§ 3.45 p.m.
§ Lord Hesketh
My Lords, with the leave of the House, I shall now repeat a Statement made in another place by my right honourable friend the Secretary of State for Health. The Statement is as follows:
"Britain enjoys high and rising levels of health care and, at its best, our health service is as good as any in the world. I believe that the principles underlying the NHS still hold good today and they will continue to guide it into the next century. The 1002 NHS is—and must remain—open to all, regardless of income, and financed mainly out of general taxation.
"But if those principles remain unchanged, the health service itself—and the society in which it operates—are changing for the better. We need constantly to improve and strengthen the NHS so that it can provide ever better care to those who rely on it. At the moment there are wide variations in performance across the country. We want to maintain the best of the health service, and bring the rest of it up to that very high standard.
"That is why the Government set out upon a fundamental review of the NHS last year. We have today published our conclusions in the White Paper entitled Working for Patients. They build on and evolve from the improvements that the Government have already made to the service in the past 10 years. They reflect a change of pace rather than any fundamental change of direction. All of our proposals share a common purpose—to make the health service a place where patients come first and where decisions are increasingly taken at a local level by those most directly involved in delivering and managing care.
"The main proposals apply to all the United Kingdom but there are separate chapters devoted to Wales, Scotland and Northern Ireland explaining how they will be applied in those countries. Implementation of the proposals will have to follow a process of discussion with many people in the service. We shall be issuing in the course of the next week or two eight detailed working papers as the basis for those discussions.
"Before I turn to the key proposals on management and the use of resources contained in the White Paper, I want to describe the kind of hospital service that I believe every patient has a right to expect. All hospitals should provide individual appointment times that can be relied upon. They should offer attractive waiting areas with proper facilities for patients and children. They should be able to deliver proper counselling to those who need it and give clear and sensitive explanations of what it going on. In addition, patients should be able to pay for a number of optional extras such as a wider choice of meals, a bedside telephone, a television, or a single room. The best hospitals already provide this and I want to see the whole service treating patients properly as people.
"We shall also ensure that patients are freer to choose and change their General Practitioner. And we shall give more encouragement to those GPs who, by offering the kind of service that people want, succeed in attracting more patients. To achieve that, we are proposing to increase the proportion of GPs' pay which comes from the number of patients on their lists from 46 per cent. to at least 60 per cent.
"People look to their GPs to prescribe the medicines they need, and GPs must have the necessary flexibility to do so. But at present, drug costs in some places are nearly twice as high per head of population as in others, even where the 1003 incidence of illness is much the same. The drugs bill is the largest single element of all spending on the family practitioner services. At £1.9 billion in 1987–88, it as more than the cost of the doctors who wrote the prescriptions. In each of the past five years, spending has risen by an average of 4 per cent. over and above the rate of inflation. Unnecessarily expensive prescribing is wasteful and takes up resources that should be used in other ways. Over-prescribing is not in the best interests of patients. We shall therefore introduce a new budgeting scheme whereby GP practices will receive indicative budgets for their prescribing costs. The scheme will be operated in a way that ensures downward pressure on the cost of prescribing without inhibiting the ability of doctors to provide necessary medicines for their patients.
"At present, because of the way that hospitals are funded, GPs are not always able to offer their patients a full choice as to where they will be treated. We want to change this by giving GPs in large practices the opportunity to hold their own National Health Service budgets. They will be able to use these to purchase as they judge best certain types of hospital services for their patients. They will, in other words, be able to provide the hospitals they choose for their patients with the NHS funds required to finance the services the hospitals perform.
