§ 3 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)
My Lords, I beg to move that this Bill be now read a second time.
This is an important Bill and an important debate, not least because we have two maiden speakers, who I am pleased to see have chosen this debate to address your Lordships for the first time.
As a starting point, we all appreciate and are proud of our National Health Service, but if the National Health Service is to continue to flourish into the next decade and the next century it needs both continuity and change: continuity with the ideals which inspired its founders, of all political persuasions; ideals which continue to inspire its staff, the Government in whose charge it is placed and, I am sure, many on all sides of this House. But change is also needed. Continuity without change is not a recipe for preservation but a recipe for stagnation. No healthy organisation can be expected to use the management and funding structures of the 1940s to address the issues of the 1990s.
The National Health Service has rightly not cocooned itself away from major technical changes in medicine, and we believe that the proposals in this Bill will ensure that it faces the challenges of the coming years with a similar, forward-looking, dynamic approach to the delivery of care to all its patients. The reforms introduced by this Bill build upon the founding principles of the NHS. In no way do they alter them. But we do not ignore the fact that there is a strong body of opinion which recognises the need for change. This includes many in the medical 1256 profession, including the BMA and the royal colleges, who freely acknowledge the need for change and the viability of many if not most of our proposals.
I want to emphasise immediately that the Bill's main purpose is to improve the quality of care. I am sure this is of concern to us all and we will debate this at length both today and subsequently. Of course, because we are looking at structures much of the detail of the Bill is concerned with details of funding and management systems. But these do not exist in isolation. Their only purpose is to ensure that the National Health Service has the right tools to deliver care. The key elements are greater delegation and freedom of action for staff at all levels, a more flexible approach to funding, which puts the patient, not the system, first, and the creation of a climate which allows all doctors, nurses, managers and other professionals to put quality right at the head of their agendas.
The continuity I spoke of is there because the basis of the NHS is unchanged and will remain so. It will remain free at the point of use. It will remain funded out of general taxation. I hope it is generally recognised that we are in the business of renovation, not demolition.
The present Government have been the custodian of the NHS for 11 years, during which time it has flourished. These proposals take further the action already initiated to improve the service since 1979. In many ways they are a direct descendant of the introduction of general management following the report by Sir Roy Griffiths in 1983. Moreover, the changes are part of a wider programme of action outlined in our three White Papers — Promoting Better Health, Working for Patients and Caring for People. The legislation we seek to introduce is merely a further step to complement the non-legislative action taken, for example, to introduce a more effective contract for general practitioners, to introduce medical audit in the hospital and family doctor services, to increase the number of consultants, to delegate functions from regional and district health authority headquarters to the operational level and to provide guidance to local authorities in improving their management of community care services. The legislation does not stand apart from all these other changes, but it does provide the motor which will allow these benefits to be fully realised in the future.
A similar evolutionary approach applies to the implementation of the changes. Our proposals both in the NHS and community care services are continuing to evolve in the light of parliamentary discussion and in the light of discussions with those who deliver care in the field. For example, we wish to make further changes to the community care sections of the Bill at Committee stage by introducing requirements for statutory complaints procedures. This was very forcefully urged upon us in another place. I feel sure your Lordships will fulfil the second Chamber's reviewing role by giving us much else on which to ponder both today and in the coming weeks.
The Government believe firmly that this is the correct way to pursue implementation of change.
1257 There will not be a big bang on 1st April 1991. This is because many of the proposed changes derive from action already under way. In other areas, such as NHS trusts and GP fund-holding practices, the running will be made by enthusiasts and volunteers. There is, I wish to emphasise, no question of anybody being compelled to participate unwillingly. We anticipate that those NHS trusts and GP fund-holding practices which may be set up as a result of the Bill's proposals will represent the most promising of those that have already expressed an interest. There are likely to be a few dozen NHS trusts in the first wave and a few hundred GP fund-holding practices. These will in effect be pilot projects and we can learn from and build on that experience. There will be ample opportunity for our proposals to be refined and developed in sophistication.
The Government have begun this process throughout the past year, as they have continued to discuss and revise their proposals with the many interested parties. There have been well over 100 meetings with representatives of the medical profession alone, and my right honourable friend the Secretary of State has invited representatives of the medical royal colleges and others tomorrow to discuss their specific concerns about how standards and quality of service can be assessed as the reforms are implemented. Knowledge in the health service, helped by central guidance, is becoming increasingly detailed and increasingly sophisticated as we learn from each other in taking the work forward.
We will be engaging in a similar process of dialogue with all interested parties in the field as work on implementing the caring for people agenda also begins to develop momentum, and, as my honourable friend the Minister for Health made clear in another place, we will be issuing detailed guidance in a large number of areas central to that agenda in the course of the coming year. These will build on the pioneering work already carried out by the Social Services Inspectorate in many areas.
I believe that this represents a sensible approach to the management of change. It does not seek to isolate artificially one or two areas to act as a test-bed for the proposals. That would breed uncertainty; indeed, cause planning blight, destroy staff morale, delay real benefits to patients and produce results of doubtful validity. But we are not seeking to run before we can walk. Instead, as I have said, the Government through the NHS management executive are taking a realistic approach to the implementation of the plans, listening and responding to valid concerns, learning from experience and, above all, keeping the main objective of an enhanced service for all patients and users firmly in view.
I shall now turn to the detailed provisions of the Bill, first, as it affects the National Health Service. Part I of the Bill deals with our proposals for England and Wales. Part II makes similar changes in Scotland and this of course takes account of the different legal and organisational framework north of the Border. My noble friend Lord Sanderson, who is listening to our debate today, will be dealing with specific Scottish issues as they arise during later stages. In 1258 addition, Part V contains some proposals which cover Great Britain as a whole.
Effective local leadership is one of the keys to achieving the higher quality, more responsive National Health Service of the 1990s. We are reforming health authorities and the renamed family health services authorities to ensure that they can meet the enhanced roles which we see for them. The former will take the lead in identifying the health needs of its population and securing access to a comprehensive range of services for them. The FHSAs, if I may so call them, will be taking the lead in planning and delivering primary care services. Similar changes are being made to the constitution of health boards in Scotland.
The authorities in future will be leaner and more effective bodies, made up of a mixture of executive and non-executive members. The membership will ensure that they have a range of skills available to them, both from their own officers and from the wider experience contributed by the chairman and non-executive members.
In the case of districts with significant teaching responsibilities, the membership will also include representation from the relevant university or medical school. Clauses 27 and 28 of the Bill provide for further changes to the role of Scottish health service bodies, in particular enabling the creation of a new special health board to spearhead health education. We are also acting to remove unduly bureaucratic obstacles, which can delay effective service developments. Clauses 1 and 2 open the way for a more effective consultation procedure on mergers and other changes to the boundaries of health authorities.
I have already mentioned the enhanced role of district health authorities. In future, districts will secure services for their patients through a system of National Health Service. Clauses 3, 4 and the parallel Scottish clause, Clause 29, provide the legal basis for this exciting change to operate. In short, NHS contracts allow money to flow freely across administrative borders and so overcome the so-called "efficiency trap" where successful hospitals feel the pinch as a result of their high activity levels. Instead, hospitals— and other units— will be funded directly for the patients that they treat.
I emphasise the fact that we are not talking about a commercial activity here. As those who have seen our guidance entitled Contracts for Health Services: Operating Contracts will know, NHS contracts will not be commercial in form but will represent specific service agreements between health authorities and units which are all part of the NHS family. They will not therefore be legally binding in the sense that they will not be the subject of lengthy litigation in the courts at the expense of patient care. However, the Bill provides for the speedy resolution of any dispute which may arise within the service.
The new National Health Service trusts permitted by Clauses 5 to 11 in England and by Clauses 30 to 32 in Scotland will be key participants in the new funding system. These clauses set out how the bodies may be established, their specific powers and freedoms, how staff will transfer to them from health authority employment and the detailed 1259 arrangements for their financial regime. I emphasise that the trusts will be fully part of the National Health Service. Their funding will derive from NHS contracts. The Secretary of State and regional health authorities will appoint their non-executive directors and there are reserve powers to ensure that they fully meet all their NHS obligations.
On establishment, the Bill provides that the trusts will have boards of directors, including both executives and non-executives. Their executive membership will include a senior doctor and a senior nurse and, where needed, there will be special provision for medical school or university representation on the board. The Bill also describes the freedoms which NHS trusts will enjoy. They will be able to employ their own staff, to conduct research, to provide facilities for medical undergraduate and postgraduate education and other forms of training. They will own their own assets and have power to borrow within an external financing limit. The Bill also contains safeguards in the form of reserve powers of direction over NHS trusts. These allow the Secretary of State to direct all trusts— for example, on matters of safety or ethics— or, in exceptional circumstances, an individual trust where there is justified cause for concern.
It is the Government's firm intention that National Health Service trusts will play their full part in medical education and research. I know that that aspect is a concern of many of your Lordships. Indeed, a thriving education and research base will be seen as a demonstrable mark of high service quality and will help to encourage NHS contracts to flow to the hospital concerned. I believe that it will enhance the reputation of hospitals, the service they offer to the community and the job satisfaction of their staff.
Let there be no doubt: the Government are fimly committed to an effective research programme and to high quality medical education throughout the National Health Service not just in NHS trusts. The work of the steering group on undergraduate medical and dental education, chaired by Sir Christopher France, the recent improvements to the funding systems for education and research and our decision to appoint a chief of research and development to spearhead research in the NHS, all bear witness to that commitment. Nothing in the Bill's proposals jeopardises that commitment. Nothing will be allowed to jeopardise it in the future.
I turn now to the family health services authorities. The proposals in Clauses 12 and 13 of the Bill will make FHSAs accountable to RHAs for the first time. The proposal will signifcantly improve collaboration between primary and secondary care, particularly in the field of prevention. At the same time, the changes will preserve the different character of the family practitioner services and avoid the unnecessary distraction that wholesale merger of health authorities and FHSAs would produce. It is a desirable change which builds on the progress that we have already made in strengthening family health services authorities in recent years; for example, through the appointment of general managers.
1260 Clauses 14 to 17 and the parallel Scottish clause, Clause 33, make provision for fund-holding GP practices. Practice funds will give GPs who apply for them their opportunity to provide their patients with the high quality care they want and need by giving them greater control over all the resources which they deploy. I am pleased to say that GPs have responded with enthusiasm to the invitation to express interest in taking part in the scheme and the Government are confident that many of the 850 practices which have expressed interest will be successful participants as the scheme develops. We shall build on the experience of those in the first wave as I have already described.
The Bill provides the framework for the scheme to get under way. It sets out how applications for the scheme will be handled, the technical arrangements for allocating practice funds and for their withdrawal for whatever reason, should that prove to be necessary. The Bill will also allow for the eventual delegation of functions relating to practice funds, which will be rightly located at regional level in the early years, to FHSAs in the fullness of time.
The proposals for indicative prescribing budgets contained in Clauses 18 and 34 of the Bill provide a framework for more effective prescribing by all general practitioners. The budgets will offer a guidline to GPs to help them examine their prescribing practice carefully and professionally. Patients will of course continue to receive all the medicines they need, as the medical profession now fully accepts. Indicative budgets are not cash limits but a management and professional tool to improve prescribing.
Improved value for money and improved quality of service need to go hand in hand. The proposals in Clause 20 and Schedule 4 to allow the Audit Commission to take over the statutory audit of the NHS from the health departments will enable us to make even further progress in that respect.
Clauses 21, 22, 37 and 38 enable the relevant Secretary of State to specify the maximum number of GPs to be added to the medical list in any one year and to make consequential provision in relation to the Medical Practices Committee and its Scottish opposite number. The Government fully expect the implementation of changes flowing from Promoting Better Health, the new GPs' contract and Working for Patients to make the use of these reserve powers extremely rare.
We will, however, be using the new power in Clauses 24 and 39 of the Bill in relation to dentist numbers. We will make regulations allowing the implementation of the new contract agreed with the British Dental Association, in particular the new scheme for early retirement. The contract represents a considerable step forward for the profession and the health service.
Clauses 57 and 58, together with Schedule 7, also remove virtually all the remaining crown immunity in the National Health Service. Both NHS trusts and directly managed services will therefore be subject to the same demanding statutory standards across the full range of their activities and will face the same penalties if they do not come up to the mark.
1261 The Bill contains provision for a small number of remaining immunities— in the field of taxation, for example— and makes transitional provision in some other cases.
I turn now to the community care sections of the Bill. Part III contains our proposals for England and Wales and Part IV for Scotland. I believe your Lordships will agree that they deserve separate, detailed description in their own right rather than being seen as an adjunct to the NHS proposals.
Once again I pay tribute to the work of Sir Roy Griffiths, whose report underpins many of our proposals in Caring for People. As with our changes in the National Health Service, the framing of our proposals has rightly taken time and careful consideration. It is right therefore that we now move ahead smartly with putting the necessary legal and operational framework in place to ensure that the benefits we expect to achieve through our proposals are realised quickly, taking full account of debates on our proposals, as we do so.
For too long community care has been a victim both of the confusion which has developed in recent years as to where responsibility for the public support for people in residential care and nursing homes should be and the low priority given by some local authorities to the development of high quality home care services. The proposals in the Bill are an important step in the programme to get community care right. Its provisions lay new responsibilities on local authorities, give new emphasis to identifying and planning to meet the needs of individuals and provide new power to the centre to see that those responsibilities are properly discharged.
The provisions on arranging services illustrate this point clearly. Local authorities already have extensive powers to provide services in their own right and to arrange services through voluntary agencies. Those powers remain largely unchanged. But Clauses 40 and 53 of the Bill supplement and augment them by making it possible for the local authority, with the health authority's agreement, to arrange the provision of private or voluntary nursing home care. The Bill is thus a key part of the machinery by which we will place responsibility for arranging residential and nursing home care of people in private and voluntary homes firmly in the hands of local authorities. So this will provide the clear identification of responsibility for the funding and management of community care urged by Sir Roy and others.
The Bill also deals with the position of existing residents in residential and nursing home care. Your Lordships will be aware that this was a subject of much debate in the other place. During debate on the Social Security Bill my right honourable friend the Secretary of State for Social Security was able to respond to the legitimate concerns raised by announcing extra resources for an interim uprating of income support levels for those residents.
Under Clauses 44 and 49 of the Bill local authorities will be expected to publish community care plans and to consult with a wide range of interests, including voluntary bodies providing services to people with special care needs and their carers. This 1262 was made clear in an amendment we accepted in another place. I hope that the preparation of community care plans will stimulate a vigorous local debate about the best forms of community provision.
These plans need to be based on identification of community care needs. Assessment will be vital in achieving this. In accordance with the evolutionary nature of our proposals the process of assessment will develop and play an increasingly important role in evolving plans. Clauses 45 and 52 provide that it will be a duty of the local authority to assess anybody for whom it could provide services and for whom it appears community care is needed. This means that anyone referred to the authority's attention as someone who might need community care has to be assessed. That applies to people being discharged from hospitals too. Where this happens we expect that the health authority will collaborate with the local authority to see that an assessment is carried out and services put in place before the individual leaves the safety of the hospital to be cared for in the community.
The form the assessment takes will be left to the local authorities. But it will depend largely on the care needs of the person concerned. When these needs include health care the local authority would be expected to involve the health authority in the assessment. We are looking closely at the pertinent point made in another place that apparent housing needs should also be notified to the appropriate authority where these are identified in the course of an assessment.
Taken together, the community care proposals present a strong package of action for better local management, a clearer central role and, above all, improved care for people who need it, better fitted to their individual needs.
I have spoken at some length in introducing the Bill. I believe that this is warranted because of the major improvements its proposals will make to the delivery of care in both the National Health Service and the social services. We are aiming to achieve what will in many ways be a revolutionary change, but revolution achieved through evolution rather than destruction. As I said at the outset, there is agreement on all sides about the importance of preserving the ideals of our caring services and the Bill does just that. I hope that this agreement on objectives will be kept firmly in mind as we debate our proposals in more detail. The Government believe in those ideals. They are what have inspired our proposals and they run all the way through them. We believe that they are the best possible recipe for continued growth and progress into the coming decade and beyond, and in that spirit I commend the Bill to the House.
Moved, That the Bill be now read a second time— (Baroness Hooper.)
§ 3.26 p.m.
§ Lord Ennals
My Lords, the House is grateful to the noble Baroness for her clear and low key explanation of what I believe to be the most important legislation introduced by the Government in this Parliament. I welcome much of what she said.
1263 I look forward to hearing the two maiden speeches. In ray view, if the Bill proceeds without amendment it will be seen as a much greater affront to the public interest than the introduction of the community charge or any of the series of privatisation measures.
I welcome the invitation of the noble Baroness that your Lordships should seek to make changes in the Bill to provide some busy work for another place to undertake. She spelt out the stated aims of the legislation— to improve services to patients and clients, to provide better value for money, to improve management in health and community care and to increase patient's choice. These are all unexceptional. However, regarding the health service hardly anyone believes that the methods proposed in the Bill will achieve these fine objectives. I hope that your Lordships will forgive me if I concentrate on the National Health Service in my speech and leave my noble friend Lord Carter who is winding up to concentrate on community care. There is no implication here that there are not extremely important issues to be considered in Clauses 40 to 55, issues which concern me deeply.
Of all the proposals for change, by far the most serious are those which challenge the basic principles of the National Health Service which have been accepted by all governments for 43 years. The consensus is being broken by this Government if they proceed with the Bill. I wish to dissuade this chronically, and maybe terminally, unpopular Government from plunging the health service into another painful reorganisation based on principles thought up by political dogmatists with loyalty to Adam Smith but no experience of the delivery of health care.
Those who are behind this measure— their names were never listed and we never discovered who put forward the proposals, except for some names which leaked out— seem not to understand the motivation of the vast majority of health service workers. Although those workers are fully entitled to a fair wage, they do not view the National Health Service or community care as a challenging source of private profit. Let us remember that before the White Paper on which the Bill is based was published there had been no consultation with health service workers or doctors, nurses and therapists. They read that document with great incredulity. They could not believe that politicians and their political advisers could really think that they knew best. The criticisms by health service workers of what is contained in the Bill have been dismissed with derision.
Over the weekend I read a paper which was delivered to the University Hospitals Association in Southampton. It was written by Professor John Dickinson who is the professor of medicine at Bart's Hospital. He wrote:Personally I find the market place proposals distasteful in the extreme".He considered,the consumption of scarce public resources on a massive accountancy exercise within what is still claimed to be a National Health Service to be appalling".I have had a similar reaction but, more importantly, so did most of those who work in the 1264 National Health Service. A document entitled The Way Forward for the National Health Service was published a few days ago. It was written by the leaders of 25 professional organisations, including all the royal medical colleges, the Royal Colleges of Nursing and of Midwives and eight of the colleges for professions allied to medicine. It was a unique document and is quite unparalleled. Never before have the colleges come together in order to state their case. They stated:There is no evidence that personal gain provides a better incentive to ensure a high standard of care than does dedication to a properly organised and financed NHS".Yesterday I received a faxed statement from another 14 professional groups, including health visitors, hospital physicists, community psychiatric nurses, hospital pharmacists, ambulance workers and district nurses. I am sure that the Minister has met those groups, but she did not comment upon them. When we reach the Committee stage I shall read several statements made by COHSE and NUPE, which are the two principal unions representing ancillary workers and others, including clerical workers, whose work is absolutely essential to those who provide the care.
There are some 978, 000 people employed in the National Health Service. That includes nurses, doctors, ancillary staff, administrative and clerical staff, ambulance officers and crews, paramedical grades, professional and technical grades and scientific and professional staff. Of those, well over 90 per cent. have recorded their opposition to the main proposals in this Bill. That is the central situation that we have to face. The vast majority of those who work in the National Health Service have through their representative organisations expressed extreme criticism, grave doubt and indeed fear of the way in which the Government propose to move. I quote again from the statement made by the royal colleges:We are ready to support proposals (if properly costed and funded) which can be shown to provide a better service. But we do not support untested proposals which we seriously believe will damage a service whose main defects are due to historic underfunding rather than defective organisation".Yesterday's staff statement had this to say:If quality of care and professional standards of service cannot be maintained, and underfunding continues, there is likely to be a deterioration in the service to patients and worsening staff morale. Under these conditions the long term prognosis for the NHS is poor".We must face that threat too. Any Secretary of State who thinks he can make fundamental changes to the National Health Service in the face of the absolute opposition of the staff who work for and care for it is a danger both to the NHS and to his party.
Yes, I know that there is a small group of managers, accountants and business men and women who see significant profits to be made in this huge market. They include those holding political appointments which were made either publicly or surreptitiously by the Secretary of State, who wants to start the process of privatisation of a great national service. Most of those people are new to the National Health Service and its motivation.
Maude Storey, the president of the Royal College of Nursing, who is known to many of us in this 1265 House, put the case very well at the RCN annual conference last week when she said that the Government's,narrow preoccupation with financial structures threatens to alienate nurses and marginalise their role".She said that the legislation,had failed to create an environment which acknowledges and cherishes the contribution of nursing to the health care team".That statement came from the president of the Royal College of Nursing. One could apply those sentiments equally to midwives, speech therapists, physiotherapists, occupational therapists, ambulance workers and NHS ancillary workers. Then one would begin to understand why the vast proportion of health service workers have given the thumbs down to so much of the Bill that is before us today.
Maude Storey referred to disillusioned nurses drifting away from the profession. I have received over the past few days letters from general practitioners who have resigned from their NHS posts. Some of those practitioners I know and some of then I greatly admire. I fear that this is the beginning of a worrying trend unless something can be done in this House to cause the other place to think again.
All NHS staff want to see improvements in NHS performance. They are not Luddites. They are prepared to work long hours and make personal sacrifices to bring about improvements. They do not want to stand still, but none of them is convinced that these important, costly notions of US-style NHS trusts to administer self-governing hospitals, GP fund-holding practices and the introduction of an internal market where health authorities buy and sell services by contract will be improvements.
I mentioned how many organisations are opposed to the Bill. I challenge the Minister to say what organisations are in favour of it. Who in the National Health Service is in favour of making these fundamental changes without trial and without testing? The statement made by the royal colleges is emphatic:There is no evidence that any of these radical proposals will improve patient care or patient access to care … there is no evidence that forcing teaching hospitals and medical schools to spend large sums on costing and billing to replace the present system of freely given mutual assistance will improve either patient care or medical education and research".Those procedures will certainly put up costs but that is a problem we shall have to face.
Apart from challenging the claims made by the Secretary of State, and indeed by the noble Baroness, the royal colleges further stated:to introduce these changes across the whole of the NHS in 1991 is completely unrealistic … a rapid and widespread introduction could seriously damage the service".Why are those views ignored? The Minister made a nice speech but she did not touch for a moment on any of the criticisms, worries or concerns that have been expressed.
§ Baroness Hooper
My Lords, if the noble Lord had listened with his usual attention to what I said, he would have heard many instances when I referred to the allegations that he has made.
§ Lord Ennals
My Lords, I listened very carefully to the speech of the noble Baroness. Of course I accept her word that she referred to those statements, and perhaps in that case she is giving evidence in my favour. Perhaps she will say what organisations in the National Health Service have supported these proposals.
The costs of the Government's programme are enormous. In 1990–1991 the Government accept that the cost of these changes will be more than £ 300 million. That is on top of the £ 85 million already spent on preparing the way for the changes. That is also before Parliament has even approved the legislation required to make the changes. A flood of new people has been brought in. They are men and women of undoubted financial wizardry. Some of them no doubt come from firms which may have gone bankrupt under the stress of high interest rates. I am not running down any of those people, but they are new to the National Health Service. Seminars have been held in five-star hotels, at the taxpayers' expense, to plan the takeover.
Some of your Lordships might suppose from what I have said that I am about to seek to defeat the Bill. That is not so. First, it would be wrong so to do. There are parts of the Bill which in Committee I shall support strongly. It may be that the new concepts that have caught the imagination of the Secretary of State and the noble Baroness have some potential for improvement. Fairness demands that we try them out in a controlled experiment. How can I or anyone else possibly reach a firm conclusion either for or against since there have been no pilot studies, no controlled experiments, no research and no systematic evaluation? The six hospitals which have been trying out the internal market concept for 18 months or so say with one voice that it is far too early to draw any conclusions.
The Government propose to enable new NHS trusts to run self-governing hospitals outside the health authorities, without trial and even without the approval of those involved. In every test of staff opinion in the units concerned there has been a massive reaction against the opt-out plans. At Guy's 90 per cent. were against; at St. Thomas', 82 per cent. were against; at the North Middlesex Hospital, 96 per cent were against; at Nottingham University Hospital, 97–1 per cent. were against; at Lewisham Hospital, 90–2 per cent. were against; at St. George's Hospital, Stafford, 93–5 per cent. were against; and at the Royal Scottish National Hospital, 94–5 per cent. were against. The turnout in most of those polls was 80 per cent., which is higher than in the Mid-Staffordshire by-election.
The leaders of the professions said last week that in their view it was wrong to impose new structures and sets of principles on the NHS when there was no evidence that the changes will improve health care. The vast majority of those with direct experience of working in the health service consider that the changes will endanger both standards of care and the availability of the service to all who need it. The 35 health service organisations to which I have referred represent well over 90 per cent. of those who work in the health service. They speak for almost all of those who work in the NHS.
1267 The colleges propose that the Government's novel proposals, rather than being introduced all over the country without testing, should be properly and systematically tested in a newly-established evaluation programme. They have even suggested the principles on which the evaluation should be conducted: health outcome; patient choice and satisfaction; implementation of service priorities; improvements in quality of care and value for money; staff job satisfaction and staff development; facilities for education and training of medical, nursing and other professions together with facilities for medical research; the development of effective measures of performance; and development of the research recommendations of the House of Lords Select Committee on Science and Technology.
Time does not permit me to do so now, but in Committee I should like to read the statements that I have received from a great many individuals and a great many representative organisations.
The colleges propose that the evaluation should be carried out through the recently created post of chief of research and development. That proposal owes much to the recommendations of the House of Lords Select Committee on Science and Technology so ably chaired by the noble Lord, Lord Nelson of Stafford. The noble Lord is abroad today, but he welcomes the proposals and hopes to take part in later debates.
We shall propose, on an all-party basis, that the new department becomes responsible for evaluation, research and development. We shall also recommend that the chief officer is strengthened by a widely representative advisory council. We recommend that the Secretary of State's proposals should be thoroughly evaluated in two pilot regions, to be determined by the Secretary of State, and should not be extended to other regions until three years of systematic evaluation have been concluded. That is a carefully thought out plan making use of existing machinery.
The objective is not to resist change or improvements but to identify and foster those changes which can be shown to be beneficial and to introduce modifications where necessary. The creation of such a department would be a guarantee to the Government, the professions and the public, that resources are being wisely spent in the interest of health for all.
What serious arguments can be set against those proposals, which come from the politicians, and the proposals which come from the professions— all those whose lives have been spent in the health service devoted to the task of delivery of care to patients? I know that the Secretary of State and the noble Baroness this afternoon have spoken of continuous evaluation, a procedure of trial and error. That is quite different from a systematic evaluation.
On March 27th Mr. Clarke said:Trying them out in only one part of the country"—which is not what we propose—would be impracticable, creating uncertainty and further delay which would have a demoralising effect on staff".Similar words were used by the noble Baroness.
1268 The opposite is the truth. It is the proposals themselves which are creating uncertainty and having a demoralising effect. As I have already proved, if those ideas were good and sound and had been proven they would be welcomed by those who work in the health service.
Can we say that those people, who have come forward with detailed and carefully thought out proposals, do not know what they are talking about? Of course not. They are the doyens of the profession. They have worked on the statement for three and a half months. Can it be said that they speak for only a small majority? No indeed. They speak for the vast majority of these who work in the health service. There is a small minority who take a different view— and I am looking forward very much to the speech from the noble Lord, Lord McColl, who is one of those who has made a deep commitment. Are those people out of touch with public opinion? Nothing could be further from the truth. It is they who work face to face with clients, patients and the public.
If one looks at public attitudes, it can be seen that the Gallup Poll published on 5th March showed that 71 per cent. of the population disapproved of hospitals becoming self governing; 82 per cent. disapproved of GP fund holding; 70 per cent. wanted to see pilot studies before any of the proposals were implemented. Interestingly enough, a massive 77 per cent. of Conservative voters, higher than the average for all those polled, with their greater knowledge of business methods, called for pilot studies.
No businessman in his right mind would put on to the market a product that had not been tried and tested. No Secretary of State would make available for use in the health service medicines that had not been tried and tested. Why should we take a different attitude in terms of structures and organisation in the National Health Service? I do not argue that we should reject the proposals. I argue that they should be tested before they are introduced across the country, successfully or otherwise.
Perhaps the noble Baroness, or the noble Lord when he replies, will explain why the Secretary of State is so sure that he is right and that everyone else is wrong. For the moment we must rely on the Secretary of State's own words. On 27th March, the day when The Way Forward for the National Health Service was published, he accused the Royal Colleges and other organisations of,trying to persuade unelected peers to put a spoke in legislation late on, after it had passed through the House of Commons".Let us look at that statement by the Secretary of State. First, if it is the collective and considered view of those who work in the NHS that,from their experience, [they] fear that these proposals will, if introduced nationwide, very seriously disrupt the NHS [and] become the subject of a gigantic and costly experiment with a high risk of failure— I quote from their statement— are they not right to address themselves to noble Lords? Let us remember that those professional bodies have put foward their views to the department and the Secretary of State with no response. Let us remember that there has been no meaningful consultation either before the publication of the Government's proposals or 1269 subsequently. Let us remember that they had sought a meeting with the Prime Minister to explain their views, but their request was refused. Can any of your Lordships say that in all those circumstances the colleges were wrong to address noble Lords? Is there one here who feels that he has the knowledge to challenge the conclusions? We shall find out in Committee.
What about Mr. Clarke's reference to passing through the House of Commons? Of course, he is right. In a Conservative-controlled Standing Committee, only two amendments out of 800 were accepted. All the rest were voted down. On Report, when other Members normally have a right to debate the measure, the guillotine allowed 285 minutes of debate for 212 amendments and 40 new clauses. In those circumstances, we are right to take our debates here in Committee and on Report as seriously as the noble Baroness encouraged us to do. That is our responsibility. Even 100 amendments proposed by the Government themselves went through undebated on a single block vote. That cannot be right in a democratic society dealing with a Bill as important as this. It was a quite unprecedented and unjustified clamp-down on the rights of elected Members.
Mr. Clarke is right: we are not elected. We know that we are not elected, but we have a constitutional role. The legislation must go through this House as well as through the House of Commons. We have a role which we must properly fulfil. As a proud Member of this House, I am determined that all of us should do our duty.
Mr. Clarke says that it is now too late for us to influence the Bill. This is the first opportunity that we have had of even discussing it. It might have been nice to have the Second Reading two or three months ago, but we could not. Certainly, we have not been able to debate the community care part because the Bill was published four days after the White Paper was published and there has been no opportunity for consultation, so we must look seriously at the proposals that have been put before us.
If Mr. Clarke says that it is too late, it is because he has jumped the gun by authorising appointments to be made and is spending money as if his unpopular ideas had received parliamentary approval. It may not be illegal, but in my view it is wrong. I believe that the House has a moral and constitutional responsibility to consider the Bill as seriously as it can and, if it is our will that we should put forward other ideas for another place to consider, then so be it.
I also understand that a growing number of managers are expressing concern about the pace of change demanded by Mr. Clarke. Last week's edition of the well-informed Health Service Journal stated:Senior managers are said to be pressing the NHS management executive to draw up contingency plans to restrict full scale implementation of the reforms to a small number of districts thought to have the greatest chance of success. These are likely to be the five or six districts, still to be named.That is very interesting. It is evidence in our favour. I believe that there will be massive support in the National Health Service and in the country for many 1270 of the proposals which will be introduced on an all-party basis in Committee here.
I have only touched on some of the issues and I have a list of others that will come up in debate, but time does not permit me to deal with them now. In the last few minutes left to me I want to make two or three other points. As I have said, the Bill is already massively unpopular with the voting public. But, like the dreaded community charge which came into effect on April Fool's Day, the time for public outrage is not when the legislation is passed. Let us remember the cheering and the waving of Order Papers when the legislation to abolish the equally dreaded rating system went through. Let us remember the applause across the country and in both Houses and the euphoria for Nigel Lawson's 1987 "miracle" budget which is largely responsible for today's inflation rate and historically high mortgage rate.
The trouble comes when the chickens come home to roost. If only there had been a simple evaluation of the community charge, how much better off they might be; indeed, how much better off all of us in the country might be.
The NHS is already in a financial crisis as serious as that in 1987 when the Prime Minister set up her secret working party which produced this largely wretched Bill. A survey by the National Association of Health Authorities, soon to be published, shows that 35 per cent. of all health authorities have not been able to budget for any growth at all to meet the rising needs of the elderly. Moreover, health services across the country are now planning cuts. So, as we move up to April 1991 and the 12 months that follow, we shall find the National Health Service facing grave cuts. We shall find it having to spend massive sums of money on reorganisation which the people involved in it, except for a small minority, are against.
What will be the situation in the country at that time? It is my humble view that the community charge is a peripheral issue compared with the future of the National Health Service. We can adjust it by a few billion pounds to soften it up a bit for next year when we come up to the election. However, if you do that, you cannot have tax cuts, but nor can you put extra money into the National Health Service. What we have seen in terms of demonstrations has been deplorable and sad, but I believe that the depth of feeling in the country from 1st April 1991 and thereafter will be much more serious and more fundamental. It is not likely to attract violence because nurses are not accustomed to violence.
