lord, Lord Winstanley, drew our attention to the shortage of nurses' accommodation. I am aware of a shortage of reasonably priced housing in some parts of the country, particularly London and the Home Counties, which affects the ability of some health authorities to fill key nursing posts. Consideration is being given to what measures can be taken. In so far as certain accommodation has been sold, often it has been inappropriate and unsuitable for young professional people to use. Therefore, it is not entirely a case of property being sold which is suitable for nurses, because it was deemed to be unsuitable for them.

Lord Ennals

Slum property.

Lord Hesketh

The noble Baroness, Lady Seear, referred to the new Health Education Authority. I should like to speak at some length on that matter. The new Health Education Authority will be directly involved in planning disease prevention and health promotion within the National Health Service. It will do that in a way in which the old Health Education Council never could. The Health Education Council stood outside the National Health Service and had only limited involvement with district and family practitioner committee planning and service provision.

The chairman of the new Health Education Authority has been given a seat at the table of the Secretary of State's health cabinet where regional health authority chairmen meet regularly with Ministers. He will thus be directly involved in the process of developing policy and service provision within the National Health Service. Not only will health education be directly represented for the first time at these meetings. The development of health education itself will also be greatly assisted by being kept firmly in touch with service needs.

The right of the new authority to take an independent stance on matters within its remit is not at issue, given that it will work, just as the HEC did, within the framework of ministerial accountability to Parliament. The policy to increase the vigour and effectiveness of action throughout the National Health Service to prevent illness and promote good health as part of the National Health Service with access to Ministers means that there will be no need for confrontation or pressure group tactics.

Lord Dean of Beswick

My Lords, will the Minister give way for a moment? As regards the chairman of the new authority being allowed a place at the table with the chairmen of the regional health authorities, the Minister must be aware that the overwhelming number of members of regional health authorities are now either members of the government party or active supporters. Therefore, where will this independence come from?

Lord Hesketh

My Lords, that is a point on which we must agree to differ. The right reverend Prelate the Bishop of Manchester referred to the suppression of The Health Divide. The Government have not been involved at all in the commissioning or publication of that document. The Government did not attempt in any way to prevent publication, and the document has been distributed and is freely available. I understand that the chairman of the Health Education Council has emphasised that at no time did Ministers intervene.

The noble Lord, Lord Hunter, brought up the important matter of measles inoculation. I am glad to say that the uptake rate in England and Wales of vaccination against measles has improved from 63 per cent. in 1984 to 68 per cent. in 1985. Further improvement is essential if children are to be spared the avoidable distress of disability arising from the disease.

The noble Lords, Lord Bottomley and Lord Soper, together with the right reverend Prelate the Bishop of Manchester, felt rather opposed to the private sector in health care. However, patients have had the right to private care since the beginning of the National Health Service, as have doctors. That follows the fundamental principle that people in this country have a right to spend their money on anything they wish including their health care. Private medicine is no threat to the National Health Service. On the contrary, the existence of a thriving private sector usually strengthens the health service by relieving it of some work and enabling it better to meet its obligations.

The noble Lord, Lord Ennals, raised the matter of occupational therapists. The department accepts that the supply of occupational therapists is insufficient to meet continually rising demand, although recent surveys show that the number of funded posts in the National Health Service unfilled for three months or more has fallen significantly.

The noble Baroness, Lady Cox, who is not present, raised the matter of pilot projects with regard to the Cumberlege Report. The points made in the report which attracted particular comment include the concept of a neighbourhood nursing service, which in some areas is already being provided although perhaps under another name. The report also recommended a manpower planning exercise on community nursing numbers. We have already amended the National Health Service planning system to ensure that we receive information on future plans for seconding nurses to district nurse and health visitor training. Unsatisfactory responses will be taken up within individual regions throughout the accountability review process.

The noble Baroness, Lady Seear, and the noble Lords, Lord Porritt and Lord Ferrier, together with many other noble Lords, suggested that the department be split up. In my humble position, I suggest that this is a subject of which I should steer very clear. The noble Lord, Lord Hastings, drew our attention to two services for epileptic people and suggested that they should be designated as supranational. An application to recognise certain special services for people with epilepsy as supra-national has been put to the Advisory Committee on Supranational Regional services. My right honourable friend the Secretary of State is awaiting the advice of the committee.

The noble Lord, Lord Dean of Beswick, referred to the possible closure of the accident and emergency departments at Ancoats Hospital. I understand that the North Manchester Health Authority will shortly be consulting the community health council and the public generally on the future of the accident and emergency departments. The Secretary of State will take into account the views expressed, and particularly those expressed this evening by the noble Lord.

The noble Lord, Lord Dunleath, drew attention to homeopathy in Northern Ireland. He kindly offered to allow me to answer his question after this debate. I am extremely grateful. Time is beginning to run out but I shall try to deal with a few more questions. The noble Baroness, Lady Turner of Camden, pointed out that 205 hospitals had been approved for closure since 1979. I agree with that. However, I remind her that that is fewer than the number of hospitals closed in the five years from 1974 to 1979 The noble Lord, Lord Rea, drew our attention to the situation in primary health care. In the consultation period the Minister chaired 12 public consultation meetings. Over 2,000 written comments were received, some of them after the 31st December deadline. The Government are now studying the large body of evidence submitted, including a report by the Social Services Committee of the House of Commons. They will decide in the light of those consultations what changes to pursue. I am sure that noble Lords would not thank the Government for reaching hasty judgments on these matters.