"These GP practice budgets will cover inpatients, out-patients and day care treatments —for instance hip replacements and cataract removals. They will also cover prescribing costs and diagnostic tests, such as X-rays and pathology tests. Large practices will be free to decide whether or not to join the scheme. It will at first only be open to practices with at least 11,000 patients—that is twice the national average. Over 1,000 UK practices could join, covering about one in four of the population. All of those practices could have their own NHS budgets of about £½million a year. Giving GPs the resources to finance services for their own patients will provide a real incentive to hospitals to improve the service they offer to those GPs. It will also enable GPs to provide a better service to patients; for example by referring them to where waiting lists are shortest. I am quite sure that GPs will want to judge the quality of service at least as much as the cost of services when they decide where to refer their patients. We have important proposals on the quality of medical service to which I shall turn later.
"But it will not just be through GP practice budgets that money will follow the patient to where work is done best. The principle will apply throughout the health service as a whole. As part of this new way of getting resources to hospitals, the present elaborate system known as RAWP will come to an end. Over the last 12 years it has made an important contribution by helping to equalise the resources available to each region, but that task has now very largely been achieved. Now we are in a position to replace it with an altogether more 1004 simple and fair system based on population numbers weighted for age and health and the relative costs of providing services. It will be much quicker to compensate those regions which treat large numbers of patients from elsewhere in the country. We shall move to a system which finances regions and districts on exactly the same system, with a 3 per cent. addition for the Thames regions because of the inescapable extra problems of providing health care in the capital.
"In future the money required to treat patients will be able to cross administrative boundaries more freely, so that those hospitals which best meet patients' needs get the funds to do so. All National Health Service hospitals will be able to offer their services to different health authorities and the private sector. All district health authorities will be able to provide finance for health services to whatever hospitals they choose in other districts or their own. As a result, we shall not in future have the frustrating situation whereby a good, efficient hospital that attracts more patients runs out of money and has to slow down its work or close wards. This new system will start in 1990 for regional health authorities and 1991 for districts.
"But improving the hospital service is not just a matter of changing the way in which hospitals receive their funds. We also want to change the way in which they are run and managed. We want all hospitals to have more responsibility for their own affairs so that they can make the most of local commitment, energy and skills, and can get on with what they are best at- providing care.
"Management can be strengthened throughout the whole health service. The better the management the better the care it can deliver. Financial accountability and value for money will be improved by transferring audit of the health authorities and other National Health Service bodies to the independent Audit Commission. The role of the National Audit Office will not be affected by this change. On management matters, it is nonsense that the Ministers of any Government should be directly involved in the detail of the day-to-day running of the whole National Health Service. We shall therefore set up a new National Health Service Management Executive chaired by the new Chief Executive, Mr. Duncan Nichol, and responsible for all operational decisions. It will be accountable to an NHS policy board chaired by the Secretary of State for Health who will determine policy and strategy for the service.
"The prime responsibilty of health authorities will be to ensure that the population for which they are answerable has access to a full range of high quality, good value services. Their job will be to judge the quality of services, to choose the best mix of services for their resident population and to finance those services. They will no longer provide and run all their local services, which will be increasingly the role of the hospital and unit managers themselves. Authorities will need to be organised as more effective decision-making and managerial bodies. We shall therefore be changing their composition to make them smaller and to include executive and non-executive members. The 1005 non-executive members will he appointed on the basis of the personal skills and expertise they can bring to the authority and not as representatives of interest groups. Although there will no doubt continue to be people who will combine being members of local health authorities with being local councillors, local authorities will lose their present rights to appoint direct their own members. At the same time we shall also be strengthening the management of' family practitioner committees along similar lines. We shall also make them accountable for the first time to regional health authorities so as to improve the links between planning for the hospital, community and family practitioner services.
"We must devolve responsibility across the whole health service. But I believe that we can also go one stage further. The next logical step in the process of extending local responsibilty is to allow individual hospitals to become self-governing. Let me make it absolutely clear that they will still be as much within the National Health Service as they are now. They will be no freer to leave the National Health Service than any unit has been throughout its 40-year history. They will have far more freedom to take their own decisions on the matters that affect them most without detailed supervision by district, region and my department. Known as National Health Service hospital trusts, they will be free to negotiate with their own staff on rates of pay, and within limits to borrow money. They will be able to offer agreed services for agreed resources through the National Health Service, and indeed in the private sector too. There will of course be safeguards to ensure that essential local services continue to be delivered locally. I believe that this new development will give patients more choice, produce a better quality service, build on the sense of pride in local hospitals and encourage other hospitals to do even better in order to compete. I expect the first National Health Service hospital trusts to he set up in April 1991.