I believe that a government who, with all their current problems, press ahead with the Bill are committing suicide by the most painful way possible. If they do so, they have taken leave of their senses. Why, some of my friends and some of my enemies alike have asked, throw a life-belt, a means of postponing instant drowning? I want the Government to be defeated. I am a member of my own party and I must honestly say here and now that I put the health of the nation as my top priority. This is one of those occasions when Members of this 1271 House have a chance to display their greater wisdom and experience than some of those in another place who seem to have lost their way.
Our handling of this great issue may give the House one of its finest hours. I believe that the country, and certainly the 950, 000 who work in the National Health Service and millions of their patients who share their concerns, now look to this House for a lead. In my view, it is up to us to show courage.
§ Lord Mancroft
My Lords, before the noble Lord sits down perhaps I may ask him this question. What about the poor old patient? Anyone, listening to the noble Lord's speech would have the impression that the National Health Service was run for its employees. I did not hear the noble Lord mention the patient. What about the poor old patient?
§ Lord Ennals
My Lords, I simply say very briefly that I referred to patients throughout my speech. I talked about patients' choice, patients' views and patients' relationships with doctors and nurses. It is largely the patients who are opposed to these proposals. Can the noble Lord not recognise that? The words are clear; the polls are clear. Every time the patients are asked for their views, out it comes, clearly and boldly.
§ 4 p.m.
My Lords, I speak as one of those to whom the noble Lord referred— the poor old patient. When I had the honour to join your Lordships' House some years ago it did not enter my head that I had been sent to this Chamber to do the work of the other place. But that is precisely what we are called upon to do today.
We have before us a Bill large parts of which were never debated in the other place. As the noble Lord, Lord Ennals, said, some 200 amendments to the Bill were made without discussion. So we have a heavy duty. We must discharge that duty not only in our own interests but also in the interests of all those who work in the service and those who depend upon it as patients. Some of us here are more dependent upon it than are others.
I believe that we should have had two Bills, one dealing with the National Health Service and the other dealing with community care. Not having had two Bills, it might have been helpful if we had been able to spend two days on Second Reading, one day devoted to the National Health Service and the other to community care. However, that is water under the bridge. As a consequence we have a huge list of speakers.
It behoves those of us who are privileged to speak early to be as brief as possible. That means that I must omit reference to the 30 or 40 briefing papers which, like the noble Lord, Lord Ennals, I have received from all kinds of professional and other bodies and from all manner of organisations on a whole variety of subjects. However, I should like to assure those who prepared those briefing papers, with great care and clearly with a great deal of 1272 thought, that their efforts have not been in vain or wasted. They will be absolutely invaluable to us during the later stages of the Bill. I believe that all the people in those different organisations to which reference has been made deserve our thanks for providing an example of what I regard as democracy in practice. So I hope it will prove after we have completed the later stages of this Bill.
My noble friend Lady Seear will deal later with community care. I shall therefore concentrate on that part of the Bill which deals with the National Health Service. I merely raise one point on community care. The noble Baroness will remember that I have been in correspondence with her about the appointment of hospital social workers. At the moment there is a difficulty. The noble Baroness explained to me how that difficulty arose. It means that in many hospitals social workers are not being appointed. The noble Baroness spoke particularly about the need for assessment in the community care of patients and also in respect of hospital patients. In the absence of the implementation of Section 7 of the Chronically Sick and Disabled Persons Act, if later we do not have enough hospital social workers in place, we shall be in desperate difficulties. I raise that matter now not in the expectation of an answer but to give notice that I shall return to it again and again until I receive an assurance that the problem has been solved.
It would be nonsense to suggest that after 42 years the National Health Service cannot be improved. Of course it can. It would also be nonsense not to realise that we must have learned a great deal during those 42 years and that we must use such knowledge. I personally accept the need for reform. However, I must make clear that I accept unequivocally the Secretary of State's repeated assertion that he has no intention now or in the future to privatise the National Health Service or to abandon the principles upon which that service has always been based. I accept that assertion unequivocally. There are those on this side of the House who may think that I am not all that wise to do so and that my trust will prove later to have been misplaced. I hope not.
It seems to me that we have a choice of two different ways in which to employ our speeches in today's debate and in the later stages of the Bill. First, we could seize the opportunity to discomfit the Government. That is quite tempting and would be quite easy; in the end it would be quite enjoyable. But I do not think that it would prove fruitful or be profitable for the wellbeing of the National Health Service about which we are all concerned. Alternatively, we can try to improve the Bill and make it workable. That is the course that I have chosen. Therefore I hope that the Government will accept that my remarks today are designed to assist rather than the reverse.
I have previously asked the Government to note that we have assembled in this House, in all parts of the Chamber and from all parties, a wealth of experience and expertise on health matters which excels that of any other forum, perhaps even the Department of Health itself. I hope therefore that the Government will heed the advice given in this debate from distinguished professionals such as the 1273 noble Lords, Lord Walton of Detchant and Lord Hunter, the noble Baroness, Lady Cox, and many other noble Lords whom I shall not name. In view of the importance of the consumer aspect and the fact that it is not fully represented at the moment in the Bill, I include the advice of the noble Baroness, Lady Oppenheim-Barnes, who is very knowledgeable on those matters. I hope that the advice of those very distinguished professionals whom we are fortunate to have in this House will be listened to and heeded. Like other noble Lords I greatly look forward to hearing the two maiden speeches which I am sure will be relevant.
It would be out of order now to talk about the new GP contract. Again, that is water under the bridge. But perhaps I may just say that if, when I entered genereal practice in the National Health Service many years ago, I had been told how often I should examine certain patients, I would have given a fairly sharp answer. And if I had been told in detail how I should do my work, I should have taken it rather amiss.
I am very much in favour of screening patients, provided that the screening is cost effective. For example, in our population there are many undiagnosed diabetics; yet diabetes is easily treated. It is easy to test urine and to diagnose a diabetic. That should be done. However, what if I am to take the blood pressure of every elderly patient every so many months? The concept of symptom-free pathology is one that I do not fully accept. If one finds that the blood pressure is raised, one has to treat it. If one starts treating it, one has to continue to treat it for ever. I am doubtful about the cost-effectiveness of some of the new procedures which have come in with the new contract. However, I shall leave that matter at the moment. Perhaps I may add that the reversion to payment largely by capitation I consider to be both regressive and regrettable for reasons which I have explained before.
As to the other proposals, particularly those concerning hospitals, it is worth noting that running through all the briefing papers that we have received is the theme of evaluation, caution, taking time and making sure that the changes will work before they are applied universally. It was, I think, my noble friend Lady Seear who said to your Lordships some time ago that no government ever get everything right the first time. I doubt whether even the great Liberal government of 1906 got everything right the first time. When one makes major changes in a structure which has served the nation well for 42 years, one should not merely conceive them. We should try out some of the procedures. But how should it be done and done in such a way as to get meaningful answers? Those are the kind of problems with which we are faced today.
With regard to the general question of hospital self-governing status, the establishment of hospital trusts is a crucial reform. Noble Lords may recall an earlier speech I made in a similar context. I had just come out of Manchester Royal Infirmary, the teaching hospital where I trained. In the debate I said that I personally believed that Manchester Royal Infirmary had no option. It had no choice other than to opt for self-governing status. Some noble Lords 1274 on this side of the House looked somewhat askance at that statement. Why did I make it? I made it because at the moment in that distinguished hospital, which has a very fine history, an old hospital is being demolished while a new one is being built inside it. The corridors and wards are full of bulldozers. There are ladders poking through the windows. The conditions are absolutely intolerable.
I believe that the major structural problems with which that hospital is faced in order to re-establish itself are too great to be solved by the normal procedures that the health service has established over the years. They can be solved only by a new procedure such as a trust with self-governing status, provided that that trust is properly constituted and has proper representation of the university, the medical school, the City and the public in that area. I believe that, given the opportunity to do things in its own way, Manchester Royal Infirmary could succeed.
I accept that there are possible advantages for the establishment of self-governing hospitals with hospital trusts. But we cannot find that out by undertaking an experiment with one hospital. We have to find out the consequences of having a self-governing hospital for other hospitals that are not self-governing and for other aspects of the service— the general practitioner service and various other factors. One cannot undertake an experiment with one hospital.
What are the problems with regard to the proposals put forward by the royal colleges? I regard the proposals as quite exciting. I shall be very interested to consider them further at the Committee stage of the Bill. However, I foresee that the Government will advance certain objections. Who chooses the regions? What happens to people who are not in the regions that are chosen? There are hospitals which have already spent a great deal of time, money and effort on preparing for self-governing status. Perhaps they should not have done so; perhaps they have jumped the gun. If they are not in one of the regions that is selected, they will shout, "Foul. Why have we been left out when we are nearly ready to go ahead?"
Those are the difficulties that I foresee. I do not believe that they are insurmountable. There may be many ways to overcome them. I should like to see some evaluation process, if not by the suggestion put forward by the royal colleges, perhaps by another method. We need a monitoring and evaluation process. I should like to see an independent National Health Service inspectorate established, but that is another matter which is not immediately related.
We then have points to raise about the so-called core services, as they used to be called. They are now called "designated services". They are services which have to be provided in every region. I do not quite know what they are. I raised this matter some weeks ago and was told by a physician from Cheltenham that there are two hospitals there and because care for AIDS comes within the alleged designated service they have to provide for it. But there are no sufferers from AIDS in Cheltenham, yet both hospitals have to provide for it. My point is not that we send AIDS to Cheltenham but that it seems illogical to suggest that every part of the country should provide for 1275 every possible form of medical activity. I do not think that that is reasonable. I do not believe that it would be cost-effective. It is not sensible economics. It is not even sensible medicine. Certain very expensive services have to be concentrated with a great deal of capital in limited areas. That could not be done if those provisions were spread all over the country. Inevitably certain standards would decline. I am concerned about the problems of research. In regard to hospital trusts, the word "may" appears in the Bill. I agree in principle with the chairman of the Committee of Vice-Chancellors and Principals that the word "may" has to be changed to "must". I hope that at Committee stage we shall ensure that that is done. The noble Lord, Lord Nelson of Stafford, will make that point when we return to our discussions.
The representation of the universities is absolutely essential. With regard to the new family practitioner committees— whatever they may be called— we must be careful to ensure that the locality is effectively represented. That does not necessarily mean that I wish the community health councils to play a totally different role; I am not sure that they wish to be represented on all bodies. They are doing an important job; They should continue to do so. But somebody must ensure that the interests of the consumer— I use that word in the broadest sense— is effectively represented on each and every one of the bodies which will administer the National Health Service.
There are so many other matters that I should like to go into but I shall not do so. I wish to be brief. I conclude with some thoughts that have not been raised in our discussions recently. At the end of the day the quality of the health service that one receives, whether in or out of hospitals depends on the quality and the nature of the people who do the work. I make no criticism of that quality, the nature of those people or their trade. But society has changed during my lifetime. Motivation has changed. Clever pupils at school do not go in for science. They study accountancy and the sterile business of money management because the incentive, the motivation, has become that of making money. I believe that more children and young persons are now brought up with that concept.
That leads me to say a few words on the way that we select students to study medicine. The applicants far outnumber the places. How are they allocated? It is purely on the basis of high academic success in a very narrow range of A-levels. For years I was a general practitioner in the National Health Service. My patients did not need somebody with all kinds of A-levels. They did not need an academic genius, but someone who could listen, who was prepared to care for them and who had a real feel about the obligations involved in the job that he was doing. If any of my grandchildren decide to study medicine— I am sure that they will attain the necessary A-levels if they do the work— and on attempting to obtain a place at medical school are offered one without first having an interview, I shall say, "Do not go to that school; try another university". We need to look very carefuly at the 1276 quality of the people coming into these professions. I do not know how one can measure it. I am not sure how one solves the problem. However, I am not satisfied that by relying wholly on high academic success in a narrow range of A-levels we are necessarily obtaining the best and most suitable people to carry out this vitally important work.
I hope that in the later stages of the Bill we shall be able to improve it. I accept that there is need for reform in the National Health Service and that some of the ideas contained in the Bill could prove very valuable. But we must take care. If we make changes without sufficient care, thought and proper evaluation, instead of improving the National Health Service we could strike it a death blow.
§ 4.17 p.m.
The Lord Bishop of Manchester
My Lords, ever since the publication of the White Paper, Working for Patients, there has been widespread discussion and concern in the Churches about the NHS proposals. Perhaps I may give one example. I remind your Lordships of the resolution that was passed in our Genera] Synod in July of last year. It was passed almost unanimously:That this Synod, noting the considerable history of Christian concern for an involvement in the provision of medical services,
Thus our General Synod voted last year in a resolution on the White Paper.
- (a) urges the Secretary of State to ensure that health and not cost is the prime objective and the requirements for economy in the use of time and money … do not undermine the provision of effective treatment;
- (b) believes that the changes proposed are likely to affect adversely the access of vulnerable people to adequate health care;
- (c) calls on the Secretary of State to extend the consultation period and only to introduce the changes if their feasibility has been established through trial projects".
The comment may be made that that was the White Paper but we are not on the Second Reading of a Bill which has passed through the other place. How far does that change the concerns that were then expressed in the Church of England General Synod? I am sorry to say that it does not change them at all. It appears that the debates which took place on the NHS proposals throughout the country, especially by the professional bodies as already referred to, have not altered the Government's mind on the fundamental issues in the Bill.
I agree entirely with what was said about the sincerity of those who are bringing forward the proposals, particularly the Secretary of State, and their commitment to the National Health Service. However, there are still many doubts about the proposals, especially in informed health circles.
There is a tendency to write off the criticism that comes from professional bodies by saying that fundamentally it is self-interest. I am the last person to deny that self-interest often raises its head in such matters. One has only to look back at the history of the creation of the National Health Service and see the attitude of certain elements within the medical profession as Secretary of State Aneurin Bevan brought forward the proposals to realise that we do not need to go overboard for criticism, however well informed.
1277 From what has been put in front of us, particularly the paper from the professional bodies already referred to, we must recognise that this case is different. The criticism is not self-interest but it arises out of deep concern and knowledge of the workings of the National Health Service since its creation. No one denies the need for reform. No one denies that resources are limited. No one denies that the principle behind audit can be valuable and it is necessary to help all those working in the NHS to realise the need for conserving scarce resources and giving value for money. Who can disagree wih the main aims of the Bill; namely, extending patient choice, delegating responsibility and providing value for money?
We also welcome the commitment of the Secretary of State and others to the main principles of the NHS. They are the provision of treatment open to all, free at the point of use and financed primarily by taxation. All that is welcome, but informed doubts remain They have commended themselves to many people in Britain, as the surveys have shown. Surely such criticisms from the professional bodies cannot be dismissed as being in any way self-interest. I see no reason to doubt the statement made in the briefing paper The Way Forward for the NHS. It reads:Our concerns are for the health of our patients and for the present and future overall standards of health care in the United Kingdom".Now that the Bill has come here from the other place it is clear that the main changes will come into effect. As has already been stressed, the function of this House is that of a revising Chamber. But we must exercise that process knowing that deep doubts remain throughout the NHS, among patients and in the country as a whole. This is not a party political matter. Surveys show that concern about the proposals is widespread and is held by people of all political persuasions.
One reason for the concern and doubt felt in the Churches is the emphasis placed by government in recent years on the value of private medicine and private health insurance. I do not believe that it is possible to carry conviction and profess a deep commitment to the NHS and all that it stands for, while at the same time constantly paying tribute to private medicine even to the extent of giving tax relief to those with private health insurance not merely after their own retirement but also to their children. That is a matter which could well undercut the fundamental principles of the NHS and lead inevitably to a two-tier service.
We must also recognise that a sense of pride and high morale is needed among those working in public service. I am afraid that in recent years no stress has been put on that. Private provision has been exalted at the expense of those giving public service in many different fields.
I turn to the main proposal which will occupy the thoughts of Members of this House during the next few weeks. It is reasonable to ask for a trial period. Although I claim no expertise in the field I have read through the briefing and the criticisms. I believe that the proposal put forward by the professional associations is reasonable and wise. If I were in a 1278 position to vote for the proposal when it came before the House I should feel inclined to do so.
I am conscious of the clock, as should we all be with such a long list of speakers. However, I wish to point to some of the doubts which have been expressed by many, particularly by the Churches. First, there exists the anxiety about the doctor/patient relationship in the face of cash limits. I was grateful for the careful phrasing of the Minister in pointing out that indicative budgets are not cash limits. We welcome that; it leaves room for flexibility. However, the relationship between doctors and patients is vital: it is sometimes called the "covenant/fidelity" relationship. It could all too easily be damaged if there were suspicions that cash was determining the form of treatment and not the needs of the patient. More attention must be paid to that issue in the Bill before us.
Secondly, we all welcome patient choice. However, the question is whether greater patient choice will work only to the advantage of the better off; for example, those with cars and ease of transport. The Church of England's board for social responsibility has produced comments on Working for Patients which are also relevant to the Bill. The board points out that the offering of services in other districts depends on a degree of mobility not available to many people. Women with small children, people without cars, low wage earners and frail and elderly people cannot reasonably be expected to travel in response to the differential availability of services. I note the comment of the noble Lord, Lord Winstanley, that in certain hospitals one must concentrate on specialist services. That is accepted. As regards treatment in general, patient choice sounds a marvellous idea until it is looked at in terms of transport and so forth.
There is also the issue of links with the local community. I am worried because local authorities appear to be cut out of the process. However much certain local authorities may be disliked and distrusted by one side or another in this House, the fact remains that they are elected. They are also links with the people in their communities. The Bill before us does not leave sufficient room for genuine elected local involvement in the provision of such services.
How do we measure value for money, on which the Bill before us lays great stress? That is not at all easy and its complexities do not appear to have been sufficiently recognised. For instance, if one argues that some hospitals are more efficient than others because of the number of beds available, or their use, or their high patient turnover, how can one also allow for the quality of service where cost should not be the prime consideration?
I turn to the question of preventive medicine and the gross inadequacies which now exist in our country. Those inequalities were pointed out in the Black Report published some years ago but they have been addressed all too little in recent years. Little mention is made in the Bill of preventive medicine and it receives only a comparatively small share of the total health budget. While I have no time to comment on what is put before us concerning community health care, it is a fundamentally important part of the whole approach to health.
1279 We must concentrate more on measures which stop people becoming ill. We must recognise that in certain parts of the country there is a tragic syndrome of smoking, bad diet, alcoholism, poor housing, and so forth, which affect people's health. Too little attention is given to this in the Bill.
Perhaps I may also mention— no doubt noble Lords would expect me to make this point, but I think it is fundamentally important— that there is the question of spiritual provision in our health services. We believe in an approach which includes attention not only to the body and to the mind but also to the spirit. I believe that chaplaincy services provided by the Churches but financed by government have been fundamentally important over the years. What guarantee is there that under financial pressures these will not begin to be eroded or even disappear? Surely something along these lines should be written into the contracts between the suppliers and purchasers of health care.
The last matter for which I have time this afternoon is to point to the danger of differential payments in the National Health Service. If there are self-governing hospitals there will be temptations along two possibly opposed lines. It may be that some "successful" hospitals will be able to pay larger salaries to attract better qualified staff; there may be others which, under the pressures, are tempted to cut corners, to underpay staff, to take on people who are less qualified, in the interests of keeping their budgets down.
We must recognise that the National Health Service, as one of the largest employers in Europe, also includes among its ranks many very low-paid people. I think a concern for the levels of pay in the NHS ought to be a fundamental consideration as we look at the implications of self-governing hospitals and moves of that kind.
In conclusion, I do not know how far amendments which will be tabled will help to meet the kind of doubts which are being expressed widely in the country and in the Churches, but I very much hope that during the Committee stage we shall be able to make some improvements there.
§ 4.32 p.m.
§ Lord Kilmarnock
My Lords, this Bill will shape the face of the National Health Service and the quality of health care in this country for several years to come at the very least, and possibly for much longer. Even if there were a change of government it will not be possible to throw into reverse the whole of this vast and complex service; nor would it be right to do so. This places an important duty on us to see that the Bill leaves this House with some significant improvements. I think that is the way ahead that the noble Lord, Lord Winstanley, wanted to adopt.
The motivation of the Government in bringing the Bill forward and the cavalier way in which they have done it are very much open to question. To alienate large sectors of the medical and other health professions as a prelude to this considerable upheaval was either inept or deliberately 1280 confrontational. Whichever is the case these reforms have not got off to a good start. But whatever their inclinations the Government have been unable to resist popular demand for the continuation of a service free at point of delivery and financed largely out of general taxation. This has been the political consensus of health care over the last 40 years, and it is the one area of consensus on which the Government have made virtually no inroads.
Much flows from this. It means that the obligation of the Secretary of State as laid down in the National Health Service Act 1977 is still in place. It is not repealed. It is still his duty— I quote from Clause 1 of that Act—to continue the promotion in England and Wales of a comprehensive health service designed to secure improvement—
It is on this bedrock that we are entitled to take our stand and to press the Government hard on the likely effect of this legislation on the fulfilment of that duty. In fact, the Government themselves, through the rather tendentious title Working for Patients have invited us to measure their proposals against their professed objective.
- (a) in the physical and mental health of people of those countries, and
- (b) in the prevention, diagnosis and treatment of illness, and for that purpose to provide or secure the effective provision of services in accordance with this Act".
Having said that, I do not regard the Bill with quite so much alarm or, indeed, loathing, as other critics have shown towards it. It was not an option to do nothing. The SDP has never advocated merely continuing the status quo. It is true that over the years we have had remarkably good value for money from the NHS owing to lower administrative costs and lower-paid health workers than in most other developed countries. That is the main reason why our percentage of GDP devoted to health care is so much lower than in comparable countries. In essence, we have adopted the much loved British approach of muddling through, relying to a large degree on ethical commitment. Admirable though that may be, it has given rise to serious gaps and shortfalls in performance, of which the most politically embarrassing was and is the intractable total of waiting lists for elective surgery which still remain at over a million in the United Kingdom as a whole.
I was going to say something about the overall funding of the service, but in view of the time and the length of the speakers' list I shall not follow the noble Lord, Lord Ennals, into the question of whether or not there is underfunding in the National Health Service. However, I must say in passing that the Government should not believe that this shake-up will be cost-neutral. There are many costs connected with the implementation of the Bill which they have not even begun to face up to. For example, the transaction costs of costing and billing, not only across district boundaries but within them, are not even mentioned in the financial memorandum to the Bill.
My main criticism of the Bill is structural. In a lecture recently Professor Nick Bosanquet, the Professor of Health Policy at the Royal Holloway and Bedford New College called the acute hospitals 1281 the "dreadnoughts of the health service". This Bill is too hospital-centred. That is because the Government believe they can solve the efficiency trap to which the noble Baroness referred, (that is, whereby hospitals which treat more cases are not being reimbursed accordingly) and eliminate waiting lists through separation of purchaser and provider in an integral market.
We on this Bench are not against an integral market— indeed, we introduced the notion into the health service debate in this country— but we very much doubt if the Government's model will have the desired result. No less a person than Mr. Enoch Powell said in 1966 that Ministers are powerless to do anything about waiting lists. And when the Government threw money at their waiting lists initiative what happened? There were improvements in some areas, but the overall situation did not improve because unmet demand flowed in to mop up the money.
There is only one cure for waiting lists— that is to ensure that no one goes to an acute hospital who does not really need to go there. This requires a dramatic shift from secondary to primary and community care, and health maintenance in general. I shall revert to this theme shortly.
My next criticism is the one that I believe is widely shared by many noble Lords who have been worried by the helter-skelter timetable and have demanded pilot studies. The Government have reacted strongly against this. Ministers have objected that it would take years to evaluate experiments, and they would be cosily and inconclusive. But this comes oddly from the Government when the whole Bill is a vast laboratory, with various experiments taking place in it or about to take place for which the Government have provided no adequate means of evaluation.
Thus they lay themselves open to serious charges on two counts. First, it is not businesslike. No service industry of comparable size could afford to neglect an evaluation of its own results in order to arrive at the best methods of improving performance, as I think the noble Lord, Lord Ennals, said. Secondly, it is certainly irresponsible, and probably unethical, to have no mechanism in place in the Bill to ensure the quality of service and the satisfaction of the patient at whom the whole exercise was supposed to be directed in the first place.
That brings me to my third criticism. Despite the rhetoric of the White Paper's title and some easement of the procedure for changing GPs, there is precious little in the Bill for the patient, which was a point of concern for the noble Lord, Lord Mancroft.
I turn now with a very broad brush to areas where improvements can be made and amendments are necessary. I have already spoken of the need to improve the primary and preventive care network and to create a health maintenance philosophy as the only hope of reducing hospital queues. In this context, the idea of the fund-holding practice is an interesting one. I can see that enthusiastic GP teams with a rather wider remit and increased ancillary support could have a beneficial effect on the health of their practice populations and act in effect as 1282 health maintenance organisations. I have read that some 85 large practices— representing, I imagine, about a million people— have applied for that status, but I think the noble Baroness mentioned an even larger number, so perhaps the noble Lord will tell us when he comes to reply what is the state of play on this at the moment. I for one do not want to stop this experiment going ahead.
However, we cannot know in advance that it will be successful, so I believe that other methods of extending primary care and health maintenance should be tried. The Government have devised a new family health service authority, to which the noble Baroness referred, and made it directly accountable to the regional health authority. However, there is a much better combination which we have long advocated; that is the amalgamation of the FPC, or its successor, with the district health authority to break down the artificial divisions between the family practitioners, the hospital and the community health services. I cannot think why the noble Baroness referred to that as an unnecessary distraction. The enormous advantage is that it would be in everybody's interests— consultants, nurses, GPs and community workers— to ensure that the patient received the most appropriate care, not necessarily in hospital. There would also be an incentive for the health authority as a whole to invest in health promotion and increase the range of GP services to avoid expensive hospitalisation.
That could be achieved by permitting district health authorities, with all their services, to become self-governing trusts in which the family health service authorities could also be incorporated. I hope to devise an amendment, not on a prescriptive basis, to open up that possibility in Committee. It should not invalidate the internal market because there would be trading between the trust and the private sector, as the Government propose. We agree with the Government that the trusts should have greater flexibility and freedom over terms and conditions of employment, over borrowing from the private sector, and over the retention of surpluses to improve services and for further investment.
Incidentally, I possess a list of those NHS bodies which applied for trust status. It includes a dozen district health authorities applying as a whole with all their services. Can the noble Lord tell us, when he replies, how the Government propose to treat those applications?
We should like to add one other refinement which would certainly stimulate the internal market: that is, to give patients a right to treatment within a given period of time. That might be equal to the average waiting time in the speciality in question in the best 20 per cent. or 25 per cent. of health authorities. If the patient did not receive treatment within that period, he should have the right to seek it from another DHA or, if the cost was no greater, from the private or voluntary sector. The DHA of origin would be obliged to meet the cost of treatment and any travelling involved, which is a matter of particular concern to the right reverend Prelate. That would do more for patients than anything proposed in the Bill as it stands.
1283 Another result of the amalgamation may be the revitalisation of GP or community hospitals, whose role may include minor surgery, strokes, convalescence, respite care, geriatric care and so forth. Those hospitals may become centres for out-patient clinics to increase access to specialist consultation. To regard as unthinkable the requirement for one doctor to spend time travelling to, for instance, 20 patients rather than their travelling to see him, is to continue to organise the NHS on the assumption that the patient's time is worthless. If working for patients means anything, that sort of devolved service should be the norm rather than sucking everything into the acute hospital.
So much for the structure. I now turn to the quality. The noble Baroness said that the aim of the Bill is to improve quality. I submit that there is a glaring lacuna on that point in the Bill, which has no provision for the monitoring of standards or quality control. It is an unjustified assumption that rewarding hospitals for increases in numbers treated will lead to increases in the quantity and quality of life of those treated.
There are several possible ways of tackling this subject. The Labour Party is keen on a quality control commission. There is also the idea— attributed to Lord Young of Dartington— of creating a core of inspectors of health analogous to the HMIs in education with comparable rights and duties. That might be linked to a strengthened social security inspectorate to cover the whole range of health and community care. There is the proposal for a national accreditation board to which NHS and private sector bodies would be encouraged to affiliate on a voluntary basis.
I hope either to move or support a new clause based on that idea in Committee, but ultimately we shall have to see which alternative gains most support in your Lordships' House and go for that. We must have a provision for the maintenance of standards and the promotion of quality in the Bill. As the Independent Hospitals Association rightly said, regulation of quality standards must be separated from the purchasers of care. It cannot all be done in the contract which, as the noble Baroness said, will not be legally binding.
There are two other possibilities which we must consider. The first concerns the Audit Commission. I welcome the extension of its role to include the NHS. However, in so doing the Government have drawn its powers more tightly than those it enjoys in relation to local government. I specifically regret that the power under Section 27 of the Local Government Finance Act 1982 was curtailed for the health service. There is no reason why the Audit Commission should not report on the impact of statutory provisions, for example on standards, or question the objectives of the Secretary of State. That is exactly what is required in an open system, and those powers should be restored in full.
Another aspect in which the Bill could be improved relates to the need for R&D on the operational side of the service. The Select 1284 Committee on Science and Technology under the chairmanship of the noble Lord, Lord Nelson of Stafford— to which reference has already made— recommended an NHS research authority to remedy that position. I believe it was Professor Maynard of York who pointed out in evidence that there was excessive emphasis on measuring inputs without measuring outputs in terms of quality of life and the results of treatment in general. The Government accepted that argument in principle, but rejected the idea of an independent research authority, preferring to appoint a chief of research and development to advise the Secretary of State and the NHS management executive.
That has been done or is about to be done. Perhaps the noble Lord can advise us whether that appointment is in place. However, the appointee could easily become a lonely and not particularly effective figure unless he is backed by a strong team which is able to inspect and evaluate that which is happening on the ground. That might be the best way of allaying the fears and apprehensions which so many of us share. The noble Lord, Lord Ennals, suggested one form of evaluation and there could be others, as the noble Lord, Lord Winstanley, suggested.
Any of the ideas I have just sketched in would strengthen rather than undermine the Bill. I hope that the Government will not reject them all out of hand. I and my noble friends are convinced that there must be a move in the direction of extended primary care and prevention. There is no other way to prevent increasing pressure on acute hospitals. If the Government do not take that on board they will find that they have initiated enormous upheaval which will not give them the results they seek and which we all want.
As I said at the beginning of my speech, my gut reaction is not one of shock horror towards the Bill. The Bill opens up some interesting possibilities of evolution for the service. However, the Government have not thought through all their measures, conceived as they were in a closet without consultation. They would therefore be very well advised to listen to your Lordships' House.
§ 4.47 p.m.
The Earl of Clanwilliam
My Lords, your Lordships will perhaps not be surprised that I was somewhat daunted at the prospect of joining your Lordships' House. I must confess that the adrenalin was running at some pressure when I was shown to the Bench next to the noble Lord, Lord Mason, who said, "Sit down, lad, you are among friends now".
I should like to thank all noble Lords who have been so kind to me since I joined this House. I also pay tribute to my distinguished and gallant father who was distinguished and gallant on several counts, one of which in particular may interest your Lordships. He was mentioned in dispatches while serving as Serjeant-at-Arms in your Lordships' House. That was quite an achievement. He was on considerable leave of absence.
It would be inappropriate for me to discuss the National Health Service Bill in a maiden speech 1285 because anything I say would undoubtedly be controversial. However, I think there is one point on which, everybody in this House agrees; the National Health Service undoubtedly needs a serious degree of reform. Therefore perhaps I may address your Lordships on complementary medicine. I refer to that medicine which is complementry to and not alternative to modern medicine, particularly referring to plant material and its medicinal uses by medical herbalists.
There are hundreds of thousands of patients of medical herbalists in this country— I am happy to say all alive and kicking, at least so long as they survive this mortal coil. There are also chiropractors who claim to have over 2 million consultations a year. Perhaps your Lordships will agree that that indicates an increasing acceptance by society of such disciplines, which are of great benefit to the country and especially to the National Health Service because they do not use NHS beds or drugs; they do not suffer from serious side-effects and they do not get sued by their patients.
With regard to research, there is the European Society for Co-operation of Psychotherapy— the in-word for medical herbalism— commonly known as ESCOP. In addition to that, of course, in this country we have the Research Council for Complementary Medicine, with a distinguished panel of doctors and patrons, and the Centre for Complementary Health Studies at Exeter University, which runs a degree course in several disciplines and the associated historical and ethical aspects.
With special reference to herbal medicine, there is the National Institute of Medical Herbalists to which the practising members belong having completed a four-year study course at the School of Herbal Medicine which is run by the British Herbal Medicine Association. That association has just issued the 1990 edition of the British Herbal Pharmacopoeia, with some 80 monographs. These 80 monographs updated from over 250 monographs which were in the 1984 edition. This pharmacopoeia will be supported in due course by a compendium prepared by the Centre for Comprehensive Health Studies at Exeter, which will provide clinical research that support the monographs.