The noble Lord, Lord Kilmarnock, asked about AIDS and hospices. The local health authorities must make local decisons about the level of spending on hospices. The provision of hospices may be the right approach in some districts. My right honourable friend the Secretary of State recently announced a central allocation of £7 million in 1987–88 to meet extra costs generated by AIDS.

The noble Lord, Lord Prys-Davies, asked me a question concerning the number of extra cases in the health service which were readmissions. Studies suggest that while some of the increase in cases treated is due to readmission, the greater proportion is for new patients. Furthermore, many readmissions are in any case a planned part of the patient's treatment.

The Government have shown how they care for patients by putting patients first. We have done this by ensuring that the health service is more efficient, more flexible, better managed, better financed and better housed. Efficiency is about putting patients first, because it is about delivering more care for every pound spent. My noble friend Lady Trumpington has already quoted some exciting and impressive examples of the improvements in efficiency in recent years.

The health service is also using resources more wisely. We are making better use of facilities. Over 38 cases were treated per bed in 1985 compared with 28 in 1978. We are also making better use of financial resources. For example, rationalisation of NHS land usage will produce £200 million from the sale of surplus land and property in 1987–88.

The health service is now more flexible, and is more responsive to patients' needs and wishes. Waiting lists for NHS hospital treatment are now over 70,000 less than when we came to power. We recognise that in some areas and for some specialties patients have to wait too long. This is a major cause of frustration, inconvenience and distress. That is why we have launched a major three-year initiative to improve waiting times and waiting lists. To help health authorities to make a more rapid progress in tackling this problem we have established a special waiting-list fund of £50 million over two years. My right honourable friend the Secretary of State recently announced the allocation of the first £25 million for 1987–88. This will support over 350 projects throughout the country and enable an additional 100,000 cases from the waiting lists to be treated. These will include at least 5,000 hip operations and 8,000 extra cataract operations. I am sure noble Lords will understand exactly what that means in human terms.

Good management is essential to the efficient and effective running of any organisation, and the health service is no exception. This is why we have taken steps to ensure that the service is better managed. The introduction of general management, as my noble friend Lady Trumpington has said, has been a big step in securing a well-run service.

Not only are we making more efficient use of resources; there has been real growth in the resources the Government have devoted to the service. That commitment to growth in the health service is a continuing one. The figures on health service finance are large. In 1987–88 we shall be spending nearly £17 billion in England alone—£1 billion more than in the last financial year, and almost three times the amount spent in 1978–79. In other words, we shall be spending about £47 million per day. This means that spending will have risen about 28 per cent, ahead of inflation since we came to power.

Finally, the service is better housed. It always irritates me that the opening of a new, modern hospital is news for only a day, whereas the closure of a hospital can be bad news for years. Our health service building programme is of a massive order. We have started and completed more than 170 health service building schemes, each worth over £1 million. In the coming financial year alone we shall be spending more than £1 billion on capital schemes, and looking to the future, over 100 such schemes costing a total of about £700 million should be completed over the next three years. This is the biggest health service building programme by any government. Look back into what happened during the previous Labour Government. It is a dismal picture of cuts and cancellations.

I fear, listening to some of the contributions made by noble Lords this afternoon and this evening, that one could end with a distorted picture of the health service today. It is a caring service. Its job is caring for individual people. It is now providing more care more efficiently than ever before. In the future we are committed to improving and expanding the service still more. That is why I am proud to stand here today and talk about the health service which we all cherish. The Government's commitment is to the people of this country in sickness and in health, today and into the future.

Lord Kilmarnock

My Lords, before the noble Lord sits down, he answered my first question on AIDS but not the second. Will he write to me?

Lord Hesketh

I will.

Lord Ennals

My Lords, let me say how grateful I am to noble Lords in all parts of the House for taking part in what has been an excellent debate. I should like to thank the Minister for the replies he gave. Fortunately my task is not to reply to the debate or we would have another debate.

Although we have discussed various aspects of the health service on a number of occasions, this is the first time in four years that we have had a debate on the National Health Service as a whole. I want especially to congratulate my noble friend, who has been congratulated by everyone. He must be feeling great.

I have three quick points. First, at the time of the Budget the Government had to decide whether to make tax cuts or to put more money into the NHS. They decided on tax cuts rather than more money. I repeat that because it is a fact.

The Minister of State, Ministry of Agriculture, Fisheries and Food (Lord Belstead)

No.

Lord Ennals

Yes, yes, yes.

Secondly, I want to emphasise what was said by a number of noble Lords about community care. Voluntary organisations and local authorities must provide services before people are moved from long-stay hospitals. As I said, is not bridging funding essential? I was disappointed not to have had a reply on that.

No one has said anything about my third point, but I believe that too many people are chock-full of pills. They are given a pill, or six of them, for every ill. I am increasingly aware of the importance of a healthier lifestyle and the value of natural medicines.

I warmly welcome the debate that we have had and feel privileged to have had the opportunity of opening it. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.