"In all these reforms we intend to concentrate on the quality of care as much as quantity and cost. I admire the progress with which the medical profession is devising systems which doctors call `medical audit' to assess clinical performance and outcomes. We intend to work with the profession to ensure that good systems of medical audit are put in place in every hospital and GP practice as soon as is practicable. What matters for all patients is that high standards of medical performance are maintained and where possible improved, and such systems should secure that.
"I turn finally to the area of perhaps greatest public concern—waiting times. All the measures I have so far outlined by making resources flow more directly to those parts of the service that deliver the best care will help to cut the length of time that people sometimes have to wait for elective surgery. The waiting list initiative will continue but we shall also introduce a number of other initiatives designed to have a more direct and immediate impact. First, we intend all GP practices to have the basic information systems they need to know where treatment is available quickest. Secondly, we 1006 shall introduce a new tax relief to make it easier for people aged 60 and over to make private provision for their health care. This will reduce the pressure on the National Health Service from the very age group most likely to require elective surgery, freeing up resources for those who need it most. Thirdly, we shall manage consultants' contracts more effectively so that the very best use is made of their time and expertise. We shall also reform the distinction award system to ensure that commitment to the service and involvement with the management of the National Health Service are included among the criteria for awards.
"Fourthly, we shall increase the number of consultants by 100 over the next three years over and above the increase in the number of consultants already planned. These additional consultants will be appointed in those specialties and in those districts where waiting times are most worrying. Finance will be made available to cover the costs of the new appointments and the supporting service for their workload. This will help us keep up the attack not only on waiting times but also on long hours worked by junior doctors.
"Taken together, these proposals add up to the most formidable programme of reform in the history of the National Health Service. They are the latest step in our drive to build a stronger, more modern, more efficient health service. For an NHS that is run better will be an NHS that can care better. They will of course mean change, but change of the kind we need if we are to have a service that is fit for the future. I trust that all those who, like me, truly believe in a health service which offers high quality care to all our people will lend their support to these reforms, and I commend them to the House".
My Lords, that concludes the Statement.
§ 4 p.m.
§ Lord Ennals
My Lords, I thank the noble Lord for repeating the Statement. What is proposed, as he accepted in his last paragraph, is a massive shake-up of a fine service that has suffered in the past from too little money and too many ill-conceived reorganisations at the hands of successive Conservative governments.
This White Paper bears all the hallmarks of a thoroughly botched up job. There is a hastily announced review conducted by a secretive hole-incorner cabal of politicians and civil servants without proper consultation with those who work in the National Health Service. There is also a blatantly leaky review team who seem unable to hang on to their own secret documents. I believe that the document, in spite of its wording, is deeply insensitive to the commitments and concerns of those who need and use the health service. It implies some fundamental changes, in spite of assurances in the Statement just read, that it proposes only a change of pace.
There is mention of a massive opt-out of hundreds of hospitals which would cease to be responsible to health authorities. They will be in competition with 1007 each other to win contracts from health authorities. Under these proposals people may get operations they do not need, if there are profits to be made, and may be refused operations they need if there is no money to be made.
Free standing, independently run, cash limited GP teams are proposed. These will be in competition with other GP teams. For the first time doctors will be given a financial motive to deny treatment to patients whom they have the right to refuse. Further, tax relief for the elderly is proposed to promote private health insurance. This was previously opposed by the Secretary of State himself. Further—this was not announced, but it was inevitable—a massive burden of bureaucracy, American style, will be imposed on the health service.