The research work into herbal material is of worldwide importance. Indeed, it is stored in the ancient civilisations of South America, Africa, India and China. It confirms much of the work of the more modern medieval European herbalists. We have a great store of knowledge in herbal materials in this county. Predictably, I refer to the Chelsea Physic Garden. I had the honour to be on the fund-raising committee when it was made a charity. Ironically enough, this garden was the nursery for medieval apothecaries whose establishment was the hostel at Blackfriars. Strangely enough, that hostel is now the headquarters of the Royal Society of Pharmacists.
In addition, there is the Royal Botanic Gardens at Kew where an enormous amount of research work is being carried out. The gardens are particularly associated at the moment with the World Wildlife Fund expedition to the Korup Forest in the Cameroons where a huge store of herbal medicinal 1286 knowledge is being discovered. Plant material, however, is being examined much more for its drug and agro-chemical use than for its herbal uses. It is the medicinal values that I wish to propound to your Lordships on future occasions.
At Kew there is a huge computer database storing a remarkable amount of knowledge. It contains material from the herbarium sheets. These are samples of plant material which have been sent to Kew over the centuries by explorers, by travellers and even by the odd interested consul in some outlying post of the Empire. They are stored with the details of climate, soil conditions and any available local knowledge. It may surprise your Lordships to hear that there are no fewer than 11 million of these sheets. That indicates the vast amount of work that needs to be done in the promotion and knowledge of the herbal use of plant material which we have in this world.
§ 4.54 p.m.
§ Lord Hunter of Newington
My Lords, my first and most pleasant duty is to pay tribute to the noble Earl, Lord Clanwilliam, on his speech. He showed charm and courage— courage not in the face of the occasional turbulence of this Chamber but because at least half a dozen orthodox practitioners are sitting on this side of the House. Further, in the spirit of maiden speeches he spoke about complementary medicine and not alternative medicine, and in that we support him.
From these Benches I issue to the noble Earl, on everyone's behalf I am sure, an invitation for 9th May when the noble Earl, Lord Baldwin, will be opening a debate in this Chamber on complementary' medicine. Everyone on the Cross-Benches and I am sure everyone in the Chamber looks forward to hearing him speak on that occasion.
§ Lord Hunter of Newington
That invitation comes from a retired professor of materia medica.
The noble Baroness, Lady Hooper, did a fair and reasonable job in introducing the Bill, including giving a framework of the situation, which I believe was right and proper in opening a somewhat complex debate. Around the world of health services there is a crisis over expenditure. This is true of the United States of America and also of Canada, whose health service has been the envy of the world. In all, the style of delivery of medical services is under scrutiny, but we are told that Canada, which everyone admires, is now the world's highest per capita spender on health care of any country with a national system.
The president of the American College of Physicians, Edwin P. Maynard, was reported on Tuesday, 2nd February of this year as saying:To date, efforts to effectively contain costs have been insufficient. Rationing is here to stay. We need to develop a logical and equitable process to handle it".We are in good company. We also need a logical and equitable process.
An important determinant of health to which our Government have begun to pay attention is the 1287 public health: clean air, clean water, standards of food preparation, occupational health and safety standards, employment, education and training and a stable working environment. Unfortunately, I suspect that if successful the prolongation of life may not necessarily save costs. A vitally important determinant of health is choice: food, drugs, alcohol, exercise and sexual habits, dramatically highlighted by the discovery of AIDS and its prevention by personal choice.
There are then the diagnostic and treatment services free at the point of access and the choice of diagnostic tests and treatments depending upon the personal decisions of physicians and surgeons. In contrast to the Canadian insurance model, in the United Kingdom, as in Sweden, it is the Government who plan, organise and deliver health services. In the USA the government's direct involvement in the US health model represents about one-third of health care activity. It is because of the situation to which I have referred that our Government have, quite rightly, had to make proposals for the future organisation and running of the health service. Their method of doing this has seriously flawed the rational consideration of the proposals, many of which are in fact strongly supported by the medical profession.
At first sight it would appear that the Government are proposing a demand-led service to replace a need-led service decided by doctors and, at the same time, with the aid of modern technology, introducing more detailed financial records and embarking on the complicated business of trying to identify the detail which should be in doctors' contracts. Later I shall be saying something about general practice, but it is as well to remember that since 1911 doctors in family practice have been independent contractors. Recently a new contract has been imposed on them— from 1st April, a few days ago. My personal view is that this has complicated the situation.
As an illustration of the demand-led proposals, it is suggested that general practitioners should buy hospital services. The proposed details for doctors' contracts, instead of trusting independent contractors who are professional people, has given rise to the greatest concern and anger within the profession. That is not made any easier by the admission in the White Paper on the health service that there is not enough information available at the moment to draw up these contracts.
As a result of the methods used and the way in which advice was taken, there are many things of vital importance which have not been considered. For example, in Canada they are moving forward with the Independent Health Facilities Act. This legislation will result in planned, quality-assured systems of community-based care providing many procedures more conveniently and less expensively than in hospitals. They will free hospitals to provide services that truly require a hospital setting. Here I mention eye testing, testing for deafness, laboratory tests and, we hope in the future, screening for cancer and seeing the consultant of the doctor's choice in a group practice. It will be quite criminal if studies were not urgently done to expand the role of allied 1288 professions in this setting though I am sure that the Government have started on this.
A study made in the United Kingdom recently has shown that referring patients to distant hospitals for special treatment is the exception and not the rule. To be forced to do this for financial considerations is, I suspect, not going to save resources. The Government proposals seem to suggest that price reflects value and that throughput effectively measures health care performance. Neither of these is correct.
I look forward to hearing the Minister's explanation of what the Government mean by that. The measurement of healthcare performance and results is the key to the whole of this situation. In this human situation price does not necessarily reflect the value of an operation or a treatment.
Another imaginative idea which does not appear to have been considered in the government plan is the Canadian proposal for a hospital incentive fund where the Government provide matching funds up to 500, 000 dollars to hospitals to develop new approaches to more effective management of hospital resources and the provision of enhanced care for patients. That could apply to all hospitals and not those specially blessed by the Secretary of State for holding a budget. I believe that through a hospital incentive fund any hospital could graduate or go back as a result of its efforts. I suspect that this kind of approach would be a great challenge and stimulus to the hospitals and probably more acceptable than the present proposals.
To offer this incentive opportunity for three to five years might present a challenge to everyone and a continuing opportunity for all institutions within the NHS to have their achievements recognised. I am sure that there will be amendments to suggest that.
The central problem remains that doctors control the expenditure but fortunately both the medical profession and the Government are enthusiastic about the idea of introducing what is called medical audit. That tends to mean different things in different places. The Science and Technology Committee of your Lordships' House, which has been mentioned, has made recommendations about improving the research and development of the health service and these have been substantially accepted by the Government. Many people believe that it is through this machinery, medical audit and the relationship between doctors and management, that changes for the future should take place based on proper evidence.
I do not think that the medical profession is against change, but is is against the introduction of new procedures and new methods, some of which have failed in the United States. I think it will be found that much of the pressure, when this matter is being debated in the House, will be concerned with the question of trying to find an evolutionary path and how that might be achieved. There is a long way to go if the American scene is any guide. Joseph Colifario Jnr, a former Secretary for Health, has stated that a quarter of American health costs (150 billion dollars) is wasted or unnecessary.
1289 The Government's response to the report from the Select Committee on Science and Technology offers the opportunity to develop and produce a health care technology research capability. The roots of modern medicine are based on rigorous scientific validation of what doctors do in order to ensure that it is always appropriate and effective.
A chief of research and development— a post which the Government have proposed— would advise on a number of matters. They are so important that I shall briefly mention them: advising the management executive on priorities for the health service; research and managing a programme of NHS research to meet needs, particularly research into the efficacy and effectiveness of the health service; supporting the creation in the National Health Service of regional and local arrangements for identifying and meeting clinical and service research needs; monitoring the service support and facilities provided by the National Health Service for externally funded research; and ensuring that research information is widely disseminated and used by managers and practitioners to improve patient care.
I am sure that responsible members of the medical profession accept the acute nature of this problem and the response to clinical audit which has the enthusiastic support of all the colleges and of the British Medical Association. Let us make no mistake about it: there is a long, long way to go until there is effective development of quality controls and the setting of priorities in expenditure. For that reason I hope that the Government will relax their approach to this legislation and respond to some of the demands in certain areas that the proposals should be tested. At the very least, the Government must indicate which are the priority areas that the chief of research and development should examine urgently, immediately he or she is appointed.
On 11th April 1984, the noble Lord, Lord Glenarthur, during the debate on the National Health Service managers, said:the noble Baroness, Lady Robson, raised this particular point on costs. The Government recognise the point they made …. To try to got this information involves a long-term programme: there is the question of computers … We cannot hope to achieve this overnight, but the important thing is to start now and not to believe that because it is a difficult task it is not worth doing. We have already set in hand a good deal of work to help develop the general capability which is sought".— [Official Report; 11/4/84, col. 1191.]That was six years ago. I believe the Government have admitted in the White Paper that things are not yet quite ready and, therefore, on their own experience, perhaps in some areas a year or two more of study might be necessary. General medical practice is arguably the element of health care closest to the heart of the National Health Service. Nine out of 10 episodes of ill health treated by the health service are handled at this level. It is in part because of the effectiveness of the British family doctor system in preventing needless specialist interventions that the NHS is relatively inexpensive compared with other OECD countries' health care provisions. Yet the family doctor service accounts for less than £ 1 in every £ 10 spent by the National 1290 Health Service. Even if expenditure on pharmaceutical services is taken into account, the figure is only £ 2 in every £ 10.
Yet it is noticeable that, despite the popularity of general practitioner care with the public, some politicians and health care planners do not seem to appreciate the extent to which the family doctor services are a community asset which should be further developed rather than ignored or undermined by unnecessary hospital contracts. The main reason for this is probably that the system has a long tradition of independence predating the formation of the National Health Service by nearly half a century.
The proposals in the White Paper and the Bill about the future of general practice disappoint me. There is no provision for married women returning to practice or keeping contact with the object of returning later. Yet 50 per cent. of medical students in some schools are women. There is no picture painted of the proper use of the professions allied to medicine or of providing, in a large group practice, facilities for investigation and examination by modern methods. It is surely important to avoid sending patients to hospital unless it is really necessary. The development of large group practices with many additional facilities and attendance by consultants would go a long way towards providing a more satisfactory service for patients, particularly the elderly and the infirm. Again, the Canadian model is a guide, with the Independent Health Facilities Act.
I suggest that an urgent study should be set up by the chief of research and development, immediately he or she is appointed, to investigate this matter. Hospital waiting lists at the moment are cluttered up with large numbers of patients waiting to be seen by consultants or to have special investigations in hospital which, in the future, should be carried out in a group practice or a secondary care centre.
In our debate in December on uncertainties in the National Health Service the noble Lord, Lord Nugent of Guildford, said (I told the noble Lord that I would quote him):I congratulate my noble friends in government on their first-class initiative, but I warn them not to spoil it by excessive haste and by making self-governing hospitals the sole objective".— [Offical Report, 6/12/89; col. 870.]One may ask: what are the areas where experiments might be done? First, there is the setting up of hospital trusts. I feel that the kind of challenge given by the Canadian example might have wide application in this country. Secondly, there is the development of general practice units which are effectively designed to provide the maximum number of facilities and to ensure that patients do not go to hospital unless they need to. Thirdly, an urgent examination of the management system in community service is needed— a point which other noble Lords may wish to discuss. Lastly, there is a message for the doctors. They must respond vigorously to Duncan Nichol's initiative in management training announced some weeks ago. With management and audit, the future lies.
§ 5.12 p.m.
Baroness Ryder of Warsaw
My Lords, I should like to thank the noble Lord, Lord Pitt, for changing places with me in the speakers' list. I apologise to the House for not being able to remain until the end of the debate owing to a previous long-standing engagement.
I must declare my interest. The Sue Ryder Foundation exists to meet the needs of people in the community, or currently blocking hospital beds, in providing dedicated and professional nursing care in a homely and supportive setting. The foundation provides beds for both terminal and intermediate cancer sufferers, for those suffering from long-term neurological diseases and handicaps, for the elderly and for those who need respite or holiday care as a support to their carers. The foundation supports any provisions which increase support for the needy and which avoid the wasting of scarce resources. As such, there is much to recommend many of the proposals in the Bill.
However, there are a number of fundamental weaknesses which cause grave concern to a voluntary organisation which seeks to help those most in need— not those who can afford to pay, or whose care needs are such that a profit can be made by the care provider; but rather those with whom others simply cannot cope. They are the silent sufferers for whom talk of a wider choice, increased resources and better provision are frankly and sadly a sick joke.
The following are matters of concern to the foundation which bears my name. The Government propose that people already receiving income support for nursing care on 1st April 1991 will continue to do so under the new system. This spells potential financial disaster for the charitable foundation, which is currently struggling to meet a projected deficit on its existing homes in 1990 of more than £ 2–5 million. This deficit relates almost entirely to the fact that whereas the Department of Social Security pays £ 235 per week to a qualifying patient in nursing care, rising to £ 245 in April and by a further £ 10 thereafter, the true cost of full nursing care in a typical Sue Ryder home ranges from £ 370 to well over £ 500 to £ 600 per week.
The Government have consistently failed to make proper provision to help with these deficiencies. The implication is clear: £ 2–5 million, the amount of the foundation's loss this year, is equivalent to the capital cost of up to two new 30-bed homes for very many sick people. Alas, these homes will never be founded. I stand here in sorrow for those who patiently wait in vain.
Henceforth, patients requiring government financial assistance for nursing care must have their needs assessed by a social worker care manager. While the involvement of other care agencies in this procedure is welcomed, it is deplorable that there is no right of appeal against the decision made. Furthermore, care managers will have to face an enormous and sensitive task and will require not only specialist training but the infinite knowledge of a god if they are to be able to assess care needs accurately and meet them. The foundation has little 1292 confidence that this will be developed inside 10 years, let alone 10 months. There could be enormous waiting lists and delays. Patients will die while forms await filling in.
Under Clause 41 of the Bill, social services authorities are to be under an obligation to prepare plans for the provision of community care services in their areas. The requirement to consult quite widely is welcomed. But why is there no requirement for them to consult the one group of people who really matter— the handicapped people themselves and their carers? For a government who pride themselves on respect for consumer demand, this surely is an extraordinary omission.
Social services authorities will be required to make contracts with service providers, such as the foundation, for the supply of care to those in need. The foundation's greatest fear is that, without a ring-fenced budget for community care, the social services authorities' care managers will be under irresistible pressure to buy cheap— as cheap as possible— and with scant regard for the special, loving care which the long-term sick and handicapped so desperately need but which will always cost more. For those who can pay, the sky will be the limit. For those who have to rely on the social services authorities' limited budgets, that sky will be very low indeed. The Government must guarantee a basic level of funding for community care.
Social services authorities will have power to inspect and police the very homes they are contracting with. This, coupled with the detailed contract terms that are likely to be demanded, leads to the danger of social services authorities adopting a narrow role, not the free-wheeling creative role which the Government foresee. There should be an independent inspection body which should also take over the registration and inspection powers currently exercised by health authorities in respect of nursing homes. I do not apologise for this frankness because I see, and hear about, by day and by night the desperate plight of people who cannot speak for themselves and who suffer unnecessarily.
Supporters of the foundation who struggle more and more to raise funds are astonished, alarmed and bewildered by the Government's attitude. We could do so much more by reaching patients and relieving their distress if only we had some real financial help, not just words or new ideas. But what are we expected to do? Perhaps I may ask the noble Baroness to assure me that practical financial help will be given which will thus save us from this ongoing tragedy.
§ 5.20 p.m.
§ Lord Clifford of Chudleigh
My Lords, and noble Ladies present, I am truly honoured and grateful to be able to express my views in your Lordships' House. Quite apart from the code of advice given to Peers making a maiden speech, my late father told me, "Make it short and nothing controversial." And being the second senior Catholic in the country, he added, "Stick to religion!". It is difficult to consider any subject as non-controversial. However, common 1293 sense directs me to talk about just that— common sense. The door of controversy has been opened, but most will agree that age blesses us with knowledge of every kind and that personal experience, as well as that of others, moulds and propagates our tree of common sense.
Age also diminishes the common, inherent sense of hearing, something we presume we are born with and so rightfully possess. There are 7–5 million people with impaired hearing in England and I wonder how many there are in this noble House. My late father was immensely grateful for the introduction of loudspeakers in the head rests of the Benches; at the same time he was fearful. As a Cross-Bencher he was nervous that he would be seen leaning, to the left-hand or to the right-hand speaker. "Deaf, not dumb" was his great cry. And sympathy for the totally deaf or partially deaf is much needed. It is also enormously appreciated. We should bear in mind that Goya, Sir Joshua Reynolds and Beethoven— all masters and admired geniuses in their selected arts— were deaf. Of course, where there is a will there is a way.
A nation like ours supports over 238, 000 blind people. Of that figure 4 per cent. are totally blind, the others partially sighted. The obvious aid offered to them is the white stick. A polite lady in her sixties sporting a fine, white collapsible stick told me a story which may surprise your Lordships. While travelling by train to Paddington, a gentleman whom the lady later discovered was a consultant paediatrician remarked upon her elegant stick and inquired whether she had chosen it because it looked chic. The lady was rather stunned by the remark but explained that the stick was carried as a form of identification and was an essential aid for those bereft of the sense of sight. Are noble Lords amazed that such a professional should be ignorant of what is almost an international sign for the blind? How many people are aware that the red and white stick is carried by those who are both deaf and blind?
Most people are born with one million nerve channels, or motorways, leading from their retina to their optical cerebrum. I am a registered blind person. Fortunately, I still have three such nerves which are active. The senses of smell, of touch and of taste are all important and help each person to create his or her world, the sum of which is contained within the brain just as much as information from the senses of hearing and seeing. The cogenitally afflicted deaf-blind are few in England— there are just over 2, 000 of them— but they are often born with stunted limbs and with heart malfunction. A substantial proportion of them are classified as rubella children, although other diseases are also partially to blame; for example, Usher's disease. In all, 49 diseases produce this combined dual loss of the senses.
The maxim that prevention is better than cure— a point that has already been raised— is so true. Immunisation or vaccination against such a traumatic stigma (a stigma for both the vector and the parents) is not only low in cost but is also sensible budgeting. To bring up a rubella child, for example, is not only demanding, tiring and frustrating; it is also a full-time job.
1294 Let us consider how many parents have had their careers disjointed while caring for a deaf-blind child. Let us also think of the money paid by the state which could be better used by the health service of any country. It could be used for training and educating not only the nation's families but also those dedicated to medicine. Training and education may be expensive, but ignorance costs more. One has so often been told that ignorance is bliss. I wonder what the blind lady on the train thought of the professional consultant's remark.
Let us think also of the state money spent from birth on heart surgery, specialist attention to eyes and ears and specialist education for deaf-blind children from the age of three and a half years. There is also transport to and from the hospital and to and from the school to consider. It is estimated that each Rubella afflicted child requires £ 1 million of state aid until education is fulfilled. The cost of educating one deaf-blind child for one year would cover the pay of seven grade A nurses of 17 years of age. It is also equivalent to basic unemployment payment of £ 34.70 per week to 1, 008 people, and it is thousands of pounds more than the basic annual income of the majority of the elected Members of the other place.
The Government's budget for the long-term sick or disabled is approximately £ 7–3 billion. The state paid education of one Rubella deaf-blind child would cover the immunisation costs for 2, 300 15 month-old children. To immunise the English and Welsh 15 month-old children, numbering approximately 600, 000 against measles, mumps and rubella each year would cost the National Health Service about £ 9 million.
To educate appropriately the deaf-blind up to the age of 19 years— an underestimated figure of 2, 000— in that one year would cost up to £ 44 million. Therefore it makes sense to save £ 35 million. Heaven knows how much more could be saved if immunisation against so many other, sometimes fatal, diseases was executed more thoroughly. It is not a subject to be taken casually.
If we consider the fact that vaccination may cost between £ 13 and £ 15, it makes sense— common sense— to encourage all parties to be so immunised against measles, mumps and Rubella. In Britain at present we operate a system, originally an American idea, of immunising 15 month-old children, both male and female, against mumps, measles and rubella (MMR). Naturally the parent has the option to refuse for philosophical, religious or medical contra-indication reasons, to name but a few. The uptake of the option to allow the child vaccination varies from district to district, but the percentage uptake in Great Britain is reasonably high; namely close to 80 per cent. In the urban areas where paediatricians are more numerous the percentage uptake is higher. But in the inner-city areas there is a lower uptake percentage. Family doctors broadcast sheets of paper about immunisation against various diseases and, along with teachers, parents and associations related to the deaf, the blind and the congenitally physically disabled, they should be encouraged to disseminate the harsh facts about caring for, and indeed being, a deaf-blind child. The RNIB— the Royal National Institute for the 1295 Blind— is preparing education packs for teachers, nurses and other groups to enlighten all parties that the afflicted are individuals, not oddities, and how best to recognise when help is required and how best to administer that help.
Our European neighbours, the French, have the equivalent vaccination— ROR— which is administered to both male and female infants at 12 months of age. Sweden, Norway and Finland started MMR immunisation before 1983. We are fortunate in this country in having an organisation called SENSE dedicated to helping deaf-blind children. The Government have a report, the Peckham Report, outlining how best preventable child diseases can be avoided and proposing a system of recall to ensure that all persons can be protected. The Peckham Report emphasises the importance of child immunisation, not just against measles, mumps and Rubella, if a healthy nation is our goal. In the World Health Organisation immunisation list the United Kingdom ranks twenty-first. That is not a position to be proud of if we wish to classify ourselves as one of the most educated nations in the world. Eighteen European countries give MMR, and with travel by air enabling more people to go round the world the figures are encouraging for those fighting to increase immunisation.
Conflicting advice on immunisation affects parents. Parents have a marked influence on the uptake figures as most vaccines are given in childhood. If there is a child chronically ill within the family or the family is of a lower income group, the uptake denial is more pronounced. Although we are aware that surveys are not completely accurate it is extraordinary that 27 per cent. of parents recently surveyed had not been influenced to immunise their children. Equally alarming is that 50 per cent. of medical practices have received immunisation default lists, maybe because 50 per cent. of parents questioned cannot remember talking to their general practitioner about immunisation.
Homeless families desperately need attention and an effective recall system is vital, as too is a forceful immunisation co-ordinator in each health district. This may at first appear expensive but, when studied in depth, the budget figures will reveal a saving. We are also most fortunate in having as promoter of the organisation SENSE one of the most senior ladies in the country, Her Royal Highness the Princess Royal. That surely underlines the seriousness of the case for child immunisation.
Despite not being able to see noble Lords at all well, I thank God for the sense of touch and the sense of smell, for being able to taste and, unlike such greats as Goya, Beethoven and Reynolds, being able to hear. We must look after our offspring, ourselves and others. It makes sense to ensure at birth the senses of hearing, touching, seeing, smelling and tasting— all common, normal senses. On reflection, it is common sense. I thank your Lordships for being so generous and tolerant in listening to me.
§ 5.33 p.m.
§ Lord Carr of Hadley
My Lords, I am sure that all your Lordships would wish me first on behalf of us 1296 all to congratulate and thank the noble Lord for the outstanding maiden speech which we have just heard. We congratulate him not only on his speech but on having the courage— and I remember that it takes courage— to seize the opportunity to speak to us for the first time on a subject on which he speaks with such persuasive arguments based on conviction, stemming from personal knowledge and experience. He showed us power, he showed us wit and apt allusion. All those combined, I assure him, make him a most persuasive debater. We shall be disappointed if he does not make use of those gifts frequently in your Lordships' House.
I shall not be so inspired by the cause on which I wish to speak in perhaps a rather mundane way— the health service proposals in the Bill. I strongly support the main gist of the fundamental principles for the reform of the health service which the Bill contains. However, as in our debate on 6th December last year, I wish to couple that support with strong warnings about the manner and speed with which these proposals should be implemented. Many of the most critical points are matters of detail which will probably come up at later stages of the Bill. In this debate I wish to confine myself briefly to general principles.
I suppose that because of my background it is inevitable that I should look at the proposals through managerial eyes. I know that to talk in management terms is liable to upset many people who are most deeply concerned with the health service. Somehow it seems to them to be inappropriate in the context of a service dedicated to people's health. In its objectives and in the type of service it provides, the NHS is totally different from a big commercial company. Yet it has one absolutely vital point in common; namely, the vital need to manage its resources with the greatest possible economy and effectiveness.
I say to the right reverend Prelate that I believe that this is a matter of moral quality and not just of commercial or monetary need. The cost of the health service is huge. Yet however large, it could always be still bigger. There is no limit to what we might find desirable to spend on health. Yet any government, of whatever party, have in each and every year to set a maximum cash limit to the cost of the health service. That is why it is so important to manage the use of funds with the utmost effectiveness in providing health care. This presents a managerial challenge of the utmost importance and also the utmost complexity.
For many years I have believed that the present structure of the direction and management of the National Health Service, of its methods of fund allocation and its lines of responsibility and accountability is fundamentally— and I mean fundamentally— inadequate. It urgently needs radical reform. Therefore I simply cannot agree with those who believe that all that is needed is more funding and relatively cosmetic change around the edges. More funding may indeed be needed; it certainly will be needed in the future. But more funding without fundamental organisational reform will not, in my view, produce the results which we all desire.
1297 Therefore perhaps I may say to the noble Lord who spoke for the Opposition Front Bench that while we should take note of the instantaneous feelings of those who work in the service, we cannot allow ourselves to be governed by them. I know from my own experience in industry that when one talks to one's; employees— maybe thousands and thousands of them in a large company— about change, nobody wants it. The initial reaction is always, particularly in Britain but I suspect elsewhere, to resist change. So we must carry the employees with us. That will be the main cause for my warnings later on.
However, we should not allow ourselves to be diverted from what a proper analysis shows to be the action needed if we are to improve our health service in line with the resources we put into it in the future. The NHS is an enormous organisation. It spends nearly £ 30 billion a year and employs over 1 million people. I believe it is the largest civilian employer in Europe, if not in the world. It is impossible, in my view, to get proper value from those huge resources of people and money under the present structure and system of organisation. I feel certain that there must therefore be major reforms. I believe that the proposals in the Bill are fundamentally right— certainly no others have been offered as alternatives to them.
It is right and necessary to undertake major decentralisation. It is right and necessary to redefine the role of the various levels of health authority and to reconstruct their membership. It is right and necessary to draw new and clearer lines of responsibility downwards and of accountability upwards. It is right and necessary to make the development of the service less producer-driven and more patient-driven, principally but not only by arranging for a significant part of the funding to follow the patient, whether it be to the family doctor service or when he or she makes use of hospitals. Those are all main guiding principles of the Bill.
It is said by those who fear these proposals that they have never been tested and proved in the health service. Of course they have not. If one approached any major organisation and said one wanted reform but that could not be achieved until all the changes involved had been tested and proved, one would never make any progress at all. One has to think hard and deeply and then have faith and implement the proposals skilfully, thoughtfully and deliberately. None of these proposals, which may be new to the health service, are new or untested. All of them have been applied and have been shown to work in other large organisations. I can see no reason why they should not be equally effective when applied skilfully, thoughtfully and determinedly within the health service. The new aspect of the proposals is that of applying them to the health service. That will be a much needed but also a very delicate and difficult task. Hence the warnings I shall give which repeat essentially what I said in December.
At a purely management level, the Government are undertaking a difficult task. I speak from personal experience of trying to carry out major reorganisations in industry. This is an area where more haste easily leads to less speed. It needs the most careful preparation and step-by-step testing.
1298 That is essential. At a purely managerial level I give that warning, but I also give it at a vital and human level and on a more political level in the sense of people's feelings and not of party politics. It is absolutely essential, although difficult, to change established cultures within the service and to carry staff with one. I doubt whether, however hard one tries, one will obtain agreement beforehand. It may, however, be possible to win increasing understanding and respect to be followed ultimately by support for the proposals. That is why I stress so strongly the need for making haste slowly although with determination. One should never be in too much of a hurry.
There must indeed be test marketing in advance of universal nation-wide application. However, I am sorry to say that in my view that should not be in the form that has been proposed by the noble Lord, Lord Ennals, and also I believe proposed and supported by the royal colleges and others. The test marketing should not be in the form of using a single region as a test-bed for a three-year period and by applying all the measures in that one region. The more I think about that, the more I believe it would be a fatal way to proceed.
§ Lord Carr of Hadley
My Lords, even if it is a matter of two regions, that is not the way to proceed, in my view. I should like to see a rather different type of testing. I conclude by making four summarised proposals. First, I wish to see the establishment of up to about 20 independently managed hospitals. Some would be independently managed within the health service and others would be of the new independent trust hospital type. At the same time, I should also like to see established about 50 GP budgeted practices. I should like the Secretary of State and all his colleagues and staff at every level to give those tests the greatest possible attention to ensure that they succeed, to monitor them as they go along and to magnify their strong points and discover and correct their weak points. They will have weak points as well as strong points and it is important, by an adequate scale test, to discover what they are fairly soon and to remove the bugs from the system before they spread nation-wide.
Secondly, I also wish to see the Secretary of State making sure that within the district health authorities there is extensive management development and dry run testing of the various contracting and purchasing methods before, and not as, the internal market system goes live. That will be an essential part of the process. However, technically and managerially it will be a difficult part of it, particularly with the lack of strength of middle management throughout the health service at the moment.
Thirdly, I should like to see the Secretary of State take an important new initiative in testing and reporting on the quality of services. I know that a great deal has been said about that in the White Paper and I am sorry that people apparently have 1299 not taken as much notice of that as they should have done. It must be an obvious and clear initiative in which I hope that the new research and development function mentioned by the noble Lord, Lord Hunter, will make a major contribution. I wonder whether the role of the chief medical officer has any part to play in this area. I am not sure what his role will be in the new set-up. Perhaps that should be looked at too. Attention to quality is needed in any case and it may be one of the most psychologically important ways of gaining the respect and eventual support of medical and all other staff. The genuine fears in connection with the proposals, apart from the natural fear of change, are connected with the fear that the new methods may lead to a reduction in quality of service rather than an improvement.
Fourthly and finally, I should like to see my right honourable friend the Secretary of State have a good look at the role of community health committees. The right reverend Prelate made an interesting point in his speech as regards how one brings the user into this matter. I do not believe that one should bring the user into the management level. Reform of the structure of district health authorities and regional health authorities is essential, but they must be accountable to a consumer body. I believe that the community health committees may provide the key to that matter. If all patients in every district could count on that body as being genuinely strong and independent and knew that it represented their needs and was genuinely accountable, that might help to change their psychological fears that the new proposals may not be to their advantage.
This is an impossibly large subject and all of us could talk about it all night. I have spoken for four minutes longer than I should have done. We shall have to go into detail in Committee, but I wish to express again my deep conviction that the Government are on the right lines and if only they will show determination coupled with patience in implementing the proposals, patients, doctors, nurses and other staff will live to thank them.
§ 5.49 p.m.
§ Lord Dainton
My Lords, I wish to add my congratulations to those of the noble Lord, Lord Carr, on the witty and moving speech of the noble Lord, Lord Clifford, which was so full of the common sense by which he and his father set such great store.
I am not a doctor and I confess to feeling slightly intimidated by the close proximity of a number of medical specialists immediately around me. However, I admit to a very deep interest in medical education which goes back more than 40 years. My involvement has included setting up the first new medical school in this country this century, increasing the number of doctors entering medical school by more than 60 per cent. during my period at the University Grants committee and, for the past 11 years, having a very close connection with the Royal Postgraduate Medical School.
My experience has taught me one fundamental principle, which I believe few of your Lordships would deny. It is the main thrust of my argument.
1300 The quality of health care received by patients depends more on the skill, motivation and commitment of their doctors, nurses and ancilliary staff than on anything else. And those essential attributes receive their major cultivation in the clinical phase of the education of aspiring doctors.
Such education must of necessity take place in teaching hospitals. It adds to the cost per patient in those hospitals compared with non-teaching hospitals. The same applies to clinical medical research. Responsiblity for maintaining the quality of the teaching lies wholly with the universities and is exercised through their full-time members of academic staff, assisted by NHS staff holding honorary contracts and posts. The major part of clinical research in this country is also carried out by those academic doctors and their staffs.
University medical and dental schools come into closest contact with the health service within the latter's teaching hospitals. When the NHS was set up those teaching hospitals were initially administered by independent boards of governors but were later fully incorporated into the health service and became the responsibility of the regional and district health authorities. The district health authorities (teaching), as they were designated, and their parent regional health authorities, from which they derived their funds, had and still have a very difficult balancing act to perform. On the one hand they had to cater for the needs of existing patients who would receive from those attentions immediate benefit. On the other hand, they had to make sufficient resources available to enable the clinical academic staff to teach and to research to the highest level.
Since the benefits of today's teaching and research will, by their nature, only be felt in the future those regional and district health authorities which had responsibility for university hospitals were and always will be the fora in which the future will confront the present. If the Bill we are debating today were to pass that situation would only be changed administratively in that some teaching hospitals would pass into the hands of the proposed NHS trusts. The fundamental tension would still exist.
As the National Health Service evolved, attempts were made from time to time by legislation to ensure that teaching health authorities, when making their plans and budgets, would give adequate attention to the needs of their university medical schools. Thus, under the reorganised health service which came into being on 1st April 1974, two members of the area health authority were to be nominated by the university. Also, liaison committees were set up between the university and the health authorities at various levels.