It is proposed to sack elected councillors from health authorities, thus ending any question of local democracy. I believe this is a further step towards the politicisation of the health service. I strongly object—I believe the public will too—to the National Health Service being used as a political football. Those on the other side of the House ignore consensus and seem to welcome confrontation. They will achieve that objective from these Benches, because we will fight for a principled, patients before profits, health service.
Over the weekend the Secretary of State for Health seemed to he saying, "Watch my lips—no privatisation". But the proposals he has announced today amount to a major move towards a private system of health care. Private agencies will be competing with each other to run the hospitals, community services and family doctor services. The health service will be pushed away from being a public service, as it has been for over 40 years. Health care will be bartered in the market place. It is no good the Secretary of State pretending that these provisions are not to be a boost for the private sector. This has been the Prime Minister's objective from the beginning. She has made it quite clear.
I believe there are grave dangers inherent in the argument that profits should replace patient needs as the principal objective of health authorities. The US system proves that. The logic of the survival of the fittest is the neglect of the most needy, the elderly and the handicapped.
Contrary to what is said in the Statement, I believe these proposals will not meet the challenge of patient choice. The trend will be for patients to be pushed to accept the cheapest option, whether it is drugs or anything else. That option may not be the best option. It is claimed that patients will have freedom to choose their general practitioners. But there will also be freedom for general practitioners to refuse to accept patients who might make heavy demands on a GP's budget.
I wish to ask the noble Lord some questions. I have given him notice of most of these questions. What is the future of the laboratory services, which fulfill a vital service today? There is a need to extend the preventive health services. Those services are accepted on all sides of the House as being an essential part of our health system. What will happen 1008 to them? What is the future for community care? That has still not been answered in the Statement.
I hope that the noble Lord will say something about the cost to the National Health Service of training for personnel who later work in the private sector. What are the cost effects of this new type of health service? Will the noble Lord say something about incentives to National Health Service hospitals to go independent? Who supports these proposals? Certainly they have not gained the support of doctors. The BMA has announced its opposition. What about the nurses and other professionals? What about the ancillaries who play such an important part in the health service? It seems sad to me that this Government see no point in seeking to achieve a consensus, as has been the case in the past.
I conclude by assuring the Minister that support for the fundamental principles of the health service crosses party lines totally. We have demonstrated that in your Lordships' House on many previous occasions. We on these Labour Benches will vigorously oppose any plans which undermine the ability of the National Health Service to meet the health needs of all the people, rich and poor. We shall fight vigorously to safeguard the principle that patients must always take priority over profits. We shall want a very early debate on this White Paper.
My Lords, on behalf of my noble friends on these Benches I too wish to thank the noble Lord for repeating this extremely cleverly worded, though nonetheless disquieting, Statement. I am sure the noble Lord will accept that, along with other noble Lords, I do not approve of long speeches on Statements. I have no intention of making a long speech. But I ask the noble Lord to accept that many noble Lords on these Benches. and I am sure in all parts of your Lordships' House, will wish at some stage to speak at some length on many of the matters itemised by the noble Lord, Lord Ennals.
I underline in particular the suggestion of the application of cash limits to family practitioner committee services and the somewhat bizarre suggestion to allow individual hospitals to become self-governing, whatever that may mean. Finally, I emphasise the omission of any reference at all in the Statement—I cannot say whether this is the case in the review, as I have not read it—to the report of Sir Roy Griffiths, or even to the report of your Lordships' Select Committee on priorities in medical research. We were promised a full response to both of those reports in the National Health Service review.
Is the noble Lord aware that in your Lordships' House there is a fund of experience, expertise and wisdom on National Health Service matters that is unequalled anywhere else? It is perhaps even unequalled within the BMA and the DHSS. It therefore follows that, if a full debate on these matters could be arranged very soon, it might save the National Health Service from catastrophe. It might also perhaps save the Government from the consequences of their own folly. I point out that it is the former of those considerations with which we are most deeply concerned. I hope that the noble Lord will consult with his noble friend the Leader of the House and tell him that there is a very strong feeling 1009 that these very important matters should be fully debated in your Lordships' House as soon as possible.