In recent years as health service costs have risen, for a variety of understandable reasons, hard-pressed authorities and their general managers have taken actions which have led to the removal of facilities for clinical examinations, the closure of wards, the restriction of laboratory investigations and other matters, all of which were needed and are still needed for teaching and research. That fundamentally important principle— not referred to anywhere in 1301 the Bill, and rightly so— the knock-for-knock agreement between the universities and the health service, which has saved an enormous amount of irritation and bureaucratic accounting, has been eroded in the course of the years. Such decisions, which place more emphasis on the present than the future, are but short-sighted victories of the present over the future and in due course will be regretted.
In another place Ministers have acknowledged that the universities' worries on these matters are "legitimate and genuine". The Minister said:I admit that we must do more work".He meant by that work on the interface between universities and health authorities.
Certainly, the Department of Health is fully seized of the problem. As the noble Baroness mentioned in her opening remarks, four weeks ago the Permanent Secretary at the Department of Health, Sir Christopher France, wrote to all general managers with advice and asked regional health authorities to set up "appropriate mechanisms for effective collaboration" with the universities.
An annex to the letter contained a list of 10 principles to achieve that collaboration. I have read them. Like the Decalogue, they are in praise of virtue and against sin. Another annex discusses various organisational models which might be adopted for the interdigitation of university-based teaching and reasearch with clinical care. I am, of course, very glad to see commended the arrangements that we have at the Hammersmith Hospital between the special health authority and the Royal Postgraduate Medical School.
I come to my main point. In the light of what Ministers, including the noble Baroness, Lady Hooper, this afternoon, have said, and the way in which officials have acted on their behalf, apparently providing ample evidence that the Government acknowledge the essential and vital importance of NHS authorities and trusts satisfying the proper needs of universities for clinical resources, I must ask this question. Why does the membership of the regional and district health authorities prescribed in Schedule 1 of the Bill make no reference to the absolute necessity for at least one, and in my view, preferably two members to be drawn from the universities?
As it stands the Bill confirms the withdrawal of the essential safeguard introduced in 1983 of university members of health authorities. It is all the more remarkable because in paragraph 3 (1) (d) of Schedule 2, which deals with the new National Health Service trusts, it is stated that a trust,regarded as having a significant teaching commitmentmust include as one of its non-executive directors a person.appointed from a university or a medical or dental school specified in the order".The omission of a similar requirement for membership of the health authorities is not only illogical but, in the light of the Government's expressed concern over the problem of the teaching hospitals, is, I hope and believe, an oversight. If I am right in that belief I would welcome an assurance from the noble Baroness or the noble Lord, Lord 1302 Henley, that the defect will be remedied before the Committee stage. I would welcome an assurance that the health authorities will be required, exactly like the trusts, to have at least one member nominated by the relevant university. That would be entirely in accordance with the Government's wishes as indicated by the noble Baroness in her opening remarks.
§ 5.59 p.m.
§ Baroness Lockwood
My Lords, there has been a general consensus in the country that the National Health Service is one of our great post-war achievements. No one has said that it is perfect or cannot be improved. Nor has it been free of criticism. All of us have had our grumbles about it from time to time and some of those have been justified. However, its facilities have been comprehensive and they have been accessible. It has been a truly national health service. Therefore, it is not surprising that when such major changes are proposed there should be considerable concern.
I have a number of concerns, some of which relate to the National Health Service side and some to the community care side, but, because of the pressure of time, I want to concentrate on three concerns relating to the National Health Service side.
First, because of my association with a number of universities, I am concerned, like the noble Lord, Lord Dainton, about the position of medical schools and teaching hospitals. Neither the White Paper nor the Bill has dealt adequately with the role of universities. Directly and as the Bill was proceeding through another place, the Committee of Vice-Chancellors and Principals tried to have written into the Bill the need for universities to participate in the strategies and decisions that will be taken when the Bill becomes law so that the spread of teaching practices remains available to students and so that research facilities are safeguarded. Those are essential needs if we are to have a continual supply of well-trained doctors and if medicine is to continue to make progress. As the noble Lord, Lord Dainton, said, so far all that has been promised is a memorandum from the Secretary of State exhorting health serivce managers to recognise the importance of research.
The Dean of the Faculty of Medicine at the University of Leeds has written to me and has put it this way:The Bill does not place a requirement on teaching hospitals, whether they be self-governing trusts or not, to maintain the necessary mix of patients, facilities and support required for the training of doctors and dentists".That provision must be written into the Bill.
Some members have already mentioned your Lordships' Select Committee on Science and Technology and its inquiry into priorities in medical research. The report of that inquiry contained a number of recommendations. One does not see an adequate response in the Bill to many of those recommendations. For example, paragraph 9.29 of the report referred to SIFT and the possibility of some or all of the SIFT funds being paid direct to the medical schools.
1303 That is not mentioned in the Bill, but, again, the Dean of the Faculty of Medicine at Leeds University writes:There is in addition a problem with the suggested method of apportionment of the Service Increment for Teaching (SIFT). The present proposal is that this would be decided by the Regional Health Authority after consultation with the Health Authority. The University is, however, clearly the most important body in taking decisions about this money and, at the very least, decisions should be made jointly between the University and the Regional Health Authority".There are a number of concerns here to which we must return in Committee.
My second concern is perhaps more fundamental because it involves the comprehensive nature of the National Health Service and its national characteristics, some of which might be breached by the provisions of the Bill. That might happen first, through the contract system whereby GPs will be expected to use hospitals and consultants within the district rather than having a wider choice as they do at present, thereby limiting their freedom and patients' freedom to choose. The Government said that there would be more patient choice, but that does not seem apparent from the Bill.
A breach might occur, secondly, by allowing hospitals to become independent through NHS trusts, thereby risking a breach in the comprehensive specialist provisions of the National Health Service. I am not talking about a single hospital because I agree that a single hospital, however good it is, cannot have specialists in all areas. However, we must within the districts, or at least within the regions, ensure that all the specialist subjects are covered.
Thirdly, a breach might occur through the possible fragmentation of the service by enabling the National Health Service trusts to introduce their own terms and conditions of service for doctors and other medical staff. In that way, we could open the door to services being available unevenly and according to salaries and conditions rather than according to patients' needs within the districts.
Those fears have been expressed by the professions and have been mentioned by a number of noble Lords this afternoon. The Government have already alienated the universities and the teaching profession by their previous legislation. They now seem bent on alienating doctors and all the other professions within the National Health Service. My noble friend Lord Ennals referred to the document which the royal colleges and many of the professions have produced. Those professions believe that the changes are too huge and too indigestible to be taken all at once. They believe that, if they are forced through, there is a danger of destablising the service.
Others have made similar points. It seems that, even by the standards of financial management, there is concern about the introduction of the changes. It is that unseemly haste which is my third area of concern. The Office of Health Economics, which is favourable to the thrust and philosophy of the White Paper, is doubtful, according to its study, 1304 Measurement and Management in the NHS, about the timing of the changes. The study states that within a few years— but not by 1991 or 1992— meaningful measures of outcomes will have been established. According to the study, the outcomes can be measured as:Reduced mortality, reduced morbidity in clinical and biological terms [and] reduced suffering and disability".That last measure is described by economists as patients' quality of life.
The study rejects cost-benefit analysis concerned with cost alone, so that is quite inadequate. On the question of efficiency and effectiveness in general practice, the report states:Any budget which is based on cost alone, merely to contain expenditure, must inherently lead to inefficiency … If all that happened under the White Paper proposals was the promised 'downward pressure' on costs without any consideration of the effects on patients' well being, it could become a very uneconomic approach to the problems of maximising effectiveness and efficiency".The National Health Service is a different creature from what it was in 1948. The economics have inevitably changed as new technologies and techniques have become available. In her opening remarks the Minister said that we were concerned about change and continuity. That is quite right. We are certainly concerned about those but we do not want the change to be so drastic that the continuity is broken.
Nobody suggests that the National Health Service should have a bottomless purse. There must be priorities and choices but they should be properly evaluated and not just costed. According to the report from which I have quoted the techniques for such evaluation are not yet proved so far as concerns the National Health Service. There have been some quite useful and successful experiments— I believe that the noble Lord who is to follow me in this debate has been involved in one of them— but we must be careful not to destroy a service which enjoys a large measure of confidence by introducing one which destabilises the system.
As the health economic study indicates, the present resource management initiative (which incidentally was extended from six to over 50 hospitals without leaving time for the first six to be evaluated) does not embrace measures of benefits. The report states that all that will be available is a comparison of the activity of different hospitals and consultants. Extending the analysis to general practice, all that will be available in the near future will be a comparison of costs. In neither case can those activities or expenditures be directly related to the quality of care or the value of the treatment provided.
The National Health Service must be concerned about the quality of care and the value of treatment. It seems to me, putting aside all the other arguments that have been made this afternoon for some built-in delay and further trials, that the evidence from the report that I mentioned indicates that financial management is yet another area that needs to be tested before we can be confident that it is an appropriate tool for the National Health Service.
§ 6.12 p.m.
§ Lord McColl of Dulwich
My Lords, although it may seem that this Bill is principally concerned with hospitals, nevertheless, I believe that the proposed changes will have a much greater effect on general practice, making it much more important and giving general practitioners more say in what hospitals do and how hospitals will develop in the future.
One of the predecessors of the noble Lord, Lord Mellish, was Dr. Alfred Salter, who was the first Labour Member of Parliament for Bermondsey. He was a very successful and popular Member of Parliament. He started his professional career as a general practitioner living in Bermondsey, which was unheard of at the turn of the century. He worked all hours of the night and day in the service of his patients, for whom he had the highest regard. He fought very hard to try to prevent disease.
But the greatest boost to the health of the people of Bermondsey came with the war and the introduction of food rationing. Before that time one-third of the British people were either underfed or ill-fed and the figure in the United States was similar. With food rationing for the first time everyone had access to adequate food, vitamins and the famous wholemeal national loaf. Today we are in great need of a drive to prevent disease in this country and general practice is in a very good position to spearhead that drive and prevent a great deal of illness. It is good that the Bill emphasises the importance of general practice.
Noble Lords are only too well aware that the National Health Service suffers from a lack of proper financial control. Only the other day it came to light that a hospital was £ 4 million overspent, largely because the finance officer put any bill about which he was uncertain into the suspense account (also known as the dustbin), where it was forgotten. In another part of the service all the bills were put into a wooden box and at the end of the month they were all paid without their validity having been checked.
As some hospitals still have no commitment accounting system they do not know until the end of the year whether they are underspent or overspent. When they find at the eleventh hour that they are overspent, there is a crisis. They close several wards and shed nurses whom they have employed from nursing agencies. But that manoeuvre may not even achieve the required savings. As 70 per cent. of the budget is concerned with salaries, the real answer is to control manpower levels.
Objections are often raised to that manoeuvre on the basis that it will reduce patient activity, but the fact is that very often it has no effect on the volume of work. The answer to the problem is that we desperately need to have better quality managers and we shall only attract them if we pay them properly. The labourer is worthy of his hire.
Another unacceptable feature of the National Health Service is the great variation in standards. In some areas patients are treated with great respect and courtesy and are given excellent care with the minimum of delay. There are other places where quite the reverse obtains. For instance, I know of two adjacent districts with a similar population, 1306 similar manpower and similar finances. In one there is high morale, and a great volume of work of high quality with very much happier patients at the end of the day. In the other district there is low morale, low output and low quality. Why is there a difference and what is the solution?
Many of us believe that the solution lies in the introduction of competition. We believe that it will help to solve that problem. It is fair to say that the Royal Colleges are fearful that competition will result in some hospitals going to the wall. Competition is much more subtle than that. It will provide the missing incentive for people to make sure that they give the kind of service that customers will appreciate. It will keep them just that little bit more on their toes. The great variations in quality and quantity will tend to disappear as the patients or customers become more and more the centre of the National Health Service activities. I believe that the right attitude should be: the customer is always right.
In some places the National Health Service is ruled by administrative boards whose members tend to look over their shoulders to those whom they represent. I believe that there are real disadvantages in having representatives on management boards. Of course the universities are quite right to be concerned at the possibility of having no university representatives at all on those boards. It is essential to have university expertise on management boards for the very difficult and complex decisions which have to be made. It would seem to be the Government's intention to ensure that such experts are appointed in their own right.
It is of course true that many of the problems that have been discussed this afternoon in the National Health Service are being addressed now. Better financial control is being introduced and in the hospitals that we have mentioned clinicians have taken part in a new form of management called the resource management initiative. The BMA and the Royal Colleges have asked the question: why not simply extend these improvements throughout the service and accept two-thirds of the NHS Bill— six out of the 10 key changes which I think are acceptable to most people? The first is the extension of quality assurance. The second is the creation of 100 new consultant posts in addition to the increase in consultant numbers which is already occurring. The third is devolving to local level as much power and responsibility as possible from what has been a rather overpowering bureaucracy. The fourth is the reform of the family practitioner committees and the health authorities in order to run them on much more efficient lines. The fifth is an effective audit for value for money by the Audit Commission. The sixth is making it easier for patients to choose their own GP and to change if they so wish.
That package comprises two-thirds of the Bill. Why is it not enough on its own? Why do we have to go further? The simple reason is that it lacks the incentives for good practice and the means to discourage deviant behaviour. As a well known GP, Dr. Martin Colebrook, has recently said in Bedford, "The better performing doctors have began to run out of altruism and are wondering if they could at 1307 least be reimbursed for the increasing costs of the high standards they practise". Altruism is not enough for most people in this country today. Human nature being what it is, they demand something more tangible.
The most important part of these reforms is the network of agreements which district health authorities will have with the hospital service to provide the volume and quality of work that is required to serve the needs of the community. The general practitioners will have a major input in reaching these agreements. There is no way that any government will tell them to obtain the cheapest, because competition is not just about cost. It often happens that the cheapest is the best treatment because it has been thought out properly and is based on sound operational research. Those general practitioners who do not have their own budget will discuss with the district health authority where they should refer certain patients for treatment. Of course in an emergency the general practitioner will be able to refer the patient to wherever he and the patient wish. The district health authority will have a contingency fund to pay for these emergencies.
However, after the general practitioners have agreed with the district health authority where, for a year or two, most of the cases should go for treatment which are not emergencies that agreement will be adhered to.
Why is this network of agreements so important? At the moment the patients tend to go on a waiting list. They are summoned to hospital often with inadequate warning, not necessarily in any recognisable order. It is a rather hit and miss affair. Inevitably the more major and interesting patients tend to be admitted first and some of the more routine problems such as repair of hernias may suffer long delays. With this new network of agreements the service provided for the patient should be much more orderly and satisfactory. The more work the hospitals do the more they will be reimbursed. That is quite the reverse of the situation today. It will prove to be a major incentive for the hospital service.
Many people are worried that self-governing hospitals will be able to pay their employees more than in other hospitals. They are worried that this will create what they call a two-tier system. Of course today there is much more than a two-tier system. It is many-tiered. Consultant salaries vary greatly from about £ 29, 000 to £ 80, 000— that is, without private practice. If a particular district health authority for one reason or another does not seem to be attracting doctors, I cannot understand why there can be any objection to paying them more to attract them to the particular district in the interests of the patients.
The Royal Colleges have suggested pilot studies for that one-third of the Bill which is controversial; namely, the general practice budgets and self-governing hospitals. The Government have also proposed pilot studies. They will be carried out by those who volunteer. It seems that about 850 general practices have expressed an interest in having their own budgets; and about 79 hospitals are interested in becoming self-governing. The idea of all these pilot studies being confined to two regions would 1308 clearly be unfair to all those who have been getting ready for such a possibility. I remind your Lordships that in a recent judgment the judge said that he would have regarded district health authorities as being negligent if they had not started preparing for these changes. He may of course be wrong. It would also be unacceptable for people who are neither ready nor willing to have this task forced upon them. It is essential to have enthusiasts to carry out pilot studies.
The noble Lord, Lord Ennals, seems to believe that there are very few doctors in favour of the Bill. I would not be so sure. I know of many secret disciples who are keeping their heads down at the moment for very obvious reasons. Perhaps I may remind the noble Lord that the BMA was 100 per cent. opposed to the introduction of the National Health Service in the late 1940s. Aneurin Bevan said that he persuaded the hospitals to join the NHS by stuffing the mouths of the consultants with gold. I very much doubt whether the present Secretary of State will resort to such activity. As a mere professor of surgery, I do not often allow myself the luxury of expressing an opinion. I find it safer as a surgeon to stick to facts. However, I should like to say that I think that Kenneth Clarke is the best Secretary of State we have ever had in the National Health Service.
Finally, if we do not provide the incentives that are required in the National Health Service, the service has no chance of evolving into what it really should be: a service that puts the patient first and treats the patient with the courtesy and consideration that everyone deserves.
§ Lord Ennals
My Lords, before the noble Lord sits down, will he tell me who he considers should decide whether a hospital should become a self-governing trust? Is it the consultants, other doctors, nurses, or others who work in the community services; or even the community itself? Is it right for just a small or even large handful of consultants to decide?
§ Lord McColl of Dulwich
My Lords, I believe that it is a management decision and that the decision should be made by the management.
§ 6.30 p.m.
§ Lord Smith
My Lords, the Secretary of State should be congratulated upon his ambition to improve the standard of patient care in the NHS. It is an ambition which for years has been recognised and freely discussed by many doctors. No reasonable doctor could expect that the Secretary of State would remain complacent in the light of serious complaints about the NHS from doctors and, more importantly, from patients. The result is this Bill. I am sure that the Government and all doctors agree that there is only one object— that is, to do what is best for the patients.
The question must be asked: has the Secretary of State displayed knowledge and wisdom in advising the Government correctly, after the most extreme and exhaustive consultation with experienced doctors who are first in line to treat patients, or does the Bill require many amendments before being passed? Anyone introducing a Bill before Parliament 1309 must have the evidence upon which it is based. I must confess that the origin of the evidence is a mystery to me. The Secretary of State did not obtain it from doctors or the presidents of the royal medical colleges; unlike Aneurin Bevan, who, in 1948, had a good relationship with Lord Webb-Johnson and Lord Moran.
For many years before 1948 I was a consultant surgeon. I experienced the introduction of the NHS together with many reorganisations and alterations of the service in its 42 years. For most of my four years as President of the Royal College of Surgeons of England the Secretary of State was Barbara Castle and her second in command was David Owen. Therefore, I have first-hand experience of reorganisation.
The Secretary of State's White Paper which preceded the Bill was exhaustively examined by all the bodies in the medical profession; for example, the BMA, the royal medical colleges, the conference of presidents, the universities and the medical schools. All those bodies criticised the basis of the details in the Bill. Some bodies castigated the Secretary of State's opinions. Some of them— for instance, the conference of presidents of the medical colleges throughout the UK— pointed out the areas in the Bill which call for improvement, acknowledging that the Bill is necessary and offering to help and not hinder. Those bodies regret the Secretary of State's refusal to debate with them his intentions before producing the Bill. He informed the presidents of his intentions but I am conscious that there is a major difference between "inform" and "debate".
It is obvious that today noble Lords will be addressed by a number of doctors in this House who are more directly concerned in treating patients than I am. I am sure that they will dissect the Bill clause by clause. However, briefly I wish to make your Lordships understand the reactions of someone who has spent his life in surgery and who, above all, is committed to the interests of patients. First, I am disturbed by the emergence of self-governing hospitals and of dividing hospitals into two groups. I should need a great deal of persuading that the proposal would not lead inevitably to two tiers of medicine, one inferior to the other. If the royal medical colleges or the conference of presidents proposed such a drastic change they would have clearly in mind the immortal words of John Hunter to Jenner, "Why not try the experiment?", and suggest that a trial run should be arranged in perhaps two of the regions. They would do so rather than gamble the future of the NHS upon the imagination of the Secretary of State, however well meaning.
Almost on a par with the proposals about which I am suspicious, the omission of so many important aspects is a worrying factor. Perhaps they should be added. I have searched the Bill for proposals for improving the teaching and training of doctors whereby the future treatment of patients must stand or fall. Where are the proposals for the maintenance of a close relationship between the universities and the NHS? There is a perfunctory reference to private practice, but where are the proposals to deal with the integration of private practice with the NHS?
1310 How can private practice help the NHS? It affects the availability of consultant cover in the NHS and might affect the financial structure of the service.
I was convinced that the Secretary of State would deal with that relationship when preparing the Bill. I am amazed that the Government are not desperate to undo the harm that was done to the NHS in the mid-1970s. If the sins of the 1970s were undone, the way would be clear to construct a new and effective partnership between private practice and NHS medicine.
A practical example may bring home the direction in which hospital medicine moved in the 1970s. Imagine that any one of your Lordships was an NHS patient in a hospital under the care of a consultant; let us say a surgeon. Let us suppose that after an operation something went wrong. There was then an emergency and a need for the consultant who at that moment was seeing a private patient. Where would your Lordships prefer the consultant to be? Would it be just the other side of the swing door in the hospital; or in a private hospital miles away; or between the two hospitals in a traffic jam?
But Barbara Castle persuaded Parliament that when a consultant wishes to see a private patient he or she must be ejected from national health hospitals in spite of the fact that the needs of NHS patients demands the supervision of the consultant as much as possible. Not unnaturally that decision resulted in the building of many more private hospitals outside the NHS. The Bill before us offers a chance to remedy that tragic situation. The private hospitals have already been built and are working well. Therefore, should not a serious attempt be made to elicit the aid of those private hospitals for the NHS?
A start has been made in the treatment of patients; but what about the teaching of students? There is no possible objection to teaching medical students using private patients. In my years at St. George's Hospital (at Hyde Park Corner and not Tooting) I took my firm into Marie Tempest ward, the private ward, for teaching. I always explained in advance to each individual patient the need for tuition, as a consultant should also discuss with every National Health Service patient. If things are put clearly, very few patients object.
To end my brief speech, I should like to say that I am an optimist. I shall support the Bill, and I hope that the effects will benefit patients. Nevertheless, I hope above all that the Government will agree with me on two major points: they should think very clearly about self-governing hospitals, try the experiment and embark upon a properly-monitored trial run; and they should make a serious attempt not at privatising the NHS, but the opposite-establishing a lasting partnership between private practice and NHS medicine. I regard that as essential to the future.
§ 6.41 p.m.
§ Lord Nugent of Guildford
My Lords, allow me to begin by congratulating the noble Lord and telling him that it is all too long since the House had the pleasure of hearing him. We have much appreciated listening to him today.
1311 I should also like to congratulate my noble friend the Minister on an admirable introduction, both lucid and convincing, of this major Bill which, as she rightly said, is the first major attempt at reform of the health service since its inception. She has had to listen to a very powerful dialectical performance from the noble Lord, Lord Ennals, who went at times into hyperbole in his enthusiasm for his subject. But there is something we have to deal with here. On her side, my noble friend has a White Paper, Working for Patients, in which there are some very good ideas. This is being backed by government expenditure on the health service which amounts to nearly 50 per cent. more than what the previous Labour Government were able to provide. So there is much to be welcomed there on which my noble friend should be congratulated.
In addition, there is no doubt about the point which the noble Lord, Lord Ennals, put to the House, with which I think he wished to convince us, that the volume of objection, criticism and anxiety from members of all sections of the health service is very powerful indeed. Papers, representations of all sorts and kinds pour through our postbags to tell us of their objections and their anxieties. So I am bound to ask myself what has gone wrong if they are feeling as anxious as all that.
There is no doubt that doctors and nurses are anxious that their relationship with patients will be disturbed. We have to recognise that they have a very special relationship with patients which goes far beyond that of professionals in other aspects of life such as solicitors or accountants because they actually deal with the health and lives of their patients. They have an element of dedication in their make-up which inspires the quality of their work. I do not believe that my right honourable friend the Secretary of State is catering sufficiently for the anxieties of professional staff in the service.
I very much support what was said by my noble friend Lord Carr. I believe the major changes are right, but the timetable for their introduction is unrealistic and is probably the major cause of the anxiety. A very strong second one is the National Health Service trust for self-governing hospitals.
There is an obvious need to reform the existing anomalies and shortages, and this has been recognised all round. In addition, there is the overriding need to meet the inbuilt growth of demand from our ever-increasing national longevity— we see splendid evidence of that in this House in the noble Lord opposite, who may well be here in another 20 years' time— and the ever more wonderful medical and surgical cures, due to the inventions not only of our own doctors but also those from all parts of the world.
Perhaps I may take a moment to relate an incident I saw last autumn and which I believe is typical. A consultant physician at St. Thomas's, whose services I am fortunate enough to enjoy, heard of a surgical operation being performed in China which might benefit his post-polio patients. Accompanied by an orthopaedic surgeon, he overcame all difficulties and visited the Chinese army hospital where the operation was being regularly performed. They were allowed to attend an operation, taking photographs 1312 and full particulars of both pre-operative and post-operative conditions to satisfy themselves that the surgery was sound. When I last visited St. Thomas's a few months ago I saw the first patient to have had the operation lying in bed after successful surgery. This was marvellous— a new way of dealing with a quite difficult problem; but it is also going to cost a lot more money.
That is typical of what is happening through the whole range: innovations coming from all over the world, with all the marvels of modern communication. So whatever additional finance is provided by the Government— here I very much agree with my noble friend Lord Carr— it is axiomatic that such is the growth of demand that there will always be shortages somewhere, however great the expenditure. In the light of this axiom it is vital to establish a system which makes the best use of resources to meet the needs of patients. That is the objective of the Bill.
The noble Lord, Lord Ennals, may have embarrassed my noble friend the Minister and the Government generally on what he thinks are the defects of the Bill, but the government of the day must take action in this field. Eventually we shall be saying to the noble Lord "All right, my Lord, what would you do, because this is the problem?" I believe that the broad strategy is right that devolves decisions about the allocation of resources as far as possible from the Secretary of State to the hospitals and GPs in the field.
I have no time to speak about the GP budget practices. I stick to the hospitals. The method of achieving this desirable end— and we have heard a most interesting speech from my noble friend Lord McColl, who has been one of the pioneers— is to strengthen the management of hospitals so that they can submit annual budgets as a basis for their allocation of funds from the Secretary of State, instead of the present system of allocation according to a theoretical formula related to population figures and similar demographic data.
The resource management initiative to which my noble friend has already referred has been evolved by my noble friend and five hospitals other than Guy's to work out how the system of management could be developed to produce an annual budget relating resources to the outcomes achieved. The resource management initiative involves the development first of all of modern information technology supported by adequate computers and a system of cost accounting reliably reflecting the cost of the various activities of each hospital.
That sounds very simple, but in practice— this is the point— it will require the retraining, at least to some extent, of every member of the hospital staff. Although the broad lines have been established by the pioneer hospitals, when it is applied to all the other hospitals the application in each case will be different. It will be a major undertaking to explain that to each member of staff and win their co-operation. My noble friend Lord Carr is right when he says that nobody likes change. Change has to be sold to persuade people to co-operate. The co-operation of members of staff must be won if there is to be successful administration.
1313 The Secretary of State has spendidly provided the funds for the project— £ 80 million— and I congratulate him. However, his timetable of introduction is far too short. My estimate, which was supported by the Select Committee from the other place after its visit to Canada and America, as my noble friend the Minister knows, was that four or five years would be needed to introduce RMI to a hospital so that it could produce its own budget. I understand that a number of hospitals have volunteered to take over from the existing six pioneers and I am delighted to hear that.
I thank the noble Lord, Lord Hunter, for his kindly reference to my advice in the debate which he promoted last December. I am still of the same opinion— that the right strategy for the Secretary of State is to make hospital reform a two-stage affair. There should first be introduced resource management initiative to achieve fully efficient management in the hospital— a major undertaking— and then allow the hospital to decide whether it wishes to become self-governing: a National Health Service trust. It must be absolutely logical that no hospital can take a decision on whether it wishes to become an independent self-governing National Health Service trust until it has modern management. It should not be difficult therefore to say that the objective for all hospitals is the resource management initiative, and each hospital can then make its choice according to how it feels.
A point the noble Lord, Lord Hunter, mentioned, and which I reiterate— I am sure it is a vital point— is that to sell better management in hospitals must help. That will be hard enough to put over, but it should be the objective of every hospital and every person in the hospital to achieve that. That has nothing to do with becoming an independent hospital. Incidentally, the hospital trust was never intended to be outside the National Health Service. I was very interested in what my noble friend Lord McColl said— that there are doubtless a lot of people who would like to have independent hospitals. Nevertheless, install the new management and then let the members decide whether they wish to become independent or not.
I say to my noble friend the Minister, who will have a long hard trail at the Committee stage, that I support this Bill in its general principles; it is obviously right. However, it is being hurried, and it is wrong to try to put the whole package over all at once. I hope that that advice will make an impact.
§ 6.55 p.m.
§ Lord Molloy
My Lords, I should first like to congratulate the noble Earl, Lord Clanwilliam, on a very interesting maiden speech, and also the noble Lord, Lord Clifford of Chudleigh who made a formidable maiden contribution— highly interesting, informative and classic in its own right.
The noble Baroness, Lady Hooper, at the beginning of the debate repeated a point that she has often made; namely, that more money has been spent on the National Health Service in the past 11 years than ever before. That is perfectly true. Yet the service is disturbed and unhappy. Staff are 1314 dissatisfied and complaining. In fact we have the worst of all worlds: spending more money in return for a more dissatisfied National Health Service.
A report recently submitted by Professor Gilroy-Bevan and a team from the National Health Service value for money unit following a study of 12 hospital operating departments found that all were short of staff of all grades. The service was reliant on a large amount of overtime by all staff. As Professor Gilroy-Bevan said, that could be dangerous because of the stress on staff. Ultimately it could be dangerous for the patient.
The report said there was need to examine training and that levels of competence should be defined for support staff of surgical and anaesthetic practitioners. That was welcomed by all operating departments' assistants. It was certainly welcomed by the representative of the ancillary staffs, Mr. Berry, of the Confederation of Health Service Employees.
I should like to concentrate on the views of the major staffs of our National Health Service. I cannot understand why the Government have introduced this Bill without consulting people who know much more about the subject than any of us. If, for example, this was a defence Bill, would they not consult the chiefs of staff of the Royal Navy, the army and the Royal Air Force? I submit that the National Health Service is also a massive defence service for our people and that there should be proper consultation with members of the various large organisations.
The BMA is of the view that the Bill does not extend a patient's choice. At present GPs are able to refer patients to consultants they think appropriate, having regard to clinical needs and length of waiting lists. Their worry is that the proposed financial scheme will compel shopping around for the most economical contract without regard to the ability of the consultant or what the patient really needs. Furthermore, the BMA is of the opinion that health authorities will indicate to GPs, who are not fund holders, where they should shop for the most economical hospitals. That will reduce patient choice and restrict the freedom of the doctor.
The BMA believes that there are many apprehensions and worries. It is concerned that doctor patient relationships will be damaged if patients fear that the cost of treatment will influence the doctor's decision. That complaint is justified: it is bad for the doctor and bad for the patient.
The BMA accepts and is happy with some ministerial assurances. However, it shares, along with the royal medical colleges and their faculties, certain concerns and has produced a figure to support its anxieties. A BMA poll found that 13 per cent. approved of the Government's proposals while 71 per cent. disapproved. All demanded proper experimental studies first.
The noble Lord, Lord Henley, may wish to comment on the case of a baby who lives in West Yorkshire and who, when only 19 days' old, developed a rare and severe form of meningitis. She was expertly investigated and treated at Airedale General Hospital, Keighley. However, she started 1315 to deteriorate and a professor at Leeds General Infirmary was asked to help. In the end she was transferred to Leeds and had brain surgery. That seems to have been successful and she was transferred back to Airedale. Now the baby is at home and being most carefully watched.
That is a wonderful example of the NHS at its best. If all the care and attention is costed and worked out between hospital and home care, it may be very expensive. In view of the cash limits, which seem to be part of the new arrangements, will that standard of care be available under the Bill? Would that touching and compassionate experience never be allowed again because of the Bill? We are entitled to an answer.
The Royal College of Nursing welcomes the Government scheme for developing a comprehensive system of medical audit covering primary health care and hospital and community health services. But it would prefer clincial, not medical, audit to ensure the inclusion of nursing audit. The Royal College of Nursing, like the Confederation of Health Service Employees, believes that the National Health Service and Community Care Bill addresses the wrong agenda. The college would prefer a shift in policy towards health promotion and illness prevention. It is perturbed that increasing skill shortages are afflicting all medical professions.
The Royal College of Nursing members also believe that the establishment of self-governing hospitals is a threat— their words, not mine— to the continuity of care and will lead to the dislocation of facilities. The Royal College of Nursing believes— and CoHSE agrees— that it will distort the labour market and worsen regional skill shortages. There is no evidence whatever that the Bill will create higher standards.
I refer briefly also to the Health Visitors' Association. I consider that association to be the vertebrae of community care. The Health Visitors' Association has a number of major worries. It is desperately concerned that the Bill fails to specify core services and that it will undermine community health services, particularly for women and children, community midwifery and district nurses. The association fears that the district nurse— an extremely important lady in our National Health Service who does so much and who is so unsung— with the community midwife will become a rump service. I hope there will be an assurance that that will not take place: the Health Visitors' Association is concerned that it could happen under the Bill.
The Health Visitors' Association has a long and distinguished history of combining medical and clinical efficiency with profound compassion and understanding. It deserves the support of your Lordships' House.
The Royal College of Physicians calls for a carefully planned National Health Service evaluation programme. It believes that the NHS should not be the subject of a costly experiment with, as the college states, a high risk of failure.