§ Lord Hesketh
My Lords, possibly predictably, the noble Lord, Lord Ennals, accused this Government of reducing expenditure and not supervising the beneficial development of the National Health Service. Before answering any questions, I should like to remind your Lordships' House that expenditure, since this Government took office on the National Health Service has risen in real terms, after inflation, by some 40 per cent. None of us should forget that fact.
The noble Lord, Lord Ennals, went on to describe opting out. The White Paper does not talk about opting out anywhere. It mentions doing something for which this Government is constantly berated from the Benches opposite. We are constantly accused of centralisation. A White Paper is presented to your Lordships' House which proposes genuine decentralisation. It proposes to return the National Health Service genuinely to the communities which it serves. We have no intention of affecting the future of the National Health Service other than in an entirely beneficial way.
I should have hoped that it might have been obvious from the Statement that the standards that we have chosen to set as the benchmark of excellence are not those of the private sector or of the United States—they are those of the National Health Service itself. Those are the standards that we have chosen as a basis for setting the standard.
I hope that the noble Lord, Lord Ennals, has observed that the first chief executive of this revamped and improved service comes not from industry, not from overseas, has not been headhunted from Wall Street: he comes from within the management of the National Health Service. Those are important points which demonstrate our commitment to the National Health Service.
The noble Lord, Lord Ennals, mentioned tax relief. All that we are suggesting is that those who have provided for themselves before retirement, and in that way assisted the National Health Service, should be allowed to continue to do so after retirement.
The noble Lord, Lord Ennals, spoke of bureaucracy. There is always the great difficulty that when one talks about management one is accused by the Labour Party of bureaucratic expenditure. The only bureaucracy which the White Paper intends to encourage is bureaucracy that saves money so that more patients can be treated in a bigger and better National Health Service.
The noble Lord, Lord Ennals, was unhappy about what he regarded as the possible destruction of local democracy in the health service. When the new arrangements for hospitals come about the hospitals will be run by people who are consultants, National Health Service managers and nursing officers. In my experience such people live close to the hospitals. The management will be committed to those hospitals as never before.
1010 The noble Lord, Lord Ennals, asked about the future of laboratories. I can assure the noble Lord that no central initiative is mentioned in the White Paper in that regard.
The noble Lord, Lord Winstanley, together with the noble Lord, Lord Ennals, quite properly mentioned community care and the Griffiths Report. The review has focused closely on the funding and management of the health services and on hospitals and family doctors in particular. The interaction of health and social care in the field of community care needs further study. That work is well in hand and the results of the review will help to advance it further.
The noble Lord, Lord Ennals, also inquired why the review has been so secretive. That is not so. It has not been secretive. Internal reviews of policy happen all the time in government departments. We have welcomed the public debate in the past year and in our deliberations we have taken account of all the contributions.
Finally, the noble Lord, Lord Ennals, asked about training with reference to a possible levy. 1 think that he may have forgotten that the private sector already makes a welcome contribution to post basic specialist nurse training. The department and private sector representatives have recently agreed to the setting up of a joint working party with the aim of increasing the total stock of skilled staff available to both services.
We have increased expenditure. We are making a commitment to a better health service on a truly accountable basis. We are decentralising rather than centralising.
§ 4.12 p.m.
§ Lord Boyd-Carpenter
My Lords, first perhaps I may support the appeal of the noble Lord, Lord Ennals, to my noble friend for an early debate in your Lordships' House on this immensely important Statement. Your Lordships' House has much to contribute and I think that it would be very helpful, not least to the Government, were an early debate to be arranged.
In the same context perhaps I may ask whether legislation is involved in any of the massive changes which my noble friend has outlined. If there is to he major legislation, that to some extent helps to answer the request for a debate but I do not think that it cancels it out. I think that a general debate on the whole of this important Statement is very strongly indicated and I hope will be sympathetically considered by my noble friends on the Front Bench.
As one who was in another place when the late Mr. Bevan introduced the National Health Service Bill 40-odd years ago, I think that it is plain that these proposals are the biggest development, reform or change—whatever word one likes to use—in the history of the National Health Service. Though they will have to be debated, and debated in fall, they confirm the immense care and trouble which our right honourable friend the Secretary of State for Health has taken in seeking to bring the health service and its organisation into a shape in which it can face the changing problems of this changing age.
There are so many points in the Statement that one would delay your Lordships by referring to them. 1011 However, I want to say how enthusiastic I am about two of those points. The first concerns the proposals for hospitals. To some extent they seek to reverse the mistake which I think that the late Mr. Bevan made in submerging the organisation and administration of the hospitals in the general system. It will help to restore to the hospitals a measure of independence and thereby help them to resume the very high standard that they maintained under the old system and the stimulus that comes from being in some measure independent.
The other point is the very interesting proposal to increase to 60 per cent. the proportion of a doctor's remuneration which relates to the number of patients on his list. That must be a good stimulus to doctors—if they need it, and some perhaps do—to give patients the service which makes patients want to stay with them and other patients to join them. I shall be interested to hear why that proposal stops at 60 per cent. If a doctor is giving service which appeals enormously strongly to people in his area and they come to his practice, I question whether it is right to limit the remuneration to 60 per cent. of his salary and whether a higher figure might not be contemplated.
Finally, I should like to congratulate my noble friend on reading this immensely impressive Statement in such an admirable way and ask him to convey to his right honourable friend the Secretary of State the approval of many of us of the great work which he has obviously done in originating it.
§ Lord Hesketh
My Lords. I should like to thank my noble friend for his very kind remarks and to answer the three points which he raised. With regard to the 60 per cent. remuneration for GPs, the noble Lord said that that may not have gone far enough. My answer to him is that we have gone quite a long way.
With regard to the matter of legislation before your Lordships' House, I am sure that it will come as no surprise to my noble friend that a considerable amount of primary legislation will be required for which the Government are committed to bringing forward a Bill at the earliest opportunity.
§ Lord Hesketh
My Lords, finally, I shall certainly draw to the attention of my noble friends who are in charge of such matters the desire for a debate at the earliest opportunity.
§ Lord Kilmarnock
My Lords, we on this Bench should also like to thank the noble Lord for repeating this extremely important Statement. In some respects the tone of the Statement is rather strange. On the first page it refers to a change of pace rather than any fundamental change of direction, yet on the last page, as the noble Lord, Lord Boyd-Carpenter, has already pointed out, it claims to be the most formidable programme of reform in the history of the NHS. Those two statements do not appear to be entirely compatible.
1012 It is not our practice to make knee-jerk reactions to government statements of this kind. I think that on balance, to make an analogy with E. M. Forster's Two Cheers for Democracy, one can give one cheer for the Statement.
I agree with all noble Lords who have said that we need a full debate, but I should like to ask the noble Lord four brief questions. I think that the proposals with regard to hospitals give least cause for worry. We favour an internal market to reduce waiting lists. as advocated by my right honourable friend David Owen. I think that some progress could be made in that respect. However, we certainly did not envisage the opting out of nearly 300 district general hospitals. Can the noble Lord comment on the meaning of the phrase in the Statement:They will be no freer to leave the National Health Service than any unit has been throughout its 40-year history".I wonder whether he can comment on what is behind that phrase.
I believe that the area that gives the greatest cause for concern is that of general practice. Cash limiting of general practice must raise extremely serious ethical problems. The doctor's duty is to his patient rather than to his budget. I should like to know whether the Minister has thought about that question and whether he has taken into account the considerable advances that have already been made on more responsible prescribing both through the limited list and generic prescribing on a voluntary basis that is very much encouraged by the Royal College of General Practitioners. On reflection, does the Minister think that the voluntary route is the best way forward in that particular sphere? Does he agree that this may well set up a ping-pong effect between general practitioners and hospitals as to who will foot the drugs bill?