1316 Other organisations which are worried include the Association of County Councils which is very apprehensive, the National Federation of Housing Associations and the Religious Society of Friends. Even the pharmacists have written to me outlining grave apprehensions and reservations.
With great respect I ask the Minister to bear this point in mind. I do not believe that we in this House, and certainly not the Secretary of State, will dismiss the views of the 12 royal colleges and the 13 distinguished medical colleges who have submitted a variety of apprehensions. They believe they should be consulted, and so do I. These grave concerns about the Bill are not only those of knowledgeable sectional interests; nearly all the country is deeply concerned. Therefore, we must make certain that money is not permitted to stand in the way of maintaining an efficient National Health Service. When Aneurin Bevan said that in the House of Commons in 1948 he had the full approval of all sides of the other place.
I believe that all the medical professions and associations, representing surgeons, nurses, midwives and health visitors, want to see an improved service. But they are gravely apprehensive about some aspects of the Bill. So are the people of this country. I ask the Minister to say that he is prepared to see representatives of these great associations who want to give of their experience and knowledge in order to assist the Government to produce a Bill which will enhance the status of our National Health Service.
§ 7.5 p.m.
§ Lord Pitt of Hampstead
My Lords, we have before us a Bill containing proposals which are ill-considered and untried and which is being rushed through Parliament at a dangerously fast rate. In the other place, the Bill, as my noble friend Lord Ennals, said, had a truncated Report stage in an all-night sitting and a limited Third Reading. The other place should have given a much more thorough exploration of the Bill. We shall have to do so.
I do not believe that a financially competitive market is an appropriate way to plan an integrated health service for patients. We all support the aims of the White Paper which said that patient needs will always be paramount and that the NHS will continue to be available to all regardless of income and to be financed mainly out of general taxation. As was said earlier, the medical profession accepts the need for better information technology, and it strongly supports the greater emphasis on professional audit and the need for carefully monitored change that can be shown to be effective. However, there is no evidence that the proposals contained in the Bill are likely to improve the health service in the way that is required. There is no evidence that the proposed changes will improve the standard of care, will improve access to care, will improve choice of care, or will improve the cost-effectiveness of care. There is no evidence whatever.
The Government claim that the reforms will improve standards of care and will obtain high quality value for money; but assertion is not proof.
1317 Many of the proposals will lead to a deterioration in patient care, will fragment the service and destroy the comprehensive nature of the existing service. Again, the Government stated that the aim was to extend patient choice; but I believe that there will be a reduction in patient choice as a result of some of the proposals in the legislation.
I am sorry that the noble Lord, Lord McColl, has left the Chamber. I was interested to hear him refer to the influence that GPs will have on the service as a result of this Bill. The funny thing about that is that I was a GP for a few years and during that time I was able to refer my patients to the consultants that I thought were the most appropriate for them, having regard to the patients' clinical needs, their convenience and the time they would have to wait.
Under the present Bill, my freedom as a GP, unless I am a budget holder, will be restricted because I shall be expected to refer my patients to the hospitals with which the district health authority has a contract. I could not be a budget holder. I was a single-handed general practitioner and my list would have been too small. Therefore, I could only have acted in the way that I have mentioned.
I believe that the noble Lord, Lord McColl, has already mentioned that provisions for a contingency fund will exist for cases that I wish to refer outside of a contract. How will it work? I should like some answers from the Minister when he replies. I had a surgery in Euston. I lived first in Willesden and then later in Hampstead. It was very convenient for me to take patients from areas in between. The consequence was that the hospitals to which I sent patients belonged to three different health authorities. What is more, the hospitals were in two different regions.
I knew that in an emergency I could refer a patient and then afterwards justify my actions. But what about the many cases which are not emergencies? I am thinking of a pregnant woman who has had problems with previous pregnancies. In the past she has had her babies at a hospital with which the district health authority has not placed a contract. Her condition is well known to the consultant she has been attending, and she trusts him. What will happen to that women under the proposals?
Though I sent most of my psychiatric patients to the UCH, I frequently had patients come to me who had gone to Maudsley of their own accord. I had a psychiatrist friend at St. George's Hospital, Tooting, not at Hyde Park Corner, to whom I frequently referred patients. I need to know what the situation will be for a GP, practising as I was, under these proposals.
Again, I shall be told that there is a contingency fund. What happens in March when that fund has run out? These are questions that I hope the Minister will answer when he replies to the debate. I am worried about these matters. I have studied all the papers, the White Paper, and I have read the Bill. The worries I have are those which I am conveying to the House. I was a GP for nearly 50 years.
I am also worried that the doctor-patient relationship may be damaged if patients fear that the cost of their treatment is influencing their doctor's 1318 decision on their clinical needs. I know that that will not be so, but it can be perceived to be so. In influencing attitudes perception is often more powerful than the act.
In order to carry out the internal market the role of the health authorities will be extended. It is essential that the professional voice is heard. They will be making all kinds of important decisions and they should be receiving professional advice when they are making those decisions. Already the question of membership of the authorities by university members has been raised by the noble Lord, Lord Dainton. I do not need to raise that matter again. There is also the question of local authorities. They have to adopt a very important role as regards community care. At the very time that they are given that role, their presence on the health authority is no longer required and they are being removed. I cannot understand that, either.
Regarding the family practitioner services, the Family Health Service Authority will have very increased powers over the general practitioners. There will now be two different kinds of practitioners; namely, the budget holders and the non budget holders. Both will need to be represented because their needs and their interests are different. I understand that there is very strong pressure for a number of hospitals to take large and decisive steps down the road towards trust status. I am told by the BMA that many of the consultants in the 79 front-runner hospitals are unhappy about self-government.
I have heard the answer given by the noble Lord, Lord McColl, but I wish to hear the answer from the Minister. I wish to know how these decisions are being made. Can the Minister say whether the staff are in a position to influence decisions; are the people who are to be served by these hospitals able to influence the decisions; are the community health councils being consulted and their views taken into account? We need answers to all those questions.
One of the anxieties about the National Health Service trusts is their ability to depart from national agreements on pay and conditions of service. Again, I notice that the noble Lord, Lord McColl, is prepared to defend that. I gather that managers are already planning for the new power that this will give them. A national pay structure for specialists was part of the original concept of the National Health Service. The idea was that it would make high quality specialist care available to all and not only to those who will be attending the centres of excellence.
We have had a fairly even spread of consultants, both geographically and by specialty. That has been essential in maintaining the quality of provision for patient care. This strategy has been a notable success, and it has won international recognition. It is one of the successes of the National Health Service and we should not allow it to be destroyed.
The Government have not produced any argument as to why there is a need to change the national pay structure for the professional staff. The fear is that the abandonment of national pay and conditions of service will lead to a two-tier health service, 1319 destroying the even spread of consultants that I was speaking about which is one of the achievements since 1948. The proposals contained in the Bill could take us back to the period before 1948 when we had two-tier services with voluntary and municipal hospitals. I remember them. In the 1930s I was a student, and in 1947 and 1948 I was practising in London. That was the situation then.
The National Health Service brought an end to the two-tier system and we must not allow it to be brought back. Moreover, it makes financial sense to retain national agreements. Self-governing hospitals will need large personnel departments staffed by experienced people to deal with local negotiations and disputes. The representatives of the staff in the various hospitals will have to spend a great deal of their time on discussions, negotiations and disputes. That is time that they should be spending looking after patients. This situation will be duplicated in hospital after hospital if they withdraw from national negotiations. I hope that the Government will rethink the matter.
Certain safeguards need to be written into the Bill in order to achieve the long-term protection of patients. There must be guaranteed local access to services. General practitioners must have the right to refer their patients to the consultants of their choice. Consultations must take place with the professions before decisions are taken on contracts and the provision of services; and their views must be listened to.
The Secretary of State has given assurances that GPs' drug budgets will not be cash limited. I noticed that when the Minister addressed the House she made sure that we took that point. But the Bill as drafted leaves it open for a Secretary of State to do so in the future. We must try to amend that. The way in which the Government proceeded to apply downward pressure on the budgets of what they regarded as overspending local authorities must make everyone stop and think. It has made me stop and think. The Government are using this same method of central assessment of local expenditure to control drug budgets. We should remember— and noble Lords who have heard me speak will know that I have made this point on a number of occasions— that the criteria used for central assessment of local authority expenditure has resulted in the most deprived areas of this country being rate capped.
Let us remember what has happened with the poll tax. The Government's standard spending assessment was 25 per cent. lower than the average assessment of expenditure by local authorities. If this method is used with drug budgets, and if the Government estimate the drug budget at 25 per cent. below what is required, from where will the patients get their drugs? How will they get them? We must make sure that the budgets are determined locally and at practice level. That is the only way in which it can be fair and at the same time not be destructive.
Finally, I want to support those who say that we must assess the reforms before they are introduced nationally. We have had proposals from the Royal Colleges, and the BMA survey showed that the 1320 patients want it. Both patients and those who serve them say that we should have evaluation before the proposals are extended nationally. We must support this evaluation proposal. My view is that this is the least we can do.
§ 7.24 p.m.
§ Baroness Cox
My Lords, I begin by declaring an interest as a Fellow of the Royal College of Nursing. However, although I will be raising matters relevant to my own profession of nursing, I hope that my contributions will transcend sectional professional interests and will reflect much wider concerns for the National Health Service and for community care.
Although I am a strong believer in the principles underpinning the NHS and a great admirer of its many achievements, I have never believed that there is no room for improvement; and, as a committed advocate of consumer choice, I have never been reluctant to support changes which will enhance choice and cost-effectiveness. Therefore I welcome many aspects of the Bill; for example, the Government's commitment to extending choice, to the provision of more information on which to base choice, to reducing waiting lists and to the general principle of audit. So far, so good. But I also share many of the concerns expressed by colleagues in the health professions.
As it is Second Reading, perhaps I may subsume specific concerns under four general themes: responsibility for care; evaluation of care; quality of care; and continuity of care. First, I shall deal with responsibility for care. There is widespread concern that there is to be no statutory membership on key bodies such as regional and district health authorities of people with professional clincial expertise and experience. To relegate them to an advisory capacity is totally inadequate. Surely it is desirable for them to have the opportunity to shape all stages of policy-making. Without such expertise, the bodies charged with responsibility for health care will lack essential information.
It is also essential that people with professional experience should be involved in evaluating the quality of care provided by the NHS and in the community. Evaluation is my second major theme. I strongly support the recommendation of the Royal Colleges and other professional bodies in the publication The Way Forward that there should be an advisory council or a research authority to assist the chief of research and development. I support the recommendation that this body should consist of approximately equal numbers of nominees of professional bodies and of the Government, together with representatives of the public. It should be responsible for systematic evaluation of the provision of health care, including standards of clinical care. And, like the noble Lords, Lord Ennals and Lord Winstanley, I also support the general principle underpinning the recommendation of these professional colleges and societies that a systematic evaluation be undertaken before the proposed changes are implemented nationwide.
As a social scientist, as a health care professional, and as a Conservative, I believe that it would be much sounder practice to introduce the proposed 1321 changes in a limited, phased programme first, to evaluate them impartially and thoroughly, and then to move ahead with full-scale national implementation in the light of lessons learnt in the first phase. As a social scientist, I have always been opposed to political ideologies which seek to impose untried blueprints. As a Conservative, I have been impressed by the writings of Karl Popper and Friedrich Hayek, with their fundamental commitment to piecemeal reform and to evolutionary change. I therefore deeply regret having to challenge a Tory Government for what appears to be to many people an arrogant imposition of fundamental change without sensitive awareness of legitimate concern expressed by experienced professionals, and without any commitment to systematic critical evaluation of the effects of change. Perhaps I may quote the Royal College of Nursing:When patients' health is at stake, the need to introduce large-scale reforms successfully first time is paramount. Proper evaluation of the proposals would assist this".That leads into my third area of concern: quality of care. There are many potential chain reactions to the proposals in the Bill. I shall give just one example— the side effects of employment policies of self-governing trust hospitals on other hospitals in the locality. There are already acute shortages of qualified staff in NHS hospitals in many places, especially in acute care areas such as intensive care units. If nearby self-governing trust hospitals are empowered to attract staff by offering them higher salaries, what assurances can the Government give that other local NHS hospitals will not suffer even more difficulties than they do now? I am sorry to say that I was not greatly reassured by the ramarks of my noble friend Lord McColl on this issue.
I turn from the subject of hospitals to community care. Perhaps I may ask my noble friend whether the Government would be prepared to extend the policy of inspecting the quality of residential care to cover small-scale providers with less than four beds. At present some of the provisions in these very small homes are little short of scandalous. How long do we have to leave vulnerable elderly people— infirm, and sometimes confused— suffering in this hidden way before taking necessary remedial action in the form of regular inspection? I should also like to ask the Government whether they would be prepared to consider a policy that all inspections of residential care in the community must be undertaken by an independent body with inspectors who are qualified in health care.
There is a great deal of confusion in the Bill between social care and health care. Many people who require community care have needs which are primarily social and they can, indeed, best be met by social service departments. However, there are many other people— for example, the frail elderly— whose numbers will increase dramatically in the next few years and who have health needs such as problems of mobility and/or incontinence. Their condition can deteriorate very quickly without adequate clinical support. Moreover, similar problems may apply to people who are discharged into the community from long-stay residence in psychiatric hospitals. Their condition can also 1322 change rapidly, especially if they suddenly stop taking medication.
I have a nightmare— which I fear could become reality— of many very vulnerable people finding that community care is a Utopian myth. They find instead that the community does not or cannot care and that the services that should be caring for them are not available to help them in their time of need. Of course, there are many areas where such people are now well looked after; and, indeed, where they will be well cared for in the future. Many of these places are situated in areas where some of your Lordships live. I think that that applies especially to this side of the House. It is perhaps those areas which justify the optimistic evaluation of the ability of all social service departments to deliver comprehensive, high quality care.
However, I have lived in a very different kind of area for 30 years and my children, grown up as they are, have been working in other disadvantaged areas. I also have professional colleagues in different parts of the country who give me horrendous examples of the problems of poor quality provision in many areas. On the basis of those experiences and the evidence which has been brought to my attention, I fear for the quality of care which will be available to many of our elderly citizens and to those suffering from chronic sickness or mental illness. That is why I plead for systematic, vigorous evaluation and inspection not only of the National Health Service, but also of community care. Moreover like the noble Baroness, Lady Ryder of Warsaw, I should also be much happier if the Government were to ring-fence resources for community care to ensure that they are not diverted to other uses, as has happened before with earmarked funds.
My fourth theme concerns the question of continuity of care. Many people, including those convalescing from serious illness, as well as the frail elderly, the mentally ill and the mentally handicapped, depend upon the smooth interaction between different sectors for their continuing care. But the Bill throws into sharp perspective the possibility of disjunctions between the acute and the community sectors. There is a real danger that the seamless web of care so carefully woven after 1974 will be broken and that the pre-1974 fragmentation could sadly reappear.
Many professions will not be satisfied that care in the community will be effective without assurance of a specified role for health professionals in a multi-disciplinary team, particularly in client assessment. Given the complexity of needs which will be the responsibility of the community services, it is not adequate to assign case management just to social services. Many vulnerable clients, such as the groups which I have already mentioned— namely, the frail or confused elderly or the mentally ill— must be entitled to a health assessment by qualified professionals. I hope that the Government will give serious consideration to a statutory requirement for health and social service authorities to collaborate in meeting both the social and the health needs to prevent clients falling through the gaps which exist between different agencies.
1323 In conclusion I must say that I deeply regret the fact that I cannot give the Bill the welcome I would wish. I regret even more that my personal doubts and worries have been reflected in, and endorsed by, the publication by the prestigious bodies which have united in an unprecedented way to urge the Government to listen to their professional concerns. It is not just a question of challenge from people with a vested interest in political opposition; nor is it a question of unelected individuals trying to thwart the will of a democratically elected government. It is, in large part, a groundswell of legitimate professional concern felt and voiced by professionals who care and who care about caring. They are also deeply worried about the quality of care that they will be able to provide in the National Health Service and in the communities which they serve to which they are deeply committed.
I hope passionately that the Government will take this, their last opportunity, to listen to these genuine concerns. I hope that they will heed them and respond to them sensitively and appropriately. I have said before, and I shall say again, that I believe the National Health Service is one of the most humanitarian institutions the world has ever known. It has provided a popular and generally equitable health service, enabling the United Kingdom to compare satisfactorily with other nations in terms of fundamental standards of health, morbidity and mortality— and often at less cost than other nations.
Therefore, I will wholeheartedly support any policies which help to put the principles which the National Health Service enshrines into practice more effectively; but I, and my professional colleagues, cannot and will not support proposals which appear to us to risk damaging this precious institution and thereby possibly harming those whom it serves. That is something which not only I but also many people throughout the country would find hard to forgive.
I hope that the Government will take the opportunity of this Bill's passage through your Lordships' House, to listen, to respond and to change before it is too late— not just for them, but also for the many people who I believe may suffer if the Bill goes through unamended. If the Bill can be amended and the proposals which have commanded wide professional support become incorporated in law, I believe that the National Health Service and community care, and all those people whom they serve, will benefit. That is our common aim and I hope we can achieve it.
§ 7.38 p.m.
§ Lord Adrian
My Lords, I shall speak briefly as I have but one point to make. I should first like to add my voice to those speakers— and the noble Baroness, Lady Cox, was the latest of several— who have asked that health professionals in the widest sense, such as those in medical schools and in the universities of which medical schools form a part, should in some way, and on the face of the Bill, be incorporated into the management structure of regions and districts as well as of trusts. In doing so, I must declare an interest in that I shall be at Cambridge for a few more years in a pre-clinical department teaching medical students.
1324 I am grateful for the reassurance given by the Minister about the Government's concern for teaching and research. However, I should be even more grateful if we could find a way in future proceedings on the Bill to transform that important concern into statutory provision. No doubt we shall be told that paragraphs 1 and 2 of Schedule 1 allow chairmen to appoint members of authorities who are either consultants, nurses or at university medical schools and that that is sufficient.
We shall also be told that Clause 5 (3) in Part I and paragraph 3 (1) (d) in Schedule 2 oblige the Secretary of State to specify teaching as a function of a National Health Service trust. We shall be told that they allow him to specify research as a function of a National Health Service trust, and that that is sufficient. Indeed, powers as discretionary as those could hardly fail to be sufficient for chairmen of authorities and for the Secretary of State. However Parliament, I believe, may reasonably become restless when the executive demands unfettered discretion on the pretext of flexibility and does it again and again in Bill after Bill.
Is it sufficient for Parliament to leave to chairmen and to the Secretary of State whether or not the teaching and research function shall be part of the concern of regions, districts and trusts? And whether or not there shall be persons with direct knowledge of hospital medicine and research on management bodies of regions and areas?
One of the thrusts of the Bill is to impose on the hospital service a management structure more akin to industrial practice than its present management. However, if we look at much industrial practice in this country, it is precisely in the functions of training and research that management appears to be deficient. In comparison with our competitors, technical professional skills other than accounting— and I do not wish in any way to diminish the importance of the contribution of accountants— are under-represented on boards. Industry has, I believe, as a consequence been slow to contribute both to research investment and to creating a well-trained workforce.
I am concerned lest the superficial and sub-Marxist analysis which separates the management from providers' interests should make us reproduce those same thoughts in health service management and thereby jeopardise both the supply of further doctors and research to improve the knowledge of disease and the delivery of health care.
I cannot help feeling that the original briefing for the Bill did not take into account just how widespread throughout the National Health Service hospitals— and not just in hospitals attached to medical schools— teaching and research have been or how important such activity is to the future of the health service. Despite the reassurances to which I referred earlier and for which I am grateful, I hope it is not too late to introduce changes in the Bill which will guard against the damaging consequences of that apparent misjudgment.
§ 7.43 p.m.
§ Baroness Oppenheim-Barnes
My Lords, I have been listening with interest during the course of the 1325 debate to the observations of noble Lords opposite and on this side of the House too. I have listened to their passionate and no doubt sincerely held views and anxieties. But I could not help remembering that period during the 1987 General Election when, day after day, we had paraded by the media and at the Prime Minister's daily press conferences tragic case after tragic case of babies waiting for heart surgery. The whole nation was alarmed and concerned.
It was against that background that pressure was put on whomever took office to embark on an urgent review of the NHS. Today we are no longer reading those particular stories in the headlines. In your Lordships' House we are debating the outcome of the review that everybody urged in 1987. Any responsible government taking office at that time would have had to acknowledge that our NHS— envy of the world as it rightly is— would be an ever-growing source of demand for increasing resources, with a voracious appetite fuelled by the new needs resulting from advances in medical science and a growing ageing population.
However, no responsible government could believe that merely throwing money at the NHS was the answer, without seeking at the same time to improve the quality and quantity of patient services. They could not do so without seeking to raise the standards of those services right across the country and without attempting to ensure that the ever-increasing resources made available were being used as effectively as possible in the interests, above all, of the patients.
This Government have thrown billions at the NHS. It is already about £ 8 billion over the past 10 years, compared with a cut in expenditure in real terms under the last Labour Government. But instead of receiving accolades or acknowledgment of this achievement, they are attacked by some noble Lords opposite and others who question the Government's commitment to the NHS.
Perhaps it is not surprising because the many major developments being undertaken in the NHS do not merit headlines as the tragic cases of those babies did during the election campaign. They merit tiny paragraphs in the media. For example, little is heard of the new Westminster and Chelsea Hospital which will cost £ 178 million. It is one of the largest projects in the history of the health service. But then perhaps a mere litany of statistics demonstrating increases in the NHS are too impersonal, so let me put it into human terms.
There have never been more doctors in the health service, more operations, more patients treated, more modern hospital facilities, more advanced techniques, more effort put into prevention and health education. There have never been more nurses and never have a government had a better record of which they can be proud than this Government have with the NHS.
That is the background to the Bill which your Lordships are debating today. The Government are pushing ahead with overdue reforms, as so many noble Lords have acknowledged. These are reforms which attempt to introduce into the health service 1326 necessary checks and balances as well as stimulus to even higher standards of service, more widely available and accessible to patients. The reforms will not only improve the NHS but will allow it to develop. That is what so many noble Lords have asked for today. Those reforms should be allowed to evolve as the lessons from them are learned.
I fear that the often hysterical opposition to the Bill has blinded and bamboozled a good many otherwise sensible people. That probably accounts for some of the poll statistics to which the noble Lord, Lord Ennals, referred. But worse than that have been the quite unnecessarily frightening stories put out to many of the most vulnerable members of the community. I find that hard to forgive. As the noble Lord, Lord Pitt, said, perhaps perceptions are often more powerful than facts for these people. I am sure that he was right.
Quite the most extraordinary attacks on the Bill have come from the trade union which— I must say with respect to my noble friend Lady Cox— has a vested interest in its patients but also in its members, the BMA. Perhaps I am being unjust to them, perhaps my criticism should be directed to their PR people. Their tactics have made Arthur Scargill appear the soul of moderation in comparison. I mean no disrespect to any noble Lord who may be a member of that trade union and whom I automatically exempt from my criticism.
I find it particularly disturbing that doctors whose influence on people is more emotive than that of most other people should exploit the situation in this way. Many of your Lordships will have received from the BMA a communication with its comments on the Bill. It opens with a paragraph which states:At present, it is rarely necessary for patients to travel to other parts of the country simply because the quality of routine treatment is inadequate locally".That is ridiculous. It is ridiculous to pretend that standards across the country are the same for all patients. Fine though the NHS is in many parts of the country, we shall improve nothing if we start from the assumption that it is perfect everywhere. It is not, and it is capable of improvement. Only a week or so ago, for example, an eminent professor of clinical oncology from Hammersmith Hospital claimed in a paper entitled Caring for Cancer that in many hospitals across the country the standards of cancer treatment were uneven, and in some cases were unacceptably bad. He warned patients that before accepting treatment they should ask what the rate of success was in the hospital they were due to attend.
We read with horror that at last week's Royal College of Nursing congress it was claimed that in some hospitals clinically dead patients were being kept alive for 24 hours for administrative convenience and to reduce paperwork on that particular day. Is that a wise use of resources— or, more importantly, is it humane? My right honourable friend the Secretary of State has produced a number of other startling examples of the diversity of standards across the country. If there is no over-prescribing in the health service, why do campaigns to hand in unwanted medicines regularly produce such huge hauls? The campaigns that took 1327 place in Dudley and Worthing produced more than 650, 000 tablets and half a tonne of medicines respectively.
What of the doctors themselves? The vast majority are of course hard-working and are committed to their patients and give them a wonderful service. However, not all doctors are like that, although the BMA would have us believe that was the case. There is still a strange mystique in the doctor-patient relationship, particularly in the case of the poor and inarticulate who when frightened, suffering or in pain approach their doctors as if they were some kind of deity. Instead of complaining, they often thank their doctors humbly for treating them offensively, patronisingly, negligently and sometimes badly. No noble Lord who has been a constituency MP can have failed to come across such cases from time to time. Thankfully, those cases represent a tiny minority. However, they are a submerged minority. The strengthening of the patients' complaints procedure is a welcome feature in the Bill.
Another fact that is particularly welcome is that the provisions of the Bill will, as the noble Lord, Lord McColl, has said, make it easier for patients to change and choose. That is the linchpin of effective competition because neither hospital standards nor doctors are beyond reproach. Standards vary sometimes to an unacceptable degree. There are some bad doctors and some inadequate hospitals. Those two minorities will not have their lives made easier by this Bill, and I am delighted that that is the case. As my noble friend Lady Hooper said, a majority of GP practices have already opted to be fund-holding practices. They will be able to buy for their patients what in their clinical judgment is the best treatment available. However, they will not be able to force that on any patient who does not want it. If patients do not want their doctor's choice, they will have to be offered an alternative. Above all, GPs will want to buy what has been demonstrated to them to represent the best care for their patients. Therefore, successful hospitals which give good treatment will flourish and grow while those hospitals which are unsuccessful will not.
Likewise, the district health authorities, hospital managers and those hospitals which opt to be self-governing trusts will tailor their services to patients' needs. They will learn a great deal about those needs from local GPs who will have much more say in how district health authorities spend their money and where they place their contracts. When planning the use of their resources and placing their contracts, district health authorities will need to pay much more attention to the wishes and needs of their own clinicians, who will in turn know the needs of their own hospital patients. This may mean that specialisation and centres of excellence develop on separate sites, but so long as they are available and accessible to all, I cannot see that that matters. That is far better than trying to stretch resources too far and too thinly in one hospital. That often leads to shortages, empty beds and, paradoxically, to the closure of successful hospitals.
1328 Before taking on new, expensive consultants with new, expensive procedures— sometimes at the expense of existing necessary services— managers will have to find out whether new services are available for patients elsewhere in the area. They will not seek to duplicate them at the expense of valuable services that they are already providing and which may need reinforcing.
I must now turn briefly to two areas of unjustified concern. They have been mentioned again and again. The first is the claim that GPs who have opted for fund-holding practices will be inhibited from prescribing adequately for their patients because they will be frightened of exceeding their budgets. It has also been claimed that they will discriminate against accepting elderly or chronic patients because of the cost that that involves. Again that is nonsense because GPs will be paid more not less for taking on such patients. Doctors who exceed their budgets will merely be invited to discuss this and compare their performance with those doctors who have not exceeded their budgets. That will be part of the inevitable learning process that will follow the Bill.
The other area of misinformation relates to the self-governing trusts. They will not be freewheeling profit-orientated institutions in which patients come second because their clinical standards will be monitored at all times by the Department of Health. They will be made to change their status if their standards do not meet requirements. What is perhaps most misunderstood and ignored by the Bill's critics is, above all, its central theme which is that most of the reforms in the Bill are voluntary. There is nothing in the Bill to make GPs opt for fund-holding practices or to make hospitals become self-governing trusts— to give two examples.
No one, least of all the Secretary of State, has suggested that on 1st April 1991 a perfect new system will emerge. It will be an evolving process and will involve inevitably some experimentation, just as the NHS itself did back in the late 1940s. Meanwhile clinical audits will be raising the quality of service. The Government's continuing allocation of record resources should provide the quantity, while the reforms themselves should ensure that finite resources are made the most of.
Those grand panjandrums of the trade union that I referred to have been speaking for their members and for patients. However, with this Bill the Government are speaking for patients alone. It is the Government who above all want a better health service with better care for patients. It is the Government who have had the courage to tackle what everyone agrees is an immense problem. I believe they have done so with imagination, ingenuity and, above all, with total commitment to the NHS.
§ 7.57 p.m.
§ Baroness McFarlane of Llandaff
My Lords, as one of those who has worked both within the National Health Service and alongside it since its inception, and who shares with the noble Baroness, Lady Cox, membership and fellowship of the Royal College of Nursing, I do not wish to make partisan points.
1329 However, I wish to side with the noble Baroness in much of what she has already enunciated so eloquently.
I wish first of all, however, to applaud the determination of the Government to improve the quality of the service to the consumer. There are many things that, across the parties, I believe we can support, such as improving quality by instituting better information systems; improving the professional and managerial exercise of quality control and better systems of budgetary control. Those of us who have worked within the health service acknowledge the need for change.
It has been said that no one likes change. I must pay a tribute to those who have worked within the health service for the way in which they have accepted successive changes over the years. Amid all the positive provisions that the Bill offers to us I remain agnostic, however, about some of the basic tenets that the Government are putting forward. The contention is that a commercial basis for the service would improve the quality of care. I lack the evidence that that is so.
The noble Lord, Lord Carr, has encouraged us to think that the evidence already exists in commercial organisations. I cannot make that leap of imagination from the pure commercial enterprise to a health service in which we have a moral obligation to remain within budgetary controls but also a very different relationship between client and professional. That is a relationship which some have analysed as a gift relationship. It is a relationship that was referred to by the right reverend Prelate the Bishop of Manchester as a covenant and fidelity relationship.
Nor am I convinced by the argument of the noble Lord, Lord McColl, that competition will right the wrongs of the health service. Again, I have no evidence that that is so. Therefore I have to align myself with that host of witnesses which has already been described today; namely, those who wish to see the government's beliefs tested before any major moves are made.
I am delighted at the proposed appointment of a director of research and development. It is just such evidence that we would ask him or her to produce in considering any future developments in the health service. I believe that we are desperately in need of evidence to support the Bill in its present form. Nonetheless, I welcome the emphasis in the working papers on the introduction of better systems of information technology, which are essential for proper management control, and on the various strategies for quality control. One is tempted to suggest that had those, and the resources being allocated to them, been injected into the present structure we might have seen dramatic improvements.
The emphasis on medical audit in working paper No. 6 and in other documents is to be welcomed. However, it deals only with part of the need to look at clinical standards and evaluation in total. I applaud the initiative of the Secretary of State in calling together the royal colleges— medical, nursing and midwifery— to consider a proposed clinical 1330 standards advisory group. Nurses, midwives and health visitors have, for a decade, used in their case management plans a systematic assessment of needs, objective statements and evaluations. The royal colleges and nurses at regional and district level have put a great deal of work into developing standards of care and indicators of care. I am heartened to see that some of those have been included in the specimen contract documentation given in the working papers on operating contracts.
I believe that the experience and expertise of nurses, midwives and health visitors will enable them to take a leading role in the broader aspects of quality assurance in both clinical and community care. However, I am not so sanguine that we have an adequate system put before us for quality assurance in the hotel services that are so vital a part of our hospital system.
The operating contracts document gives some reassurance that standards will be stated and sanctions can be applied. However, that gives no ultimate reassurance since the controls are bounded always by the Secretary of State's powers to limit what may be the necessary resources required to achieve desirable standards. In the present system of budgetary control I find no reassurance that the future may be any better. In that system, when budgets are tight, we have seen the more vulnerable aspects of care sacrificed. I think particularly of nursing establishments being eroded, of nursing education— particularly post-basic nursing education— being sacrificed. We all know of the problems of the inadequate supply of skilled nurses in areas such as paediatric intensive care. We have also seen a diminution in the numbers of health visitors and district nurses being trained. We have seen a diminution in the number of innovative posts, which are essential in preventive services and health education. Those are the very areas where we need to concentrate some of our future energies.
There seems a strong case, therefore, that the ultimate quality control for all parts of the service should not be so inbred but subject to an independent inspectorate. I believe that the principle of an inspectorate is accepted in the education system and in the social services. I see no reason why it should not be accepted in the health service.
The plans for community care, while spelling out some necessary basic principles, fail to recognise the sophistication of the assessment process in which health, social and psychological needs are so intimately intertwined. The training of district nurses and health visitors has prepared them for a first-level assessment of needs. In their case management plans, physical, psychological and social needs are included. Yet nurses in the community are experiencing a great deal of uncertainty about their future. They see a fragmentation of the different authorities which are their employers. They see the web of continuity of care, to which the noble Baroness, Lady Cox, referred, being eroded and the very necessary planning for discharge from and admission to hospital sacrificed when budgetary control is imposed.
1331 The question of responsibility for nursing education concerns me. I see a fragmentation of that responsibility between regions, districts for post-basic nursing education, universities and the statutory bodies such as the English national board. I wonder whether it is not appropriate to consider some delay in that fragmentation. It may be that the role of co-ordinating the nursing education function should be left with the statutory bodies, which should develop as self-sufficient agencies.
In respect of nursing education within the higher education sector, both in universities and in polytechnics, I believe that we have never considered the service implications of teaching and research in nursing. I ask that some consideration be given to the extension of SIFT for the purposes of nursing education and research.