As regards the eight detailed working papers mentioned in the Statement, can the noble Lord say what degree of consultation there will be on those matters? Will GPs, the BMA and other interested bodies have a proper opportunity to comment and make their own proposals or counter-proposals? After all, even Aneurin Bevan consulted the doctors, but there is not much sign that that is the line which the Government want to take.
My fourth question on community care has already been dealt with. The noble Lord said that it was irrelevant. However, that is not the case. I understand that 60 psychiatric hospitals are likely to close in the next 10 years, pushing out into the community 20,000 patients. That is a massive problem which certainly ought to have received attention in such a review.
Finally, perhaps he can tell me when the Government will reply to the Griffiths Report. With regard to the financial aspects, I deplore the tax break. It goes against the principle of a neutral fiscal policy which has always been proclaimed by the Chancellor. I believe that the Secretary of State was not too happy about it either. Can the noble Lord say whether the tax break for elderly people who already have private insurance, which will not in fact generate very much more money into the health system, is simply the thin end of the wedge with a view to 1013 extending the practice to the whole of the community? That is obviously the logical direction to which it tends.
I should be very grateful if the noble Lord would answer those questions. Of course I support all the recommendations for an early debate.
§ Lord Hesketh
My Lords, the fact is that the hospitals will be no freer at all to leave the National Health Service. I must emphasise the important point about the Government's proposals for allowing hospitals to become self-governing. They will become self-governing as National Health Service trusts. They will be part of the National Health Service.
The object is not to let them opt out of the National Health Service but to provide a better service at a local level. As regards consultation, we have had a considerable amount of discussion both within and outside the department, including the professions, the professionals and all those involved in the health service. As regards cash limits, the introduction of some discipline through the use of budgets is by no means the same as cash limiting. The objective of the scheme is to place downward pressure on drug expenditure.
The key word in relation to prescriptions is "indicative". Many of your Lordships may have watched "TV AM" this morning and seen an interview with a GP, who found it interesting to learn where certain sums of his money were going and was able to take action to reduce the level of his expenditure. The word is "indicative". It is not "trying to strongarm" or "force". The word is "indicative".
The noble Lord said that tax breaks could be the thin end of the wedge. That is far from the case. As I said earlier, the object of the exercise is to allow people who have contributed to private insurance schemes all their lives to continue to do so in retirement. I am sure that your Lordships' House approves of a concept which will not only help those who take part in the schemes but reduce pressure on the fastest growing sector of the National Health Service and also encourage people to spend money on their health rather than on imported consumer durables. I think that that makes fiscal as well as medical sense.
§ Lord Broxbourne
My Lords, I should like to ask my noble friend about the rather oddly named "indicative drug budgets". It could mean almost anything. The scheme is referred to in Chapter 7.15 of the White Paper. The operation of the scheme is described in Chapter 7.18 as:The Secretary of State for Health will publish shortly a working paper which will set out the detail of how the scheme will be implemented, for discussion with interested parties".Can my noble friend say in this context what "shortly" means? Who are the interested parties? As my noble friend inquired, will legislation be involved? Shall we receive all this information before the debate?
§ Lord Hesketh
My Lords, I fear that my noble friend is somewhat pre-empting the matter with his assumption that a date for the debate has already 1014 been fixed. I believe that I am correct in saying that the period of time of which we are speaking is within the next one to two weeks with regard to the discussion document. As regards the interested parties, it will of course be those parties who are interested in this subject.
§ Lord Nelson of Stafford
My Lords, I congratulate my noble friend on repeating the Statement this afternoon. As chairman of the Select Committee which investigated medical research, I should like to record some disappointment that there has so far been no mention of research in this review, as we have heard it described today. Our studies showed that there were considerable inadequacies in the National Health Service in relation to the provision of clinical research and health services research. I hope very much that the Minister will have something to say this afternoon or certainly during the debate on this important topic. There is no doubt that research has a very important contribution to make to the very objectives that the Minister has outlined to the House. If it is not included, it seems to me to be a lost opportunity to bring into this review the important aspect of research and the contribution that it can make to the objectives that he has outlined to us.