My last point concerns the membership of the authorities. I should not want to plead any representative membership. However, I would ask that the major cost centres— the universities, the medical profession and the nursing profession— should have adequate representation.
§ 8.10 p.m.
§ Lord Rea
My Lords, at this point, two-thirds of the way through the debate, I shall not attempt to give a comprehensive Second Reading speech on the Bill. I can remember no Bill on which I have had more wide-ranging, well-informed and urgent briefings. Like the noble Lord, Lord Winstanley, I think that this is two Bills wrapped into one. In the time available to me, I cannot pay adequate attention to the community care aspects of the Bill when there is so much to say about the National Health Service proposals, but that does not mean that the community care aspects are unimportant. Far from it; properly organised and financed community care will make a profound difference to the effectiveness and costs of the National Health Service.
Like everyone, I am thoroughly in favour of the stated aims of the Government's legislation. As my noble friend Lord Ennals said, they are irreproachable. Who could disagree with providing patients with greater choice or enabling the whole National Health Service to achieve the standards of its best units? As my noble friend pointed out, it is a pity that, without exception, the representative bodies of those working in the National Health Service believe that the proposals in the Bill, with the exception of the proposed improved information systems and the increased use of clinical audit, will in effect work against the achievement of those desirable aims to which I referred.
In what I think is a sober critique of the proposals, the Royal Colleges and the other professional organisations in the National Health Service in their joint statement considered that,the introduction of the changes in the way proposed could very seriously disrupt the National Health Service".Those are serious words, but I can assure the noble Baroness that they were declared only after long and serious deliberation.
1332 The proposals for the changes came from a small, high-level group working behind closed doors whose ideas originated outside the National Health Service, some from across the Atlantic and some from market-oriented economists in the United Kingdom. Little account seems to have been taken of the wide research base that exists in this country on the functioning of health services, or of the opinions of those who have spent their lives in such research.
Although the White Paper which introduced the Bill pays lip service to the National Health Service, it seems to have missed two fundamental advantages of the NHS as it now stands. The first, which has been mentioned by many speakers, is its truly comprehensive nature. Not only is it available to anyone, however poor, but high standards are available throughout the country. Successive governments have tried to monitor that and upgrade through RAWP and other measures those regions which were under-resourced. That is not to claim that every hospital is equally efficient. That is of course not the case. It is also well known that certain groups, mainly middle class, are more adept at using the system than others.
Secondly, as has been pointed out by many people, the National Health Service gives remarkably good value for money in terms of GNP. Although expenditure on health is rising in real terms, as the noble Baroness, Lady Oppenheim-Barnes, said and as we are frequently reminded, it has stayed level in terms of the gross national product at about 6 per cent. That is very low compared with other countries at an equivalent stage of economic development with a stable and ageing population such as we have. An increase of £ 2–8 billion— 10 per cent. of current expenditure— which would enable many improvements to be made, would still leave GNP at only 6–6 per cent. whereas France, Germany and, as has been mentioned, Canada and the United States spend from 9 to 12 per cent. of their much higher gross national product per head on health.
I can only ask why, if the present system is popular with the public and professions alike and is comprehensive and economical, is it necessary to make such fundamental changes? I am not saying that everything in the garden is lovely, but I maintain that the basic system is sound and a great deal sounder than the national health services of many other countries.
As a general practitioner, my role in the debate is to focus on the proposals as they affect primary care. My noble friend Lord Pitt has expressed better than I can many of those aspects and I agree with all his words. After I have done that, I want to look briefly at my other favourite topic— the position of junior hospital doctors— and allude to the evaluation plan which has been proposed by the professional colleges.
As an experimental idea, the granting of funds to certain general practices is interesting, but, as a proposal to be widely adopted without prior assessment, it is risky and mistaken. In the first place, the necessary information on costing of hospital and community services is not available and it will be difficult to put that information in place in the proposed timetable. As with other aspects of the 1333 proposed system, there is no evidence that the price of any health activity will reflect its quality. The right reverend Prelate the Bishop of Manchester pointed that out clearly. I am sure that he was not only referring to spiritual values, although they are vital; how can they be costed in money terms?
More seriously, as my noble friend said, I see major difficulties between the doctor and the patient, if the patient feels that decisions about access to treatment are affected by cost considerations. I am told that some patients have jumped the gun. A doctor has already been accused of dissuading a patient from a hospital referral to save money to put in his own pocket because the patient thought that the reform was already in place! General practitioner funds will be subtracted from the money which is allocated to a district health authority to purchase care for its population. There will be nothing to stop fund-holding general practices buying private care for some patients.
Initially, private hospitals could well lower their prices to attract custom. That would easily be possible as they are often run by large corporations with a flexible financial policy. Some district health authorities might contract directly with the same private institutions. That might result in certain National Health Service hospitals attracting less custom and less funding and they might have to restrict their services or close down entirely. That is one way in which National Health Service funds could be diverted into the private sector. When a local National Health Service hospital has restricted its services or closed, the private institutions could put up "heir prices and thus greatly increase the costs to the NHS of providing those services while at the same time making a profit. That may not happen quickly, but it is a possible scenario. For instance, GP budget-holders might well wish to encourage their patients to opt for private insurance schemes for hospital care, thus saving money in their budgets. People who say that the Bill will not harm the National Health Service and will not favour private, profit-oriented, and eventually much more costly health care, must answer those points.
I should like to return to a point that I made with regard to the economical running of the National Health Service. The noble Lord, Lord Kilmarnock, said that one of the reasons for this was that the staff of the National Health Service are so badly paid. That may be one part of it but I believe that it is the structure of the health service as it stands that makes for its remarkably good value for money. For instance, there is the referral system of primary health physicians to secondary care at hospitals. Also quite important is the non-reliance on item of service payments— the capitation system in practice and the salaried system for National Health Service doctors.
I regard indicative prescribing budgets as a lesser but irksome evil. The Government could save themselves much trouble by simply using more effectively the present scheme of PACT (prescribing, analysis, and costing). Since that was introduced two years ago we have seen the proportion of generic prescribing by general practitioners rise from 36 per cent. to 40 per cent. I think that costs could be cut further if a generic substitution policy were adopted 1334 as in hospitals. So as to obtain the agreement of the drug industry, that could be coupled with extending patent life so that all new drugs have a 10-year protected market life under patent after licensing.
I turn to the question of junior hospital doctors. By creating 100 additional consultant posts over three years over and above the already planned 2 per cent. expansion of consultants, the Government claim to be assisting the junior hospital doctors' situation. While that is definitely a move in the right direction, it is only just holding the situation because of the greatly increased work of junior hospital doctors. Their work is yearly becoming more onerous because of increased throughput in hospitals and the increased technical complexity of hospital treatment.
Not only is a much greater increase in the number of consultants needed, but much more could be done immediately. At the appropriate stage I shall move an amendment to reduce the average weekly hours of junior hospital doctors to 72 hours, as in the Private Members' Bill passed by your Lordships' House last year. The Hospital Junior Staff Committee of the BMA feels that legislation is the only way in which the current intolerable situation can be improved. A recent survey conducted by Dr. Robin Dowie at the request of the Department of Health revealed that the average number of hours of duty of junior hospital doctors is now 90 per week.
I should like to end by backing the suggestion of the Royal Colleges that the widespread introduction of these reforms should be preceded by a suitable phase of evaluation. Like the noble Lord, Lord Hunter, I believe that the proposed new post of director of research and development could well be used for that work. I am aware that the National Health Service constantly needs to be assessed and changed in order to make it more effective, more pleasant for its users and health workers alike and to make it good value for money. However, these changes should flow from good research, as your Lordships' Select Committee suggested, and not from a think tank of economists remote from the real needs of patients of the National Health Service.
Finally, I should like to make a small additional remark. Some noble Lords will know that the health Minister with a small team visited Leningrad last year to look at what is known as the Leningrad experiment, in which radical changes in the financial arrangements and referral systems between polyclinics and hospitals were being carried out and assessed in Leningrad and two other regions in the Soviet Union. In fact the changes were found to be too ambitious and unworkable. They were greatly modified and the modified plans are again being tried out. If the Russians can work in that way why cannot we do it in this country? In fact the health problems of the Soviet health service were far greater than ours. They took the sensible step of introducing radical reforms in a limited pilot study. I am sure that that is the right way for this country too.
§ 8.25 p.m.
§ Lord McCluskey
My Lords, it is my privilege to be the honorary chairman of a body called the Scottish Association for Mental Health. It is a voluntary 1335 organisation which, in co-operation with many of our federated local associations, provides services in community care for people who have mental health problems, including people who are recovering from mental illness and those who have recovered but who still find it difficult to live outside an institution. We provide sheltered housing, sheltered employment, employment training, counselling and day centres. We also try to create opportunities for the users of the services to tell us, the providers, of their desires and real needs. That is very important. We also try, in relation to community care, to influence government, the local associations, the health boards and all the statutory and other agencies.
I have outlined our activities simply in order to establish my credentials as a mere layman to intervene in this important debate. We in the Scottish Association for Mental Health are a significant front line force in the field of community care. We spend about £ 3 million a year. We are funded partly by the Scottish Office, partly by gifts from the public and some excellent trusts, and partly from other statutory bodies. Mostly, however, our full-time staff has become expert in devising and constructing our services, especially in relation to employment training and residential accommodation, to fit the criteria of those bodies with funds to dispense. Thus we obtain large funds from government agencies and indeed from the European Community.
We welcomed the reports of the Audit Commission and Sir Roy Griffiths drawing attention to the failures of three decades and the need for urgent action. However, in Scotland at least, the Government's response to those documents in Part IV of the Bill has been rather disappointing. That disappointment is shared by others who provide community-based services for the elderly, the mentally handicapped and other vulnerable people.
In relation to community care and particularly people with mental health problems, the Bill requires local authorities in Scotland to assess the needs of those who have such problems, to decide upon the services that they require and finally to prepare plans for the provision of community care services. However, when I look at the final two paragraphs on page xi of the Explanatory and Financial Memorandum, it confirms what Ministers have already made clear; namely, that there will be virtually no new money in relation to these plans and services. In Scotland that is particularly serious because community mental health services are greatly under-developed compared with those in England and Wales. On a per head of population basis Scotland has one-third of the supported accommodation places available in England and one-fifth of the local authority day care places that there are in England.
Of course, the other side of that coin is necessarily that a far greater proportion of the vulnerable population of Scotland has to remain in psychiatric institutions because they have nowhere else to go. I put forward very tentatively the calculation that Scotland needs £ 50 million of new money to provide alternatives to institutional care for the one-third of 1336 the current psychiatric hospital in-patients who could be released into the community. That would do no more than bring our community services up to current English standards and levels.
As I understand the documentation that issues from the Scottish Office, the only new money— it is to be provided under Clause 55— will amount to £ 1 million. That is the specific grant, the money earmarked for mental health services in Scotland. I am afraid that even with regard to that money there are powerful disincentives to claiming it. The reason is this. Local authorities which sponsor other claims and obtain grants for specific projects will have to meet a part of the cost of those projects from their own resources. When the grant-aided projects are up and running and the grant has been used up, then the revenue deficits will have to be made up by the local authorities out of their ordinary funds. That means that the expenditure will have to be funded to a substantial degree from the proceeds of the community charge. Indeed the truth is that any new money for community care is likely to have to come, to a substantial degree, from the community charge. I fear that to give local authorities the responsibility for the community care services and to ask them to finance those services from their ordinary revenue, including the community charge, may be a recipe for disaster. However, we also fear that the flow of money from the European Community— for which we are extremely grateful— is likely to diminish as the Community assumes new responsibilities in relation to developments in Eastern Europe.
The future therefore does not look good. At best, we seem to face stagnation; at worst we may face decline. The Bill tells the local authorities to prepare a blueprint; but it does not seem to provide the bricks and mortar. The Bill raises expecations; but it does not provide the means whereby they can be fulfilled.
The reality is that the future for community care depends not upon the clauses in the Bill but upon the provision of money and new resources to enable services to be created and run. It depends critically upon the actions to be taken by central government. I ask Her Majesty's Government in relation to Scotland to give the most serious and urgent consideration to the proposals that we in the voluntary sector have advanced.
Perhaps I may say one word about the voluntary sector. It is important. At the present time voluntary organisations provide in Scotland a quarter of all residential places for the elderly, nearly all residential places for the physically handicapped, a half of those for the mentally handicapped, and more than a third of those for the mentally ill. We have a broadly similar share of day care provision.
We ask of the Government first, in the exercise of the powers contained in Clause 48, that the Scottish Office should develop a clear strategy of the type and volume of services that it is realistic to provide within available resources and also that it should set realistic targets. The advantage the Scottish Office has is that it can stand above and apart from the local authorities and the health board whose interests in this field are bound to conflict. I believe that the Scottish Office must address itself to possible 1337 mechanisms for transferring money and staff from health authorities to social work authorities in order to permit the movement of people from care in institutions to care in the community.
Secondly, dowry arrangements, such as are found in England, must be introduced so that the Scottish health authorities can be encouraged voluntarily to finance the smooth transfer to the community of those patients who do not need sophisticated hospital services.
Thirdly, the principal providers of community services are to be the private profit-seeking companies and the voluntary agencies. They are sometimes bracketed together under the title "the independent sector". But there is a vital difference between the private sector and the voluntary sector. Private companies can raise capital from investors— investors who will ultimately hope to reap a reward from the profits. But the voluntary sector cannot betray its traditions and start trying to make profits out of the needs of the most vulnerable people in our society. We therefore have the greatest difficulty in raising the capital which is absolutely necessary in order to provide, for example, residential care. I could give other examples. We also believe that joint planning in Scotland has failed. We urge the Government to think afresh— and it is the Government who must do that— about how joint planning can be made to work in Scotland.
Finally, we urge Her Majesty's Government to engage in a real and greatly enhanced programme of health education to teach us all about the character and consequences of mental illness but essentially to help us to lose our irrational fear about mental ill health. Such education is essential if the community is to be brought to understand the philosophy of community care and indeed to be prepared to pay for it.
If Part IV of the Bill provides a starting point for such initiatives, it will indeed deserve a welcome from all of us who, like the noble Baroness, Lady Cox, believe in the overwhelming value of real community care.
§ 8.35 p.m.
§ Lord Mancroft
My Lords, before I begin my remarks I must declare an interest. I am a director of a company which is currently in partnership with a health authority to provide care for those suffering from drugs and alcohol problems. I believe that it is the first venture of its kind. I hope that it will not fall into the trap that was outlined so eloquently by the noble and learned Lord, Lord McCluskey, when he spoke of the problems about profit in the private sector. Such ventures— I shall not go into them now— need not fall into that category. They can provide;, as this does, a standard of care not currently available in the health service at a very much cheaper price than the health service can provide. I believe that it is a goal worth seeking. I hope that we may be able to consider that at a later stage.
I also speak today with the backing and knowledge of Turning Point, which is the largest charity dealing with those with alcohol problems. I am the chairman of the Addiction Recovery Foundation which 1338 researches and publishes information for the treatment of drug addiction. I am also a trustee of Adfam National which offers help to the families of drug addicts. It is the largest charity in the country currently doing so. I have received almost identical briefing from the Standing Conference on Drug Abuse about which I can speak in the absence of my noble friend Lord Rodney, who is the chairman, and from the National Council of Voluntary Organisations. Their views are very similar.
Unlike the noble Lord, Lord Winstanley, I am very glad that the National Health Service and community care aspects of the Bill are being spoken about and debated at the same time. It is that part of the Bill which concerns me most where health service and community care overlap. It is that area in which I see the most problems occurring.
However, in general it is absolutely right that GPs should have greater freedom since they are possibly the mainstay of the National Health Service. They are at the front line. To give them more freedom to operate in the way in which they wish to do must be good. It is right that hospitals should have much more autonomy. Given the size and complexity of hospitals today, it is much better that they should be able to operate in the areas in which they think best, free from central controls. In short, when a system works well it is good to take off the controls, to release it from the stranglehold of bureaucratic regulations.
However, the other side of that coin is this. It is very dangerous to release controls from a system previously under direct control which may not work well, possibly because— as in some areas of community care— health authorities and local authorities have not completely met the obligations that they should have met. An example, although perhaps not a good example, is Mr. Gorbachev's perestroika where the relaxing of central control on a weak system has led to a total collapse.
In other words, the theory of the Bill is right but I am worried about the practice. Clearly it is a framework Bill. Although the framework may be sound— and I believe that it is— it will be of little use unless the regulations that go within the framework are also sound. Therefore, it is up to my noble friends on the Front Bench to persuade us in Committee and on Report, if not tonight, that the details are right.
I am closely involved in the provision of treatment for addiction to drugs and alcohol. It is to that difficult group of patients that I wish to draw attention. The problems come loosely under three headings. The first is assessment. Currently only local and health authorities may make assessment of an individual's needs. But that will not work because many authorities do not have the expertise to carry that out. As a result, patients are often wrongly assessed, not assessed at all or are sometimes placed in inappropriate facilities. It is vital that voluntary and private sector facilities can make on-the-spot assessments and referrals in the knowledge that payment will be forthcoming. Usually that is not the case at present. Any delay whatever can lead to a patient walking away without receiving the help that he needs but sometimes does not want.
1339 The second problem is mobility. Drug and alcohol misusers are geographically highly mobile— a pompous way of saying that they move about a great deal. Appropriate facilities are not available in all areas so that the system must be flexible in taking patients from many miles away and at the drop of a hat. Under the current proposals, facilities will need to contact officials in authorities possibly unknown to them and many miles away before accepting patients. That will lead to a considerable increase in the administrative costs of the already financially overstretched facilities.
In her letter to me dated 22nd January 1990 my right honourable friend the Prime Minister wrote:There is nothing in the National Health Service and Community Care Bill to prevent local authorities from charging each other for patients receiving care in an area not covered by their home authority".That is most heartening, but what will make the home authority pay? As the Minister said earlier, authorities have always had the power to do so but unfortunately they have rarely exercised it. I know that my noble friend is aware of the problem and I hope to hear further assurances from her.
The problem falls under the area of responsibilities, the most important part of all. The Bill before the House allows extreme flexibility to local and health authorities but hardly anywhere does it oblige them to meet those obligations. What will make the authorities pay for what until now they have never paid for?
I am a trustee of a recovery centre in Kent. There are approximately 30 beds and usually several are available. It has been open for four years. During that time not once has Kent County Council social services department or Canterbury and Thanet Health Authority as much as made an inquiry, sent a patient or donated a penny. Indeed, in recent letters, they made it abundantly clear that they see no contractual arrangements with voluntary sector organisations because in the area there are so many private sector beds available for the treatment of drugs and alcohol misusers. In fact, in that area there are no beds available for drugs and alcohol misusers.
A similar case concerns Broadway Lodge, the oldest establishment of its kind, having been operating for approximately 17 years. It is in the West Country and deals with this form of treatment. During those 17 years Avon and Somerset social services department has never sent a penny or a patient. It simply does not want to know. That situation occurs again and again throughout the country.
Most of the facilities have relatively short-term patients. Even the smallest hiccup after 1st April 1991 will lead to their immediate closure. They are all underfunded and could not stand even a month's interruption in cash flow. I know that there is a statutory complaints procedure, as my noble friend mentioned earlier, but we need to know more about it. By the time a complaint has been made, thought about and mulled over the facilties will have gone bust. They cannot wait for complaints procedures to catch them up.
1340 Already many local authorities have stated that they regard drugs and alcohol misusers as being low on their list of priorities. That was the case in the past and it appears to be so now. Previously that large group of patients has been shunted between health and local authorities, often falling between the two stools. Few health authorities, and even fewer local authorities, have specialist facilities to deal with them. Neither has been keen to refer such people to the private or voluntary sector specialist facilities which are available.
My right honourable friend the Secretary of State made it clear that local and health authorities must work together to formulate a policy and then submit it for scrutiny. I ask the Minister to explain precisely how that will work in practice because upon that detail rests the success or failure in this area of community care.
Last week a facility with which I am connected assessed a patient named John. Two years ago he was admitted to an NHS facility suffering from chronic alcoholism. He was prescribed medication and released back into the community. When we saw him last week he was still drinking and also chronically addicted to the prescribed drugs. Owing to his physical state, which was mostly brought on by the prescribed drugs, we sent him to hospital as an emergency admission. The casualty unit immediately referred him to the addiction unit, which would not accept him. He was sent home with a bottle of alcohol in one pocket and a bottle of pills in the other. Finally he was admitted to a private clinic yesterday because none of the statutory organisations was willing to accept him. That is only one example which is common and which we see every day. Such cases will continue unless the local and health authorities' obligations are clearly defined and unless they are compelled to perform.
I know that my noble friend is aware of those difficulties and I am encouraged by the speed at which she and her colleagues have responded. However, we need to know in detail— and I have used that word before because it is important— exactly how the system of community care will be examined at the local and regional levels.
Other noble Lords mentioned co-ordination. It was also mentioned in the White Paper and by noble Lords on the Front Bench. We need that co-ordination to cut through the red tape and separate health authorities from local authorities and the statutory from the voluntary and private sectors. Before I can give the Bill the full support that I should like to give it I shall await the details that I expect to hear debated in Committee.
As it stands, however, it undoubtedly reaches to the core of the NHS's problem— that of a top-heavy, centralised management. If resources are managed at a local level the most important part of the NHS— the GPs and the hospitals— will be free to give the marvellous service which the nation expects and which the dedicated staff of the NHS are expert in providing, unfettered by the red tape of central management. I hope that all noble Lords will respond positively to this tremendous and brave step forward.
§ 8.48 p.m.
§ Baroness Masham of Ilton
My Lords, we have before us a mammoth piece of legislation. The health of our nation is of vital importance. We who have had our lives saved by the skill and experience of those who work in the National Health Service know that it is of vital importance to keep up the good standards. Where they can be improved we strive to do so.
During the past few weeks many noble Lords will have heard people expressing great concern about the Bill. They come from interested bodies representing the medical and nursing royal colleges, those supplementary to medicine, patients and many organisations representing the wide span of disabled people I hope that your Lordships will try to put safeguards into the Bill.
At present the emphasis of the Bill appears to be on money. It does not appear to recognise commitment or something which many modern people appear to have forgotten; that is, dedication. Over the years many people— medical, business and lay— have given millions of hours of service in helping to run the health service. The Government do not seem to value this. They are now cutting the numbers of people represented on district and regional health authorities to 10, five of these being paid officers. This is a new idea. Until now officers have been advisers. How many paid officers will speak out when a general manager is sitting over them and their job promotion is at stake? What will their relationship be with other officers with whom they work? Will they become the favoured few? This seems an undemocratic procedure.
There are many wise and willing people who would offer their services free with travelling expenses paid. I should have thought that when money is short, which it is, it would be better to use the money for patient needs. A rich businessman who can well afford to give his services will be paid, while a severely disabled person crippled with arthritis will have to buy her disabled aid to enable her to turn on a tap to fill the kettle.
Only on Friday night I heard an occupational therapist from Hampshire say that they were going to have to start charging disabled patients for their bits of equipment. With disabled people having so many extra costs for daily living— even shops now put a charge on delivery of food— their costs of essentials seem to be increasing all the time. They will soon have to start begging unless something is done about it. I often think that taxi drivers are good indicators of how the country is thinking. Last week when I came to your Lordships' House in a taxi the driver told me in a matter of fact sort of way, "Britain is no longer a caring country". I hope that by making some improvements to this Bill your Lordships can prove him wrong.
Recently I chaired a small committee of people from interested organisations representing disabled people and incontinence advisers, who are concerned about the lack of information in the Bill about specialist services. To take incontinence as an example, this is a problem which is most distressing to many people. If patients do not get expert advice 1342 and treatment a urinary infection can cause kidney problems and lead to early death. It would be serious if this service were lost between health and social services. These two cannot and should not be divided. Health and social services should have close links and working relationships. It is often very difficult to achieve this as the people working in the two departments are often different kinds of people who work in different ways.
The general public who are healthy and well have no idea that at such a basic level people who are incontinent are having many problems. They are having to buy pads or have them rationed or cut off. The mother of a spastic daughter who cannot speak and is doubly incontinent, living in a Cheshire Home, was told that she would have to pay for her daughter's incontinence pads as the Cheshire Home has nursing home status. The mother has to choose between supplying her daughter with pads or giving her a holiday. She cannot afford to do both. Other people have been told that they cannot have the pads which are the most suitable for them. If this goes on there will be an increase in pressure sores and all sorts of problems costing the health service millions of pounds. In addition to this, there are difficulties for carers who may find dealing with other people's urine and faeces none too pleasant. If people do not have adequate pads, life will become unbearable.
I am sorry that I have had to bring these sorts of things before your Lordships, but it is the duty of Parliament to understand the problems of all people who will come under the legislation and to realise how hard life is for some of them.
Is it not better that a developed country such as ours should look after its members who need basic devices which enable them to cope in a more satisfactory way? Good practice would include a continence adviser acting as a focal point; provision for a regular and adequate supply of incontinence aids; and reasonable access to a urodynamic clinic. Authorities should identify a consultant and a physiotherapist to take a special interest in incontinence.
Without doubt, that part of the service should stay with the health authorities. There are many problems which could be classed as grey areas which might be thought to belong to health or social services. If the health authorities try to fob them off on to the social services who do not have the necessary expertise, those services will fall between the two, with disastrous results and much hardship.
There is widespead concern by many severely disabled people with conditions which are treated by special units— most of them supra-regional but some of them almost unique— that their special conditions will no longer be catered for. It would be very helpful if the Minister could give an assurance tonight that those services will be protected. I do not know whether the noble Baroness, Lady Hooper, can imagine what anxiety this Bill is causing to the many people who depend on hospitals and helpful general practitioners for their survival and well-being. For someone who has broken his neck or his back, treatment in a spinal unit with specially trained staff, medical, nursing and therapy, who understand the 1343 complications and the special needs of such patients is vital. Nobody knows when they will become a victim of a serious condition such as paraplegia.
Can the Minister tell the House how the system will work? Most health districts do not have spinal units. They send their patients beyond their districts and often beyond their regions. Will there still be a quick system of getting the correct treatment? Another question which needs an answer concerns the crucial aspect of spinally injured people who need access to the expertise provided only by a spinal injury unit for an annual or biannual check-up. A check-up at a general hospital may be cheaper but inadequate. For some years spinal units have come under the Department of Health. With the turmoil and insecurity the Bill is causing, will they remain under the wing of the Department of Health for direct funding and for their security?
There are other special units applying treatment for other conditions. They also need to know about their future. What will that be if hospitals become independent trusts? Every one needs to be cost-effective, and the correct treatment has been found to be cost-effective over and over again. For example, spinally injured people who have developed complications such as pressure sores while in a general hospital awaiting treatment at a spinal unit require expensive treatment by the spinal injury unit. Will the general hospital reimburse the spinal injury unit for that, since the incidence of pressure sores will be the fault of the general hospital?
Another question which needs an answer concerns patients who are going to remain with a long-term disability and who are often unable to leave hospital because appropriate accommodation is not ready. That is very costly. Will local authorities reimburse spinal units or other specialist hospitals for the additional time spent in hospital, because it is their responsibility to ensure that appropriate accommodation is provided? An example is provided by Stanmore, which in February, in a unit of 20 in-patients, had eight who were either unable to leave or who had to go to unsuitable accommodation because appropriate housing had not been arranged.
Severely disabled and elderly people fear that they will not be accepted on the lists of general practitioners because the Government put so much pressure on the subject of cost. The British Medical Association ran a campaign against the charges in the White Paper and the doctors' contracts. The result has been to confuse and frighten the most vulnerable and ill patients. The noble Lord, Lord Rea, spoke of that.
The Government and the BMA should get together and find a way of assuring patients that they will receive the correct treatment and will not be left to worry and become more ill through the stress of insecurity. Patients feel that they will be pushed around to the cheapest option and not the best for their condition. If the freedom of choice is reduced as to where a GP can send his patients for consultation, only discontent will ensue.
Good medical services for all are essential. Many improvements are needed. For instance, better systems of interpreters are needed for confidential 1344 consultations for ethnic people who do not speak English. A better choice of food is needed for ill patients. We live in a multi-ethnic population in some inner city areas. Does the Minister think that hospitals which are run by trusts will be better at providing those facilities or will those facilities be neglected in some hospitals?
Many people are worried about improving standards and having an independent monitoring system for standards and patient care throughout the country. The Patients' Association could do that job if it was provided with the tools. Who better than an association which is patient-oriented— a consumer organisation— to monitor a system and gather information? I hope the Minister will take note of that suggestion and report back to her senior colleagues.
A very unlucky group are the haemophiliacs. There is real fear stemming from the changes to the National Health Service, the main worry being how charges from districts for individual haemophilia care will affect the quality of service that is at present offered to people with haemophilia. Most people with that disease are not treated in their own district. Treating haemophilia is very expensive. In many hospitals the cost of factor 8 concentrates take up most of the pharmacy budget. There is therefore a possibility that some districts will attempt to cut costs by offering a reduced standard of care and quality of treatment.
Most people with haemophilia now receive comprehensive care. The Haemophilia Society does not want to see any reduction in service on account of these reforms. We must ask the question: when the Government called their White Paper, Working for Patients, did they mean that the patient would come first?
I should like to pay a tribute to NAWCH— the National Association for the Welfare of Children in Hospital. It has improved the conditions for children in hospital and their parents over the past few years. Without its pressure the acute preventive and rehabilitative services would not have developed as they have, with a much more humane approach to open visiting and attitudes of staff to patients. I hope that the services to children will continue to improve.
Even the hospital chaplains feel uncertain about their future. They have always accepted the Ministry of Health circular RHB (48) 76 to be of great importance. In that circular hospital authorities were advised that they should give special attention to the provision of spiritual needs for both patients and staff. The circular states:The Management Committtee or Board of Governors should appoint chaplains for more than one denomination for every hospital for which they are responsible".That advice may have been included in the Bill, but I could not find it. I have been on holiday and have not had time to check each part of the Bill. Perhaps the Minister would be good enough to tell the House the situation with regard to hospital chaplains because I serve on a regional health authority chaplains' committee.
With health care there should be clear points of contact, good information and good quality of 1345 service. There should be good working relationships. The importance of public health and health promotion should be given high priority. There should be co-operation and communication with social services; good models of care should be built on. With community care the overriding anxiety must be that there may not be adequate funds to provide the services needed. Most directors of social services must want money to be ring-fenced so that they can plan services. I wonder whether the Government decided on the Care in the Community plan in this Bill because they thought it would be easier to means-test the clients.
The drug and alcohol abuse problems continue to grow. The Royal College of Phychiatrists called alcohol abuse the most serious public health issue of our times. Almost half the income of drug and alcohol treatment centres, most of which are run by charities, comes from Department of Social Security rents, paid for the residents under the Registered Homes Act. From 1st April 1991 those rents will no longer be payable. The agencies understand that when the funding for community care is transferred to the local authorities it will be based on a standard spending assessment. They feel the needs of alcohol and drug services will not be taken into account. This will mean that many services will not survive. Perhaps the Government will think again so that these services are protected.
I conclude by saying that I am sure the universities and teaching hospitals will find ways of protecting their interests and forging a way forward, because any government will know that these contain the stars of society with the bright brains. If they are not given good teaching facilities and research prospects they will leave and go to other parts of the world where their skills are wanted. I am not at all sure about the weakest and most vulnerable individuals who are ill and disabled. They need protection and their interests covered by legislation. How disappointing it has been that more of the Disabled Persons (Services, Consultation and Representation) Act 1986 has not been implemented. I hope that your Lordships will find ways to help these people, who often cannot speak for themselves, by passing amendments which will improve the Bill during its passage through your Lordships' House.
§ 9.10 p.m.
§ Baroness Gardner of Parkes
My Lords, it was of course very moving to listen to the noble Baroness, Lady Masham. She certainly speaks from knowledge. One comment she made struck me forcefully. She referred to the "turmoil of insecurity". That is the worrying aspect at the present time and why I welcome the Bill and believe that it must be implemented as a whole— the sooner the better.
It is that turmoil of insecurity that is causing all the genuine worries and anxieties that the noble Baroness outlined to us this evening. People should not be faced with the fear of not knowing whether they are to lose their incontinence pads. That is an unbelievable degree of alarm caused to people who are perhaps the least able to stand up and fight for themselves. However, they have a doughty champion in the: noble Baroness, Lady Masham.
1346 The important aspect of this Bill, and the reason why I welcome it, is that it is in the interests of the patients. Patients must come first. As someone who has worked for over 30 years as a National Health Service dentist, I understand the professional side only too well. Nobody likes to see any great change that might disturb their lives, but the health service has reached the point where it needs change.
I remember well the reorganisation in 1974. I am not sure whether I correctly understood my noble friend Lady Cox who referred to the risk of going back to pre-1974. There are some parts of this Bill that will go back; for example, the hospital system will be closer to what it was before 1974. I believe that it was better then. Since then, I have been on what was called a retained board of governors but is now a special health authority. I was involved with a hospital that did not change its structure in 1974 and which did not come under the area and then the district. It is the closest to a self-governing hospital and the system works very well. I believe that it is in the interests of patients to go back to that type of hospital, and under this Bill we shall be able to do that.
The other change in 1974, I believe for the better, was the elimination of executive councils and the bringing in of family practitioner committees. There were various structural changes of benefit. In the days when I served on the Inner London Executive Council, it had a great professional majority. I was one of the professionals. The doctors would say to us, "If you do not vote with us, we shall not support the dentists tomorrow". It was worse than any trade union arrangement that I have ever come across. I was delighted that in 1974 that overwhelming professional majority went, because it was too strong a vested interest. It suited me that we were protected but it was not right: the patient was not coming first.
I have been asked as a dentist to speak also for the pharmacists. I welcome the Bill on their behalf. The pharmacists are delighted that Schedule 9, paragraph 16, makes clear that there will be a greater role for them. As your Lordships probably know, there are over 6 million visits a day to pharmacies in this country. This area is an ideal centre for the promotion of better health. I will not go into all that they do but we all know that pharmacists provide essential checks and balances in the supply of medicine and act as a great safeguard, particularly when someone who is tired, overworked and under pressure is writing prescriptions and can easily specify the wrong dosage without thinking.
With the unique education and training that pharmacists are now receiving, they are pleased that they will have some role in advising and helping the patient. They say that it is quite right that they should have nothing to do with prescribing for the patient because that is not their field. They believe in the ethical precept that the doctors continue with all prescribing. The pharmacists believe that it is important that the people who prescribe the medicines should not gain financially from supplying them and that the people who make a profit from the supply should not be the ones to decide what is supplied. They believe that to be a very good feature of the provisions.
1347 As regards dentistry, the new dental contract will be good. It comes into effect in October. It will provide continuing care. It reflects the changing needs for dentistry in the population. I have expressed concern before, and I shall do so again, about the situation in London. There is need for London weighting in order to recognise the very high costs involved in practising in London. I fear that if we do not have that provision we might lose national health dentistry in large areas of London. Recently I heard that 70 out of the 90 dentists in the Kensington area had said that they will not be able to operate the national health contract unless something is done to provide a London weighting. At one stage I had the opportunity to put that point to the Secretary of State. He said he is open to considering it, but that the London dentists must make their case. It is up to them to do so.
Over tea this afternoon one of the distinguished Members of this House told me that when the health service first came in— I was not in this country at that time— it was stated that as the health of the people improved it was expected that there would be a decrease in National Health Service expenditure. That is quite believable because at that time, over 40 years ago, if you had a bad heart the only treatment offered was bed rest. No one could have envisaged the unlimited demands that would come to be made on the health service. Resources have also been a problem for all governments.
Now there are so many very special treatments that one can have. I believe I have told the House before that since 1974 I have been on the board of the Brompton National Heart Hospital which is a special health authority That hospital has been using efficient management and accountancy techniques for years. It has been very fortunate in having a capable chairman and chief executive. There is a marvellous spirit in that hospital. The building of phase 1 of the hospital will be completed and fully operational this year. It is desirable to complete the job of building phase 2, and I put in a marker for that right now. Many of the patients are still in the south block, which is 110 years old and is structurally unsound.
I have heard Members speak on the other side of the question so I wish to make the point very clearly. There is a great need for local negotiations and local agreements with staff. I attended the meeting here when one of the major unions in the health service opposed that view and said that it believed in retaining national negotiating scales. The trouble is that London hospitals are in competition not only in terms of nursing skills but in terms of the demands of the City, which is offering high secretarial rates. The porters can do better anywhere else; the catering industry is also offering big money. The hospitals are simply not in a position to attract staff of the calibre that they want.
I remember that earlier a noble Lord said that we do not pay enough to the managers of the hospitals. That is true. It requires quite a degree of dedication to be an efficient manager of a hospital or a health authority. I know that in the private sector such posts are more highly paid. I would never wish to 1348 get to the point where we lost the dedication of the health service staff which is so valuable. It is good to retain dedication, but not if people suffer badly financially in the cause of that dedication. I heard the noble Baroness, Lady Masham, say that it was not good to have people as paid members on health boards and authorities. I do not agree with that. The more efficient the management, the more it will be able to rationalise spending. Everyone seems to be generally in favour of clinical audit. If it is done efficiently and well, it will free resources so that instead of endangering the facilities that she referred to, it will make them more available. This must surely be the aim.
It will help hospitals in that they will be paid for the work that they do for patients. That would apply to the spinal injuries unit to which the noble Baroness referred. The money will go with the patient. The Brompton Hospital says that if it had received the money for each patient that it had treated over the years, it would be much more viable than it is now. I am sure that the spinal injuries unit would be in the same position.
§ Baroness Masham of Ilton
My Lords, the noble Baroness misunderstood me. I am a supporter of money following the patient. I was concerned about the authority members of the district and regional committees. If money is very limited, a good many excellent people will give their services free. I was referring not to the staff but to the committee members. But I am all for the money going with the patient.
§ Baroness Gardner of Parkes
My Lords, I thank the noble Baroness for those comments. I still hold the same view that it is now an accepted practice to pay people for whatever time they give up. Any question of payment within the health service for committee members would be fairly minimal, as it is in local authorities. People would be reimbursed for out-of-pocket expenses. These are not full-time competitive jobs which people would be aiming to get. The dedication would still be there. But it is wrong that we should rule out people who cannot afford to give their time for nothing. We should not rule them out by saying that we shall not pay the committee members. It should be open to anyone to serve on those committees. They should not be prevented from doing so on financial grounds.
I see that local authority members will no longer serve as of right. That is no bad thing. When I was a local authority member, we had great difficulty getting elected councillors to attend the area health authority meetings. Three councillors had the right to sit on the authority. I was very often the only one there, as I was interested in health. It is difficult because all councillors have so many other demands on their time. Now that responsibility for education in London lies with local authorities, councillors will find it even more difficult to attend such meetings.
When I was a member of the area health authority, I found the real difficulty to be that decisions were not made. Decisions were deferred. Whenever a controversial item was on the agenda, we would arrive for the meeting to find a rent-a-crowd at the 1349 door. The decision would not be made that night. As a result, we were faced with all kinds of problems. With the abolition of the area authority the problems moved on to the district authority. I now read in the newspapers all the time that the district has been a disaster ever since. It is important that people should not be frightened of making decisions and that they should be capable, as the noble Lord, Lord Carr, said earlier, of assessing the quality of the evidence, making a decision and then going ahead with it. I know that there is genuine worry among staff everywhere, but I do not believe that piecemeal implementation will help. Monitoring will help and quality control is important. In dentistry and in the general practitioner services there has always been an excellent complaints procedure. I hope that that procedure will continue under the reorganisation.
A different concern in London is the high capital value of property on valuable sites. I understand that there will be protection for the first year or two but that eventually a capital return on the value of the site might be required. I ask the Government to keep a watching brief on this matter. It may be that protection will need to go on for longer. Only when the process is operational will people be able to see what effect this will have. Another important point concerns the arrangements for rent and reimbursement between educational institutes attached to major hospitals and perhaps occupying part of National Health Service premises. This applies to the Eastman Dental Hospital and it is a point to be borne in mind.
I do not believe that the Bill is one to be frightened about. We have an excellent reputation in medicine. Small children with bad injuries or burns are brought from all over the world to be treated in this country. We have a good deal to offer in humanitarian and international terms and to our own patients nationally.
If we have anything to worry about, it is the national tendency— and it comes right through from driving test days— to look too often into the rear view mirror instead of keeping our eyes on the road. I say that we should welcome the Bill; that we should put the fear of what is ahead behind us; and that we should look forward and keep going.
§ 9.25 p.m.
§ Lord Seebohm
My Lords, we have at last reached the stage of discussing community care. The doctors who have spoken thus far have virtually ignored the subject. Indeed, so far as I know, there has been no reference whatever to Parts III and IV although it is possible that the noble Baroness, Lady Gardner of Parkes, may have mentioned them. I was most interested in two speeches which touched upon the subject. One was the very moving speech made by the noble Baroness, Lady Ryder. However, most of her speech concentrated on social security and not on the NHS or community care, which are the subjects of the Bill. Nevertheless, she mentioned another matter to which I shall return later.
In her doom and gloom speech the noble Baroness, Lady Cox, said a good deal about community care. I could not disagree with her more. I do not believe 1350 that the Bill can do anything but improve matters. Moreover, it makes even clearer in my mind, as the noble Lord, Lord Winstanley, said, the feeling that we should have had two Bills. I say that because it is really very difficult to speak in a Second Reading debate on subjects which are as diverse as these two. Of course, they are interdependent: on the other hand, the contexts in which they arise are completely different.
I shall deal only with Part III of the Bill which concentrates on community care in England and Wales. I was very glad that the noble and learned Lord, Lord McCluskey, spoke about Part IV, otherwise I should have felt slightly guilty about leaving out Scotland. I always feel that Scotland is so different and therefore I am always very careful about what I say in relation to Scottish affairs.
Nearly 20 years ago your Lordships passed the Local Authority Social Services Bill which followed the report of a committee which bears my name. The Bill was commendably short and had to be interpreted by reference to the report which engendered it. The essence of the report was first to create an administrative structure which would act as a platform for future development; and, secondly, to point out the main deficiencies in social provision and give some pointers towards the direction in which it might proceed. We had no crystal ball for forecasting more than that fact.
The Bill which we are discussing today is of a similar nature. It makes little sense without first studying the White Paper, which is, in my view, an excellent document in both content and presentation. To a large extent the Bill amends previous legislation and many paragraphs begin with the words,The Secretary of State mayor include the words,under the guidance of the Secretary of State",and so on. That raises the question of how much of the White Paper, which, after all, is not a legal document, ought to be put on the face of the Bill.
I realise that the first stage of the implementation of the Bill is for local authorities to produce plans for approval by the Secretary of State. It may be here that practical matters will be decided. I shall give as an example what I think should be on the face of the Bill. In paragraph 7.7 on page 56 of the White Paper the following words appear in referring to mental health care:The essence of this is that the needs of each patient both for continuing health care and social care are assessed before discharge; that effective arrangements are made as to how in principle those needs are to be met, including the maintenance of appropriate registers"—and this is the important part—and that a named individual is appointed to ensure that they are met in practice".That provision seems to me absolutely vital. We have the very sad example of schizophrenics who frequently discharge themselves from hospital before they are cured. They go on their way without any nominated carer; they do not take their medication; they get into trouble; and some even find themselves in prison. They are still ill. There should be a 1351 nominated carer for all disabled people, quite apart from the mentally ill, who are being discharged from hospital, and arrangements for their care should be properly made before they are discharged.
I believe that Sir Roy Griffiths has done a remarkable job; we should all be grateful to him. It was a great relief to me that he came down firmly on the recommendation that the prime responsibility for community care should rest with local authorities. If we consider the number of agencies involved in the present system of delivery of social care, it seems designed to create an infinite number of stools between which the client may and does fall. To me, co-ordination has always been a dirty word. For such an important matter as community care there must be no doubt where responsibility and accountability lie.
To bring about a comprehensive system there must be brought together not only health and social services but the voluntary bodies, volunteers, charitable organisations, housing and of course the private sector. This is the platform on which the whole structure will be built. There must be no division of responsibility between departments. The social services department must be firmly and solely in control.
As I see it, the structure will be on the following lines. The director of social services will, as now, continue to be the chief executive of the personal social services. He will need first a deputy whose sole duty will be to inspect and monitor the whole system of care. While he must have an independent role uninfluenced by any other body or agency, the ultimate accountability must rest with the director, who is responsible for the satisfactory working of the whole system.
Secondly, the director will need to appoint either a second deputy or senior assistant director who will be the general manager responsible for community care. He in turn will need a number of specialists to deal with personnel and training, with the placing of contracts with all external bodies, with finance and, above all, with producing the assessment not only of those needing care but of respite care for informal carers. The latter now provide about 80 per cent. of all care for the disabled. They number approximately 1–25 million people.
Those who are to fill the new senior posts should be appointed the moment the Bill is enacted. There should be no waiting until the appointed date of 1st April 1991. Funds must be provided now so that recruitment can start immediately. The first duty of the team will be to take a comprehensive view of all the available resources of care in the local authority area. The second duty will be to start an assessment of the need for care in the area. At this point the closest liaison with the health services will be absolutely essential. General practitioners will play a vital part. From the start discussions must take place with the district health authority, which must be a party to the plan.
An assessment must be made of the additional personnel required and of the need for, and method of, training carers, who in many cases will be 1352 multi-disciplinary. Only then can a plan be produced for submission to the Secretary of State for approval and a meaningful costing made. Incidentally, planning would be easier if we knew whether the Government propose to implement those parts of the 1986 disablement Act which remain in limbo.
The noble Baroness, Lady Ryder, talked about the necessity for ascertaining the views of clients of carers about their needs. This surprised me. I have also been surprised by the number of agencies which have written to me on the same subject. It seems to me improbable that anyone would try to assess a person without asking for their opinion. However, I seem to be wrong there, and if the provision is so important it must be put in the Bill.
I cannot help wondering who the carers will be. According to the White Paper— but again not in the Bill— there will be needed 5, 500 senior management staff, 2, 500 with assessment and case management responsibilities, 12, 000 middle and first line managers, mainly in care establishments, and 115, 000 involved in the direct delivery of care and support. The need for care can vary from a weekly visit from a home care worker to the possibility of 24-hour duty by a highly qualified nurse trained in mental health. I know that the British Association of Social Workers would like most carers to be qualified social workers. But does it believe that more than a small proportion of those people mentioned in the White Paper could possibly be qualified social workers? Some local authorities are already understaffed and are having their staff cut further.
I must refer to resources. If the Bill is likely to make sense when it becomes an Act, adequate resources must be found. If that does not happen, those who have been assessed will be shattered to find that their expectations have been raised only to come tumbling down like a pack of cards. Paragraph 8.27 of the White Paper states:Government support for community care expenditure for local authorities will be distributed through the Revenue Support Grant in the normal way by taking account of the Standard Spending Assessment for the Personal Social Services. Details of how this will operate will be discussed with the Local Authority Associations. The Standing Spending Assessment formula will continue to take account of the amount of expenditure appropriate for local authorities to incur on supported community care services, including authorities' increasing responsibility for clients who would previously have been funded through social security payments. The phasing of the additional funding will need to be considered".The phasing of the additional funding certainly should be considered. That is a vague promise in my view. The additional financial needs will only become clear when local authority plans are prepared and submitted. Admittedly, specific sums are being set aside for training, and are being set aside from health authority funds in the case of those with mental illness. However, I must point out that it all stands or falls on the quantity of finance that is available. The projected government expenditure to 1991–92 shows, for the first time ever, that social services will receive proportionately less of gross public expenditure than ever before. As a proportion of GNP, again for the first time ever, there will be a proportional cut. Seen alongside the projected expenditure on health, the Government's claim that 1353 we are providing what we can afford must be debatable.
I hope the question of ring-fencing the new delivery of community care can be reconsidered and that special consideration can be given to the start-up expenditure, which must include the costs of computerisation, data processing and building. A lot of building will need to be carried out, for example for hostels. Much of that may be non-recurrent, but it must be considered. Of course the National Health Service provides prevention and care for everyone, including the disabled. That explains why the Bill devotes 45 pages to the NHS and only seven, in Part III, to community care. But let us not forget that community care is about the millions who can never be cured. Many cannot be cured from birth to death, or from middle age to death, from the strokes or whatever misfortunes they have suffered. Community care is also very much about the aged whose last days have so often been miserable.
For those reasons I welcome the Bill, subject to the financial considerations that I have mentioned. It gives new hope and help to the helpless and must stir the imagination and conscience of us all. However, it must be made to work.
§ 9.38 p.m.
§ Lord Donoughue
My Lords, I wish to follow the noble Lord, Lord Seebohm, in concentrating on the community care aspects of the Bill. That is partly because that approach will aid brevity— I am sure the Minister will welcome that— and partly because the bulk of the debate has concentrated on the National Health Service, as does the bulk of the Bill. I feel that my noble friend Lord Ennals has in particular said most of what needs to be said on that. Community care is a cosy term and has been part of the social policy jargon for the past 30 years. It usually receives a consensus support across parties. Like motherhood, everybody agrees that it is a good thing.
However, the reality of community care is less pleasing than the rhetoric. Part of that reality is that it is now to be based ultimately on what the Government call informal carers. They are the 5 million or so relations and friends who are required to provide that so-called community care. The central point is that a large majority of those will almost certainly receive absolutely no assistance from any community care service in carrying out that crucial government-imposed responsibility. Community care will continue to be predominantly individual care from which the Government often opt out.
As has previously been pointed out in this House, the reality of community care can be seen in inner city railway stations, along the Thames embankment and in the cardboard cities of Waterloo.
Some 60 per cent. of our homeless single people are suffering from an identifiable mental illness. They have been discharged from mental hospitals, often with no arrangements having been made as to where they are to live or for after-care. The Audit Commission report of 1987 into community care showed that 25, 000 of those discharged had been 1354 lost; they had disappeared into a nightmare social underworld. Those are the victims of the reality of community care, whatever the rhetoric.
The policy goes back many years and across governments. Therefore I am not interested in making party political points. However, the reality of community care has worsened because the financial constraints on local government have grown more severe. Back-up services to community care have suffered accordingly. In that situation, which is a social crisis, we welcome the Government's action in legislating to try to sort out the mess. However, we must be clear about what results the legislative changes will produce. Above all, we must be confident that the legislation meets the basic test of improving the life situation of both the disadvantaged people and those with the responsibility to care for them.
In that context, I have two main anxieties. First, the local authorities are being given the lead responsibility but will not be given the resources to meet that responsibility. Then no doubt we shall be diverted into the boring game of bashing local government instead of dealing with the social problems and individual tragedies with which the legislation should be concerned.
My second worry is that that policy will end up bogged down in arguments about structures of finance and administration. I am concerned that we shall lose sight of the impact of those new arrangements on the people who use the services. The current trendy jargon when discussing the problem is "consumer sensitivity". I am in favour of anything which resists what is called producer dominance. The commendable efforts of previous Labour Governments to help the less privileged in society were frequently defeated by the selfishness of the producer groups, those working in the social services who seemed to think that the object of the services was their own welfare rather than the welfare of the under-privileged they were paid to help. Therefore it is right to place emphasis on what the community service customer needs.
Do the Government know what they need? Have they asked them? Do they really believe that somebody suffering from severe mental or physical disability who may have spent the past 20 years in a mental hospital can really exercise the rights and choices of a consumer as in a commercial market? Of course not. He or she is poor and often without skills. Certainly he cannot exercise the basic consumer's right to switch to another product or service if dissatisfied.
We have some evidence of what the consumer wants in that field. I have no doubt that the Minister is aware of the work of the Birmingham Community Care Action Project. It has done studies in that field and found that disadvantaged people and those caring for them have modest but clear expectations that the services be available when needed and be flexible to suit individual requirements; that services be provided at times convenient to the lives of the customers and not just to suit the convenience of social workers; and that the services be provided in a way— this is very important— which maintains dignity and does not humiliate those using them.
1355 Against that background of concern and need, we can look at the legislation and assess whether it offers hope of an improvement in the reality of community care. Will sufficient money be made available to local authorities to service the carers and the cared for, including the deep well of need so far unrecognised and unmet? Will the Government fulfil their statutory obligations to provide an explicit set of individual rights and entitlements; in other words, to implement in full the Disabled Persons Act 1986? Will the Government make effective their commitment to developing a service which is consumer-led rather than producer-led— for instance, by giving specific direction to local 1356 authorities about the benchmarks and standards according to which the success of the services can be assessed?
The reality of community care is often depressingly inadequate. It could be greatly improved by the implementation of sensible legislation. I should like to think that such legislation is being put before us today. A number of its provisions promise well and are to be welcomed; but my fear is that the new approach to community care will prove once again to be mainly rhetoric and once again just another way to reduce expenditure on the poorest and most disadvantaged citizens in our community.
§ 9.47 p.m.
§ Lord Hastings
My Lords, I want to speak about community care, particularly the likely effects of the Bill upon the provision of services for the mentally handicapped.
I am a patron of the Camphill Villages Trusts and am familiar with many of its schools and communities for adults which it prefers to refer to as working communities in a family environment rather than residential homes. That is a more accurate description. There are some 30 of those communities spread out throughout the United Kingdom and Ireland, so Camphill is a national and international organisation.
There is great anxiety at the moment among those communities as to how they will fare when responsibility for their welfare is turned over entirely, or almost entirely, to local authorities. The Bill is so vague. It is not explicit at all until and unless you read the White Paper and even that needs a great deal of clarification. I am glad to say that, according to Clauses 44 and 47, the Secretary of State intends to ensure, with some determination, that the Government's intentions are carried out. In the first place, plans must be produced and published, so that they can be seen in the locality, and the Secretary of State must approve them.
The Secretary of State has also taken powers to enforce the regulations and the provision of the resources provided by central government in the first place. It occurs to me that those are powers which he can enforce by mandamus when he is thoroughly dissatisfied with the performance of a particular local authority; in other words, he can make them spend the necessary money. That can only be at the expense of other services which the local authority provides for education and so on. If that is so, I do not see why the Secretary of State does not ring-fence that expenditure and make quite sure that his wishes will be carried out by providing the sums necessary for that very purpose.
On reading the White Paper I note that the Welsh Office apparently is to provide specific grants for the provision of services not only for mental illness but also for mental handicap. That does not appear to be the case for England and Scotland. Therefore, my first question for the Minister to answer when he replies is this. Am I right in that assumption? It would be very useful to have confirmation one way or the other.
Clause 412 states that no accommodation may be provided for those already resident in relevant premises, which refers to registered homes and other places. When he reads that clause the layman will ask himself, "But what on earth happens to them?" I have read the White Paper and I presume that this is a backhand method of referring to the reserved rights for existing residents mentioned on page 73 of the White Paper. If so, why not say so in plain English?
1358 That brings me to the point made by the noble Lord, Lord Seebohm: ought there to be some more explicit reference to the White Paper in the Bill itself? Otherwise, one cannot understand anything about it. If I am wrong I wish to know to what and to whom this clause refers.
Later in the same clause it is stated that the Secretary of State may exclude classes of person by regulation. I should like to know what he and his department have in mind. At the end of that clause it says that none of this will affect the validity of contracts made before the date on which the Act comes into force or after that date. Does that refer to existing residents or only to new residents or both? The matter needs clarification.
Clauses 42 and 43 refer to payments to the local authorities but not, so far as I can ascertain, to payments by them. That is not explained at all in the Bill, but it is to be found in Chapter 8 of the White Paper. That chapter makes it clear that the Government's policy is to even out the level of payments to claimants in residential homes and in the family home.
The care element will be included in the unified budget which is to be supplied to the local authority by central government. But what guarantee is there that that care element will be passed on to the residential homes which receive it at the moment and will continue to need it if they are to remain in existence? After all, a residential home costs more because there are facilities provided such as workshops. So far as Camphill is concerned there are workshops for almost anything one can think of: weaving, woodwork, glass engraving, horticulture, farming, bakeries, creameries, cheese-making— you name it, they have got it, I am sure, in one place or another. Such facilities cost money. They must be funded from the care element of the unified budget. I hope that the Secretary of State will ensure that that is so.
It is stated in the White Paper that existing residents will be funded by the Department of Social Security. Is this to be in perpetuity or is it gradually to be faded out? I am not clear on that matter.
The new residents who will be funded by the local authorities will be calculated on a different basis. Therefore in one residential home— to use a legal phrase— one will find people being funded differently. Is that the intention of the Government? It strikes me that it is quite likely that the new scale may be less than the previous scale received from the Department of Social Security, especially in view of the Government's professed intention to give a bias to the provision of home services in the family home and, strangely enough, a bias against residential homes. Yet elsewhere they are encouraging the local authorities to use the voluntary service more and more; and they will need to do so.
The Government refer to the likely decline in the number of people residing in residential homes. I do not know whether they mean to bring this about by deliberate policy. However, I shall lay a straight bet 1359 of £ 100 with each of the Government Ministers on the Front Bench that in 10 years' time, or sooner, they will be proved utterly wrong and that the demand for residential accommodation will increase rather than decrease. If it is their intention to make the demand decrease, that will be unforgivable.
Finally, there is the question of assessment. The local authorities will have to assess new applicants for grant aid. In what way will that affect the voluntary organisations? Will they be told who they can take into their communities? They are very expert in assessing the people whom they wish to come and whom they can accept into their community. No social worker from the local authority will be able to say whether or not a particular person is suitable for that community. Will the money that the local authorities will provide for residential homes enable them to nominate people for these places? Equally, will they be able to refuse to allow such homes to take people from outside that local authority or health authority area?
People come from all over the place. Although the local authorities may have a larger number of residents from the local community, there are bound to be people from beyond that. I wish to know whether the local authorities will have power to interfere in this way. Until these questions are answered— and I hope that the noble Lord will be able to write to me about at least some of them if he cannot answer them this evening— there will remain a gnawing anxiety and real fear among Camphill communities and other voluntary organisations which provide residential accommodation and therapeutic services to the handicapped people whom they serve. The sooner these fears are allayed, the better. I welcome the intentions of the Bill. However, like other noble Lords, I wish to be certain that the Secretary of State will ensure that its provisions are carried out and provide the funds to enable local authorities to do so.
§ 10 p.m.
§ Lady Kinloss
My Lords, I wish to make only a few small points about what is a wide-ranging Bill. As was said by the noble Lord, Lord Winstanley, and my noble friend Lord Seebohm, perhaps it should have been two Bills. My comments concern Part III on community care.
Much has been said about ring fencing the money transferred from social security budgets to the local authorities' revenue support grants. Any local authority department officer who is planning a year or perhaps two or more ahead must have a clear idea of the range in which he is to act; in short, how much money is to be made available to him. The current phrase is "ring fencing". It means that the money transferred would be clearly identified and could be spent only on community care. Such a mechanism has already been accepted by local authorities in connection with the recently introduced training support grants which can be spent only on certain areas of training. I understand that they cannot be vired to any other purpose.
1360 That is a matter of special concern to the North Yorkshire authority's department of social services. I understand also that the association of county councils wish the Government to consider ring fencing the money that is transferred from social security budgets to the local authorities' revenue support grants.
I have always supported the Government in their plan to provide care in the community for long-stay residents in psychiatric and mental handicap hospitals. Many local authorities have plans for providing care in the community for long-stay residents in psychiatric and mental handicap hospitals. However, many of the resettlement plans are based upon an individual's entitlement to social security benefit. That helps to underwrite the costs of many of the schemes which have been planned for resettlement. I urge the Government to include in the transfer of resources to the local authority a sum to cover the needs of people for whom planned moves have already been initiated. That measure would have the effect of creating a better life for many of those people in realising the capital revenue assets associated with long-stay mental hospitals.
North Yorkshire authority, together with many others, has considerable anxieties about the calculation for the transfer of social security resources from central government to social services authorities. It would urge that a formula for transfer must recognise the existing social security commitment to an area such as North Yorkshire. A particular anxiety is the transfer of resources to help in resettling transfer patients from long-stay hospitals into the community. If the money was given to the Department of Social Services, it could be transferred to the voluntary organisations concerned. In fact, those now in private homes are protected but those in hospital after April 1991 will not be protected.
The way in which the amount of money will be calculated is of great anxiety to the North Yorkshire authority. Is it to be based on the number of elderly people who can benefit or the number currently in homes? It is in agreement with the principle of community care but is worried about its funding, particularly in an area as large as North Yorkshire where there are many towns and urban and rural areas which are scattered and isolated.
MENCAP, the Royal Society for Mentally Handicapped Children and Adults, believes that full implementation of the Disabled Persons Act 1986 is fundamental to community care. Sections 1, 2, 3 and 7 of the Act are still not implemented. Can the Minister say whether any of that is likely to be implemented before April 1991?
As it stands, the Bill provides for a specific grant to be made to local authorities for social services for people with mental illness. Should not specific grants be made to meet the social needs of people with mental handicaps and people with physical or sensory disabilities, as mentioned by my noble friend Lord Clifford of Chudleigh in his most moving maiden speech? This would ensure that the grants were ring-fenced and so used for the purpose intended. If the disabled persons legislation of 1986 1361 were fully implemented it would define those who come within it as having serious physical disabilities, and a specific grant would ensure that their needs would be met.
The Royal Association for Disability and Rehabilitation feels that Section 3 of the disabled persons 1986 legislation is particularly important as it provides the framework for assessments and gives disabled people the right to a written statement of the outcome of the assessment and, if they disagree with the assessment, the right of appeal. If the person concerned is included in discussions that may take place between providers and arrangers of services, it would be cost-effective and ensure the most appropriate use of services. It is also vital that a duty is written into the Bill for local authorities to consult disabled people and their organisations on their community care plans.
The National Children's Bureau is concerned about those children in care who are mentally or physically handicapped who are discharged into the community when they become young adults receiving services. The Bill before us does not appear to give that group entitlement to the help which the implementation of the 1986 legislation would give. I hope that the Government will be able to say that they are implementing the remainder of that legislation.
§ 10.7 p.m.
§ Lord Auckland
My Lords, I begin my observations with an apology on two counts. I shall not be able to remain to the end of this debate, partly through constraints on travel to the Home Counties and partly because I returned only last Sunday having spent eight days in New Zealand as a guest of the New Zealand branch of the Commonwealth Parliamentary Association. That meant fulfilling engagements from the Bay of Islands to Christchurch, which involved some 30 hours of flying time.
Forty years is a long time, and any organisation, be it a health service or any other, is in need of reorganisation after that period of time. In many ways the Government are to be congratulated on having formulated this Bill. After all, no Bill which deals with an organisation which employs over a million people can ever be perfect on first flush. There are clearly imperfections in the Bill, and your Lordships' ability to use revisionary powers in the remaining stages of the Bill are to be tested to the full because if ever there were a need for your Lordships' House to give a Bill a toothcomb examination this is it. There are those on all sides of your Lordships' House who can do just that.
I have taken part in a dozen or more health service Bills in my 31 years in this House. One of the problems with the health service has been the number of White Papers, Blue Papers, multi-coloured papers and Royal Commissions which have looked into it. However, this is by far the most important and significant development in health service history. In fact, I would go further and say that this is probably one of the most important Bills to be introduced into Parliament, certainly 1362 during my tenure in your Lordships' House. The Bill itself is relatively brief compared with some of the Bills we have had to discuss. Some of the criticism has been completely unjustified; other criticism is the other way round.
About a week ago— allowing for time changes— I was in Wellington Children's Hospital. The visit was of only a half-hour duration because of other commitments, but I wanted to see at least one hospital during my time in New Zealand. I have visited hospitals there before and also in Australia. The Bill has attracted considerable interest in that part of the world because New Zealand has many of the problems which we have: a shortage of nurses and doctors, and under-funding. My impression is that they, too, want to restructure their health service. It is worth remembering that our own health service was based on the one in New Zealand. It does not need much imagination to realise that we treat upwards of 50 million people a year while New Zealand treats around 3 million people. Therefore, the problems that we face are hardly surprising.
I should like to deal briefly at this stage with two aspects of the Bill. First, the opting-out of hospitals and, secondly, Clause 18. The idea of self-governing hospitals has much to commend it, at least in theory. However, there is genuine worry, particularly in the Royal College of Nursing— I have a daughter who is in the nursing profession, but I am certainly not the only Member of your Lordships' House in that situation— as to how all this will be funded and what the position of nursing staff will be. Clearly, that matter must be closely examined in Committee. There is also a question as to how much discussion there was with the nursing authorities before the Bill was planned. I spoke to a number of nurses and, like most other noble Lords, I received reams of correspondence from all kinds of organisations, including the Royal College of Nursing. At this late hour I do not intend to develop that argument.
I hope that my noble friend and kinsman the Minister will take on board what was said by my noble friend Lady Cox who made a most admirable speech and who has tremendous experience in this field.
The other matter on which I should briefly like to dwell is Clause 18; the indicative budget for doctors' practices. People who are not in the medical profession find Clause 18 enormously complicated, and I certainly do. However, I discussed these matters in particular with the pharmaceutical industry. There is evidence that on occasions doctors have over-prescribed. That is a serious matter. However, I hope that too much veto will not go on to research and the activities of the pharmaceutical industry, because the fact is that people are in hospital for much shorter periods, particularly for conditions such as the removal of the gall bladder— I speak from experience— and other conditions which 20 years ago meant a very long stay in hospital.
Clause 18 needs particularly thorough examination when the Bill goes into Committee. The success or otherwise of the Bill depends very much on how the doctors and nurses are able to operate therapeutically.
1363 One complaint made these days, not only by doctors and nurses but also by physiotherapists and others, is about the amount of time they have to spend on management and at meetings. In my view, that is not what they should be doing. Their job is to treat patients. This Bill— it has been said many times but I shall say it again— is about patients and about those who treat patients. At this late hour I shall say no more, but this is an opportunity, after 40 years' experience of a great National Health Service, to put that into effect.
§ 10.15 p.m.
§ Lord Thurlow
My Lords, as the noble Lord, Lord Auckland, referred to New Zealand perhaps I may mention that I was in New Zealand when that country introduced its health service. One of the salient weaknesses of a pioneering measure was the uncertainty as to how it would be administered. We perhaps have grounds for wondering how this Bill will be administered.
I intend to concentrate solely on aftercare for the mentally ill. Other speakers have referred to aspects of this in the context of aftercare generally, but I shall concentrate entirely on the mentally ill. First, I endorse the congratulations from the noble Lord, Lord Seebohm, to the Government for the impressive progress that the Bill represents in creating a splendid framework for care. Accepting Griffiths is a tremendous step forward. However, there is a vast difference between a framework and the delivery of services. There has been a yawning gap in the past and the National Schizophrenia Fellowship is deeply anxious that local authorities responsible for aftercare of the mentally ill will fail to muster the resources that are necessary for the many ingredients that the Bill acknowledges are necessary: hostels, day centres, specialist nurses, an administrative structure, named individuals and other facilities. This is not a cheap option.