§ Lord Hesketh
My Lords, I am very grateful for my noble friend's comments. I am sure he is aware after having heard the Statement that the review has concentrated on hospitals and family doctors in particular. I am certainly well aware of the importance of medical research and will draw his remarks to the attention of my right honourable friend the Secretary of State.
§ Lord Tordoff
My Lords, I must comment on the adequacy of the response to the noble Lord, Lord Nelson of Stafford. I understand that the report of the Select Committee was in the Government's hands almost a year ago—in fact in February last year. The reply from the Government to your Lordships' House was delayed because it was intended to include it in the White Paper review. Why has it not been included in the White Paper review after the promise given to your Lordships' Select Committee?
§ Lord Rippon of Hexham
My Lords, while I warmly welcome much of the Statement. perhaps I may press my noble friend on one point. Why do the Government persistently regard democratically elected councillors as unrepresentative of local interests and concerns?
§ Lord Hesketh
My Lords, I am very grateful to my noble friend Lord Rippon for raising that point. I should point out to him that he will see in the White Paper a very important statement; namely, that the object of the programme that we are proposing, whereby we shall be reducing the numbers involved on boards, is to reduce membership to people who have in part a straightforward technical contribution to make. There are other people who will not be on the board, such as contractors and those who might 1015 have an interest from another side and another place, as well as other parties. This is in no way an attack on local authorities.
§ Lord Rippon of Hexham
My Lords, on that analogy, why do we not leave government to the Permanent Secretaries?
§ Lord Trafford
My Lords, I should like to ask my noble friend, if he can, to reassure us on a point which I think will concern a lot of people: namely, there is the possibility raised in the rather short outline of the White Paper that he has given that hospital services going under the hospitals trusts (320) could lead to a two-tier hospital service. I am sure he will agree that one of the great functions of the National Health Service over 40 years has been to disseminate talent and equality of care, and good care, all over the country. Can he reassure us that this will not be reversed; that this process which has gone on for 40 years will continue and that there will be no question of two-tier-type hospital services?
§ Lord Hesketh
My Lords, I am grateful to my noble friend for his question. He is entirely correct in stating that on paper some 320 hospitals could fit the profile but I think it is true to say that we in the department are certainly not expecting 320 hospitals to be in National Health Service trusts right away, or probably ever. The key is to provide a shining example which will be to the advantage of every hospital up and down the kingdom and which will result in standards not only being equal but improving.
§ The Lord Privy Seal (Lord Belstead)
My Lords, may I intervene for just one moment? I think it is fair to say that my noble friend has dealt with the questions that have been put to him comprehensively and succinctly. For that reason we could probably go on for a long time, but we are well over the period the House itself thinks is right for a Statement. May I suggest that we take a question from the noble Baroness, Lady Lockwood? I also know that the noble Lord, Lord Tordoff, has a point that he particularly wants to make; and then I think we ought to pass on to the next business. Meanwhile, I give an assurance that I have certainly taken on board the fact that the House expects a debate on this matter.
§ Baroness Lockwood
My Lords, I wonder whether the Minister can assure us that the two very bland paragraphs on pages 37 and 38 on training and research are not the only responses that the Government are going to make to the House of Lords Select Committee on priorities in medical research. These two paragraphs do not in any way address themselves to the recommendations of that Select Committee report.
§ Lord Hesketh
My Lords, that is certainly not the case. I can assure your Lordships that responses to the Secretary of State's letter of 21st November 1988 to the regional health authority chairmen on your 1016 Lordship's Select Committee are being considered at this very moment.
§ Lord Tordoff
My Lords, I thank the noble Lord the Leader of the House for what he said, but in this case the noble Baroness has made the point for me.