Care in the community is now recognised to be much more costly than the old-fashioned and outmoded arrangements for vast institutional care. Some local authorities cannot and will not raise adequate resources themselves for large contributions. The Government acknowledge that the 3 per cent. that they have raised in the past has been derisory but many of our local authorities are now under great budgetary pressure and I cannot see that being relieved.
The excellent framework of the Bill, therefore, may remain bones without flesh and the nightmare envisaged by the noble Baroness, Lady Cox, may be realised. I hope not. It is up to the Government as the supervisor and co-ordinator to see that the scandal of discharged patients who have in the past been put out into the streets is not perpetuated.
Strong central monitoring and supervisory functions are a cardinal necessity. We recall that the first recommendation of Sir Roy Griffiths was that a Minister should be designated specifically for community care with machinery to identify the results of local authority social service activities and to distribute the specific grant. I doubt that the Bill will work satisfactorily without that.
1364 I would like briefly to mention training requirements. As noble Lords have pointed out, a vast army of specialised and trained staff is necessary to implement the Bill properly. I believe my noble friend Lord Seebohm mentioned the figure of 115, 000 in relation to one of the grades. Are the Government setting in motion the training arrangements now to enable this very large personnel requirement to be met? In previous debates on mental illness in your Lordships' House we have referred to the disparity between the requirements for community psychiatric nurses and the actual force at present on the ground. That will be multiplied. I endorse the hope expressed by other noble Lords that the framework will be balanced by adequate resources.
§ 10.21 p.m.
§ Baroness Faithfull
My Lords, I apologise to your Lordships' House and to my noble friend the Minister for not having been here at the beginning of the debate. I was in Kent speaking to Kent magistrates on the Children Act. I shall be speaking in the main, except as regards one particular point, on community care. I began to wonder whether that subject was in the Bill at all because I am the 33rd speaker and only seven of them have mentioned community care in their speeches. So I almost gave a shout of joy when the noble Lord, Lord Seebohm, rose to his feet and spoke entirely about community care.
The directors of social services have taken the challenge and they are looking forward to implementing the Bill on community care. In fact, many of them at this moment, having read the Bill, are working towards plans in their areas for community care. I am in a very real dilemma because, on the one hand, I understand the comments made by the noble Baroness, Lady Masham, and by my noble friend Lady Gardner of Parkes that uncertainty is a bad thing. If it goes on too long people are uncertain. They do not know where they are going and they want matters to come to a final point.
On the other hand, the time-scale for the social services departments to plan for this Bill is very short. I also have to bring to the attention of your Lordships that not only will the social services have to implement this Bill; they will be implementing the Children Act in the same year and at the same time. Therefore, I am bound to ask my noble friend the Minister whether that fact has been taken into account by both Ministries. Has he taken into account that the two Bills will have to be planned for and carried out at the same time? I am sure that my noble friend the Minister and the Secretary of State have taken this into account. If they have, it has not been made clear either to the directors of social services or to us.
Therefore, I am in a dilemma. The sooner this Bill comes into operation the better because uncertainty is bad for patients, doctors, nurses and social workers. Equally, the Bill must be implemented well. The National Health Service had extra money both to plan and to institute changes following the publication of the White Paper Working for Patients.
1365 But local authorities have had no money to carry out preparatory work and to plan. Nevertheless, realising their responsibilities, many have embarked on plans. Two local authorities have told me that 10 per cent. of their staffs time is spent on planning. If 10 per cent. of the staffs time is spent on planning, other work is not being done. This indicates that extra staff will be required.
The noble Lord, Lord Seebohm, gave some figures. They are accurate, I am perfectly certain, and they are frightening. I speak on this point with deep feeling as a retired director of social services and local government officer. In local government, as is probably well known to the House, estimates are prepared in August, September or October for the following year. How are social services departments to produce estimates for the implementation of the Bill when they do not know how much money they will have? I support the Bill. I agree that some things need to be altered. I support community care because I think it is in the best interests of patients. But this point must be explained to the House and in particular to those who are planning in social services departments.
I support noble Lords who have spoken about the recommendation in the Griffiths Report for ring-fencing of money for this purpose. I speak with feeling for my colleagues in local government. If one has only a certain amount of money and then a crisis arises, the local authority treasurer will look to take a little money from one department and a little from another department. As a director of social services I would arrange my estimates. But then something would happen in the local authority. The treasurer would send for me and say, "I am afraid that you cannot have that £ 10, 000 this year because something else has happened". Unless there is ring-fencing, and unless money is allocated for the implementation of the Bill, what I have described will happen and money will not be channelled to local authority social services.
Perhaps I may say to my very dear and noble friend Lady Cox that I cannot agree wih her. The noble Lord, Lord Walton, will speak after me. I was going to say to the noble Lord that, with two people from Oxford, the last shall be first. The noble Lord will know that there was a close relationship in Oxford between social services and the medical profession. We were friends. We worked as equals and we listened to one another. We worked as partners not only with the doctors but with the health visitors and the district nurses. We were one service, not three. I am sorry that the noble Baroness feels that the medical workers and the social workers do not work together.
§ Baroness Cox
My Lords, I pointed out that in many areas there is good co-operation. I know that people are being well served and will be well served. But I am afraid that in many areas— and examples will be forthcoming in Committee— there are genuine problems. I do not see that these solutions will help those problems. However, I recognise the point that the noble Baroness has just made in regard to some areas.
§ Baroness Faithfull
My Lords, I am grateful to my noble friend. Perhaps she will tell me one day where the bad areas are. I should like to know.
It is late. I should have liked to say many things but I shall cover only one or two other points. I shall deal first with residential care. We all talk about community care as if it were the horizon and the sun. However, there are some people who wish to be in residential care and not community care. It is most important that there should be a choice for individuals. If there is no choice for these people, and they are merely assessed and put into places where they do not wish to go, they will not do well.
In mentioning residential care, I know that I am straying into the fields of social security, as did the noble Baroness, Lady Ryder of Warsaw. I am aware that there has been an increase in grants; namely, £ 5 per week for residential care, £ 10 for nursing and £ 15 for hospices. Nevertheless, I regret to say that those increases will not cover the costs incurred. I am patron of an Alzheimer's disease hospital which has received enormous gifts. It has no loan charges and no mortgage. But, despite that fact, the lowest cost for residents is £ 320 per week. In the case of Alzheimer's disease a great deal of residential care is needed. There are many other points that I should like to make about residential care but I shall leave them for the next stage of the Bill's proceedings.
Many noble Lords have mentioned mental illness and mental health. They have spoken in particular about schizophrenia. Between now and 1991 will the Ministry close more mental hospitals? If that is the intention, it will redound in 1991 on the community care of the social service departments. I am thinking especially of the Maudsley Hospital and of the Cassel Hospital. If mental hospitals are being closed now, what will happen in 1991 when, as the noble Lord, Lord Seebohm, pointed out, no patient can be discharged from a mental hospital without a plan having been made for his future? No such plans are being made for these people at present. If the Cassel Hospital is to be closed and the Maudsley Hospital's facilities reduced how will that affect the standard of community care when we reach 1991? That is not so very far away. Many of us are deeply worried about that aspect of the matter.
I should also like to point out just how important it is that we look after our children, that we ensure that there is an integrated service for them, that the standards of care are high and that there is inter-agency collaboration. I refer especially to collaboration in regard to the new Children Act.
I speak with diffidence on the health side of the matter. Although I have worked very closely with doctors, health visitors and district nurses, this is not specifically my ground. However, I should like to say a few words about the general practitioner service. The noble Lord, Lord Hunter of Newington, has already spoken on the matter. The GP service is the gateway to the health service. It is the bridge which lies between the health service and the social workers.
In Oxford we had a very notable medical officer of health. We had a population of 110, 000. We now have seven health centres, five of which are 1367 purpose-built. Before those centres were built, the plans were sent to me for my approval. I found that no room had been provided for the district nurse or the social workers. However, at present the health centres— that is, all but two of them— have a room for the social workers, a room for the health visitors, a room for the district nurses and a room for the doctors.
At this point I feel that I should mention a most incredible health centre at a funny little place called Hinckley in Leicestershire. One of my colleague doctors is now running that centre. The health centres should be developed and they should become day hospitals in the community. That is where people should go. It means that they are in their community. That sometimes has its disadvantages: the last time I went to my health centre, my name was called out to see the doctor but I never reached her. One woman rushed up and said, "I wanted to talk to you about my meals on wheels which are not arriving". These are medical, social work community centres. That is how we should develop them. Perhaps the noble Lord, Lord Rea, agrees with me. Many surgery buildings would not lend themselves to this, but these are the lines along which we should go. I should like to speak for longer but I shall not do so. Again, I ask my noble friend the Minister how the social services will deliver what they are keen to deliver in the short time during which they have to implement two Bills at once. Perhaps the Minister will be able to inform me.
§ 10.35 p.m.
§ Lord Walton of Detchant
My Lords, there can be few Bills coming before your Lordships' House which have generated so much frenzied debate elsewhere as this one. I much regret the aura of confrontation which has clouded many of the consultations between representatives of the medical profession on the one hand and government Ministers on the other. Let us hope that the debate will now proceed in an atmosphere of constructive collaboration, exploration, trial and assessment. Then those proposals of demonstrable benefit to patient care can go forward expeditiously while those shown by experience to be potentially detrimental can be modified or even perhaps abandoned according to the needs of the service.
One major difficulty which I and others who have spoken have found in commenting upon the detailed provisions of the Bill is, first, that it is not, to say the least, in its use of construction and language, light bed-time reading. Secondly, so many of its proposals are to be implemented by order or regulation by the Secretary of State that one is compelled to take account in debate not just of the Bill itself but also of the proposals set out in the White Paper which preceded it.
Your Lordships have had the benefit of hearing the clear and comprehensive statement by the noble Baroness, Lady Hooper, in introducing the Bill into your Lordships' House, and many notable contributions by noble Lords this afternoon and evening. Perhaps I may now attempt to highlight what I see as being some of the principal proposals 1368 in the Bill and White Paper which I personally commend to your Lordships as being likely, in my view, to improve the NHS and to bring substantial benefits to patient care.
First, it is good to see that the Government have reaffirmed their commitment to providing a National Health Service which will in most respects be free to the consumer at the point of delivery. It will be largely funded from the products of general taxation.
Secondly, I welcome the proposal to introduce clinical audit into both general and hospital practice. That will not mean in this sense a financial or management audit, but a systematic, critical analysis of the quality of medical care including the procedures used for diagnosis and treatment, the use of resources and the resulting outcome for the patient. However, while I and I believe the medical profession, now give this proposal enthusiastic support, it is important to recognise that such activities are time-consuming. They will inevitably divert some resources away from direct clinical care, with obvious implications relating to staffing levels and funding.
Thirdly, I also commend the Government's emphasis upon value for money and upon improving the information being made available to patients about services available at hospitals and in the community. That will enable them to make better informed choices about where and from whom they will seek medical services, subject only to some relatively minor reservations which I shall mention later.
Fourthly, though again subject to some reservations which I shall mention, I offer a cautious welcome to the proposals in the new GP contract to set general practitioners targets for immunisation and various types of screening. The proposals which will bring family practitioner service authorities within the jurisdiction of the regional health authorities, and the arrangements relating to the transfer of funds when patients move from the ambit of one health authority to another, are also to be commended. I also favour a much needed improved complaints procedure.
What are the principal problems which I see in relation to the major provisions of the Bill and of the White Paper? Why is it that I and many other doctors have serious concerns about some of them? I listened carefully to the lucid speech of the noble Baroness, Lady Oppenheim-Barnes, but I make no excuse for returning yet again to the issue of funding. The potential demand for health care is, of course, infinite and Her Majesty's Government are now devoting more financial resources to the NHS in real terms than did any of their predecessors.
Despite the fact that more patients are being treated, the service still remains chronically underfunded, as several noble Lords have said. I shall not labour the point, but in cash terms in 1987 we spent about £ 300 a head while France spent £ 500 a head and Germany £ 600 a head. We need more consultants in all specialties and we need more funds to provide for the immense advances in medical care and treatment which are being discovered almost daily, and to cater for an ageing population.
1369 However, I find it exceptionally difficult to see how the complex financial accounting systems which the Bill will introduce can be implemented speedily, even with increased staff, when existing salary scales make it almost impossible in many districts to recruit qualified accountants and when medical secretaries are leaving the service in increasing numbers because of the greatly increased rewards they can obtain in the private sector. Therefore, we need a new baseline for NHS funding. I hope very much that the additional funds which the Secretary of State is able to obtain in the future for the service will be used to fund the much needed additional consultant posts to which I have referred and to reduce the intolerable pressures, especially upon junior medical staff, as referred to by the noble Lord, Lord Rea.
I should say again in passing that I only wish the Treasury were not so implacably opposed to earmarked taxation. If it were not so, how nice it would be to have an index-linked, income related health tax. Can we assume that the Chancellor's recent decision to allow tax relief on substantial single charitable donations is the first chink in the Treasury door? Perhaps that is not the case.
In general medical practice I personally regret the emphasis upon increased remuneration via the capitation fee with the specific objective of encouraging general practitioners to compete for patients. I am not personally in favour of unrestricted advertising by doctors, having seen the unfortunate effects of such advertising in other countries, as well as the results of advertising by laymen of the services provided by some private clinics in the UK which have clearly shown that some of the most effective advertisers are the least able providers of high quality services. However, I am greatly in favour of the widespread ethical dissemination via practice leaflets and annual reports of detailed and comprehensive information by doctors and practices to enable patients to make a better informed choice.
Two further concerns that I have relate, first, to the fact that some excellent doctors work in areas of the country where they have a virtual monopoly of medical care in the local population and therefore no prospect of increasing their list size, and, secondly, to the fact that for many years the profession has been urging that GP lists should be reduced in size to enable doctors to spend more time with individual patients. I also hope that in confirming targets now set for cervical screening, for example, the Government will accept— I know they are fully aware of this— that some practices number many nuns and members of ethnic minorities among their patients and therefore simply cannot meet the higher targets proposed.
With respect to practice budgets, I trust and believe that the Secretary of State has been able to reassure the profession that no unreasonable constraints will be imposed upon freedom to prescribe. But it is clear that budgets can only be set in close consultation with the profession. I recall the concerted professional opposition which was widely orchestrated when the limited list of drugs prescribable under the health service was introduced. That list has proved to be adequate and generally 1370 accepted. I greatly deplore the reported suggestion by some doctors that they might decide to remove from their lists certain patients with conditions which are expensive to treat.
Variations in prescribing costs from one practice to another throughout the country suggest that some with very high costs could usefully scrutinise and reduce them without detriment to patient care. However, in other practices it is probable that drug costs are too low.
The final issue in relation to general practice which concerns me is that relating to hospital reference in which the money will follow the patient. I believe that it would be very difficult, if not impossible, for practices and health districts to introduce the necessary financial accounting procedures within the timescale envisaged. I strongly urge a prolonged period of trial and careful assessment of those changes in a limited number of practices.
Secondly, I accept that it is reasonable that GPs should normally refer patients for specialised advice and treatment to one or other of the hospitals in the district where they reside and that where, for special medical reasons, a patient is referred to a hospital outwith the district the appropriate funds should be transferred. However, I am concerned lest those arrangements may mean that a budget-holding practice would be tempted to choose the cheapest of several options rather than the best. That arrangement might result in an unfortunate reduction in references to the inevitably more expensive hospitals in teaching districts. That would have serious consequences not least for patients who may sometimes be deprived of the highest standards of care but also for undergraduate and postgraduate teaching and research.
I turn lastly to the hospital service. I do not propose today to comment on the very important proposals in the Bill on community care which, as certain noble Lords have said, might well have deserved a separate Bill. The interest and involvement in all health matters of our great universities with medical and dental schools is now very intimate in relation not only to the provision of services through clinical academic appointments and undergraduate teaching but also in relation to postgraduate and vocational training, continuing education and research throughout all regions. In my view, it is therefore absolutely crucial— as the noble Lord, Lord Dainton, has proposed— that a university voice should be heard as of right in all health authorities, from the region down to each district.
Similarly, I am convinced that such authorities must each contain within their membership a suitable number of health care professionals responsible for providing clinical services to patients as well as other members able to express the consumer interest. In my experience, advice from officers is not enough. I shall hope in Committee to give more detailed reasons. I recommend a university voice in each district. Although this is of the greatest importance in teaching districts, virtually every health district in every region is now to some extent involved not only in undergraduate 1371 medical education but also to an increasing extent in postgraduate, vocational and continuing education of doctors and other health care professionals.
Perhaps I may mention research— briefly at this late hour. For many years, the support of medical research in our universities has been based upon the so-called dual support system. Through that system the universities, with funds derived from the UGC, now the Universities Funding Council, provide the environment, accommodation and infrastructure of technical and secretarial support in which the research can be done. The Medical Research Council, charities and foundations cover only the direct costs without payment of overheads.
A similar situation has long been acknowledged, if never formally agreed, in relation to research in NHS hospitals in which much fundamental research, bringing outstanding benefits to patient care, has been and is being done. It is similar to the so-called knock-for-knock agreement through which the clinical services provided by university staff with clinical contracts are compensated for by the teaching given by staff employed by the NHS.
A December 1988 survey in the Oxfordshire health authority, reported to the steering group, under the chairmanship of Sir Christopher France, which is examining in depth the inter-relationship of DES and Department of Health funding for teaching and research, found that expenditure on research in that district was about 1–5 per cent. of the annual revenue budget. That is one good reason why I and many others believe that such costs require to be separately identified and protected within the budgets of all health districts alongside those for teaching, thus changing SIFT (the service increment for teaching) into a service increment for teaching and research.
It was good to learn last July that the Secretary of State seemed to agree to that proposal when he addressed some members of the medical profession, but I do not see any evidence that those important matters are addressed in the Bill. Similarly, it is all too easy to overlook the absolute necessity of identifying separately in authority budgets the funds needed to support postgraduate, vocational and continuing education. Many financially hard-pressed authorities have tended of late to overlook the agreement formally enshrined in the original National Health Service Act of 1946 and in the regulations which stemmed from it that, whereas postgraduate education in taught courses or whole-time research leading to a higher university degree is the financial responsibility of the universities, the postgraduate and vocational training of physicians, surgeons, general practitioners and all other medical specialties, as well as that of all other health care professionals, clearly falls within the responsibilities of the NHS, as is the case with continuing education of all doctors, in which medical audit will clearly play an increasingly important role. Earmarked funding within health authority budgets to enable postgraduate deans to fulfil that responsibility is clearly essential.
1372 Finally, perhaps I may say a few words about self-governing hospital trusts. I am not fundamentally opposed to that proposal, especially if the small, independent governing bodies of directors of such trusts become in some respects comparable with the boards of governors who used to govern many of our large teaching hospitals. As a former member of a regional hospital board, several hospital management committees and an area health authority, I was often disturbed by the fact that some members of those bodies appointed by local authorities all too often appeared to put the interests of their constituents first, ahead of the needs of the service. However, I hope that, if and when such trusts are established, in the beginning they will be relatively few in number until we can assess fully how they work.
Secondly, I believe that it is essential that they cannot opt out of providing the range of services which the regional and district health authorities require them to provide. Thirdly, their directors must include in my view some who are able to explain and support university teaching and research interests as well as some clinical staff working in the relevant hospital or unit.
Fourthly, I am opposed to the proposal that they should be allowed to set their own salary scales for all grades of staff as uniformity in such scales, certainly in medicine and nursing, has been one of the strengths of the service. That proposal would create a difficult situation for academic clinical medicine and for junior medical staff in training. However, I would not be opposed to paying local allowances comparable with London weighting to assist in the recruitment and retention of staff. Finally, in order to ensure the maintenance of high standards of care in those hospitals, I believe that an independent system of accreditation or inspection is clearly needed.
I hope to have the opportunity of addressing again some of those important issues in Committee with the sole objective, shared, I am sure, by all noble Lords, of improving this important Bill in the interests of patients and the service. Many members of my profession have been accused of being deliberately obstructive and of opposing the Bill in its entirety, but most, I am sure, wish to be helpful and constructive. I well recall one hospital administrator who said that his job required him to serve the interests of 200 consultants, of whom 193 owed allegiance only to God and the other seven did not even accept that jurisdiction. However, it is significant that for the first time the royal colleges and other bodies representing all the caring professions have come together to urge slow and selective implementation and careful assessement of the results of those fundamental and as yet untried changes.
I hope therefore that the Government, in recognising the principal concerns which I and many of my colleagues feel about some aspects of the Bill, will recognise that we also wish sincerely to acknowledge its good points upon which all of those working in the service will hope to build, given adequate resources and adequate time and information in order to be able to do so.
§ 10.55 p.m.
§ Baroness Seear
My Lords, the Bill that is before your Lordships' House today is only the most recent in a long line of Bills which have been based upon Greer. Papers. Yet the Bill offers some exception to that because the community care section, to which I shall devote most of the few words that I wish to say, was preceded by the excellent report of Sir Roy Griffiths. I suggest that that is one reason why the community care recommendations have had widespread acceptance and not met with anything like the degree of criticism that has been encountered by the rest of the Bill.
It would be very interesting to know who drafts the Green Papers. Who are they and what are their qualifications? Those who draft the Green Papers set the agenda for the whole debate. Noble Lords who have sat on committees will know that if you can set the agenda, you are three-quarters of the way toward achieving the conclusions that you wish to have. I have challenged before (and shall do so again) the practice which has grown up of deserting the old idea of having a public inquiry into matters of such a degree of importance on which will sit representatives of the various interests concerned. They are people who have special knowledge and experience and who have differing points of view. They have to thrash out those differences and arrive at a report to which their names are attached. They have reputations to be lost should they produce half-baked ideas. I believe that that is a very much better way to produce legislation than by way of anonymous Green Papers.
I suggest that if that process had been adopted before this Bill was produced to your Lordships' House, a great deal of the criticism that has come from all sides, not only from the medical profession, would have been averted. Those who voiced their criticism would have contributed to the formation of ideas before the Bill was produced. Surely that is the way to achieve acceptance for change.
The people who are involved in change have to be involved also in determining and discussing the nature of the changes to be undertaken. I regard the abandonment of that method as an extremely bad practice that has grown up. We are given instead anonymous Green Papers. I should truly like an answer as to who drafts them, how those people are selected and what are their qualifications. I think that Parliament is entitled to know.
There is another bad practice which finds its place in this proposed legislation and about which we on these Benches and other noble Lords have complained; namely, that so much of what determines what happens when the Bill is turned into an Act and its provisions implemented is to be left to regulations. A great number of decisions about what happens to patients at the end of the day will not be on the face of the Bill or in the Act. There will be no primary legislation. Matters will be decided by discussions and by civil servants to a very large extent. Parliament will have no opportunity effectively to alter what is decided in those regulations. In particular, all that is of importance 1374 in the whole (it is indeed the whole but a very short whole) of the community care section will be embodied in regulations.
That is just not good enough in a country which is supposed to have parliamentary control over the important changes and developments in social policy. That is all that I want to say about the background to the Bill. I do not intend to speak about the health side of the Bill. I am not qualified to do so and many other noble Lords have spoken from a deep basis of knowledge about that.
I want to talk about the community care section. Like other noble Lords, I believe that it should be in a separate Bill. If it had comprised a separate Bill, we could have hoped to have— and perhaps more easily insisted upon having— more of the important detail that will determine the nature of community care written into the Act, which is where it ought to be.
Even after what has been said today, I do not know whether the Government are fully conscious of the scale and importance of the developments proposed in connection with community care. It is not only a question of emptying the institutions. There are a great many people who will need community care who do not find their way into institutions. That is one of the purposes of the legislation: to keep them out. The community care will be good enough. Therefore they will not find their way into institutions. I should like to say how much I agree with the noble Baroness, Lady Faithfull, that for some people community care is the better option. The idea that one should have almost everybody in community care seems to me a great mistake.
However, that is not the most important factor. The important factor is the scale of, and the need for, community care and the cost of it. There is no indication in the Bill as to how those factors will be met, or indeed a full recognition of the enormous nature of future needs. Unless very adequate services of a good quality are provided, we are heading for a disaster. I use that word deliberately. I can foresee a situation in which there are not adequate resources to back up those who are put back into society, into the community.
"Community care" is a nice phrase. But how much does the community care? How much will it be prepared to pay? How much will the Government put in? I wish to give one or two examples.
One of the most important aspects of community care— a very down to earth one— is the adequate provision of domiciliary help. Those are people who come into the houses of old, infirm people who cannot do the housework, the cleaning and all the humdrum jobs that have to be done. Unless they are very good quality, well trained people, the results can be appalling. A great many people who work in this field are very concerned about it. They are doing all they can to ensure that there are good staff available. There is nowhere near enough staff at present to deal with that aspect alone; namely, the provision of the domicilary care workers who need to be properly trained. Such care workers have a great deal of responsibility. They work on their own 1375 in the houses of people who are very often elderly and who cannot stand up to them if there is any abuse. Those old people are afraid— I have experience of this happening— to complain to the organisers because they are so dependent on the people who come into their houses. Unless there is proper training, supervision and control the whole scheme can break down on that one issue alone.
We urgently need better community nurses. There have to be plenty of people who can go into the houses to help with the bathing and other tasks that need to be undertaken. They are very time-consuming, skilled tasks done without supervision in respect of people who are not in a position to stand up for themselves if things go wrong and who again will be afraid to complain because they are so dependent.
We need day centres. They are not cheap but we need them very badly, both to help the old, frail persons themselves, and to help those who are looking after them. We need respite centres. Those are only a few examples. Another is Meals on Wheels. I could go on.
If one considers the numbers involved, they add up to an enormous bill. If we do not have a considerable amount of resources there could be a squalid disaster. I beg the Government to think again about ring-fencing money for those purposes. Unless that is done, when hard pressed local authorities are looking for money for any urgent causes, the temptation to raid the money which they know ought to go on community care but which can be grabbed for something else will be almost irresistible. Unless there is ring fencing, we have no guarantee that resources will be adequate to meet the needs of the people about whom we are concerned.
I wish to speak in particular this evening not so much about the people who need the care but about the carers in homes, in families. They will be asked to do a great deal of the caring. I declare an interest as the President of the Carers National Association. It is estimated that 6 million people are caring for people in their homes who are not capable of caring for themselves. Not all are desparately sick but they need care. Two-thirds of those are caring for people single handed. That is a figure which should give your Lordships pause for thought.
They need protection but I do not see the word "carer" anywhere in the Bill. If the services are inadequate— and to some degree they certainly will be— who will undertake the caring? It is normally a female member of the family living in the house. Perhaps it is a daughter or the wife who is available. However, about 25 per cent. of known carers are men. They must cope as best they can.
Almost everyone in your Lordships' House must know someone in that position and therefore I ask you to be realistic about the matter. If you are looking after an infirm or disturbed person you can be raised two, three, four or five times during the night. Most people can put up with that for two or three months. But if it continues for six months it will drive them almost round the bend. Unless the services are adequate that is what we shall be asking 1376 of carers. Even if the services are adequate the burden on the carers will be considerable. They will be caring for the person 24 hours a day, seven days a week, 52 weeks a year when the help from outside is not available. Some of the rights of the carers should be incorporated in the legislation.
I do not wish to sound harsh but one must also recognise that a so-called carer has a right not to care. It must not be assumed that a member of the family will automatically assume responsibility. Many of them do so for a mixture of reasons but mainly because they feel a desire and an obligation. However, some do not and it is wrong to take for granted the fact that because someone lives in a particular house he or she will be prepared to make drastic changes in the way they live. That is what is required. I know carers who cannot get out for an hour to do the shopping because the old people for whom they care will not let them out of their sight. Not all those old people are sweet and agreeable; often the only power that they have left is the power to bully the person looking after them. Unless we recognise those rights the difficuties experienced will be great.
Furthermore, alongside the needs assessment of the person to be cared for there should be a corresponding needs asessment of the person undertaking the caring. Such a person's needs are different but just as heavy. There should also be a more generous invalid care allowance than now exists. Adequate, full-financed community provision— and it will be expensive— is essential. Legal protection for the rights of and help for the carers is also essential. Unless we provide that the proposals contained in the Bill will have positively evil results.
§ 11 p.m.
§ Lord Carter
My Lords, a number of noble Lords have said that we are considering two Bills. I propose to concentrate on that part of the Bill concerned with community care. I am aware of the lateness of the hour, but I also wish to comment briefly on some of the points raised in the debate.
In her clear introduction of the Bill the Minister poured cold water on the evaluation exercise of the Royal Colleges. She said that in her view it had doubtful validity. How do the Government know, or do they assume that they know the answers before the questions have been asked? She also said that the Government have taken time over consultation. No fewer than four months were given for the responses to the White Paper— the biggest change in the health service since 1948. Things certainly speeded up by the time we reached community care because the Government allowed four days between the publication of the White Paper Caring for People and the publication of this Bill.
The noble Baroness also said that responsibility for care would be firmly in the hands of local authorities. I believe it is correct that local authorities and health authorities are still awaiting a proper definition of their respective responsibilities. The Association of London Authorities has pointed out that the local authority associations are particularly concerned 1377 that the timetable for implementation of the transfer to local authorities by April 1991 seems unworkable. This was a point that was made extremely well by the noble Baroness, Lady Faithfull.
I should like to say a few words about the speech of the noble Lord, Lord McColl, and his brave new world of customers, competition and the monetary disciplines of the deviant behaviour of the businessmen managers— a world where altriusm is not enough. This was an idea supported by a curious combination of secret disciples and bright-eyed enthusiasts. I hope the noble Lord will not be offended if I say that I was irresistably reminded during his speech of the well known remark of John Maynard Keynes, who said:Practical men, who believe themselves to be quite exempt from any intellectual influences, are usually the slaves of some defunct economist".I think the noble Lord said that the more work the doctors do, the more they will get. We have seen what can happen when that is taken to extremes. We have seen what can happen in America, with evidence of all the unnecessary tonsillectomies, appendectomies, hysterectomies, and the rest. There are real dangers of the practice of the marketplace being taken much too far in the health service. We must be sure that there are safeguards against this.
Perhaps the noble Lord's most revealing remark was when he said that managers should decide if hospitals should become NHS trusts. Apart from the fundamental lack of democracy in that approach, and the unspoken assumption that the professional will always know best, surely the noble Lord knows that in non-profit-making organisations the managers who have no entrepreneurial or equity stake get their kicks by making their organisations bigger.
Another point which we welcome from this side concerns the intention of the Government to introduce an amendment to deal with pharmacists. I am delighted that the Government intend to amend the Bill and to recognise their wider role. It is one which is relevant to health in general and to community care in particular.
I must say a word about the outstanding maiden speech of the noble Earl, Lord Clanwilliam. I think he will be pleased to know that there is an intention to put down an all-party amendment which deals with complementary medicine. There was also the outstanding maiden speech of the noble Lord, Lord Clifford of Chudleigh. We have a particular reason to thank him because there is concern over the way low-incidence disabilities such as deaf-blindness with only a few people in each of the local authority areas with the condition, will be cared for under the new proposals. The noble Lord did a great service to the House by bringing that to our attention.
Returning to the evaluation exercise that was mentioned in the outstanding speech of my noble friend Lord Ennals when he introduced the debate from our side— and indeed there were many of your Lordships who pleaded for more time, and this applies just as much to the community care aspect of the Bill as to the health service aspects— perhaps I may give some friendly advice to the Minister. She 1378 might remember that it was originally intended to introduce the poll tax over a period of ten years. Then it was to be introduced over three to four years while it was run-in and all the problems were ironed out. Then, with all the excitement of the Conservative Party Conference, it was agreed to bring it in overnight. With the poll tax we now have the classic case of Nemesis duly punishing hubris. We could have exactly the same position with the National Health Service reforms if the Government are not prepared to give more time. There are strong arguments for a similar evaluation exercise in the field of community care. As I said, local authorities are very concerned at the rushed timetable with which they are faced.
The Bill proposes a fundamental change in the planning and provision of community care. The mixed economy of care, the promotion, a choice of independence and the monitoring of the quality of community care are all extremely laudable, and we agree with that. However, the Bill seeks to secure those changes by making local authorities responsible for planning and enabling the provision of care.
The Government, to their credit, accepted the central recommendation of the Griffiths Report, regarding the lead role of local authorities. However, they effectively torpedoed the implementation of the recommendation by rejecting the other and crucial recommendation that community care and the budget should be protected by ring fencing or ear-marking. A number of noble Lords drew attention to that point.
No additional funding has been provided for the infrastructure of administration. Just eight of the new functions of local authorities are to produce and publish a community care plan and revise it regularly; to publish the criteria for the undertaking of individual assessments; to carry out individual assessments; to carry out the assessment and collection of the contributions towards the costs of services; to create the monitoring and inspection units; to set up the complaints procedures; to create the purchasing and budgeting systems and to set up the systems of the case management. They have to undertake all of that with no extra funds. In addition, local authorities have to provide all the information technology and the software systems with no effective database of the potential demand that there may be.
Following the introduction of the poll tax in all its glory, there is now genuine reason to doubt whether the proposals in the Bill for community care will work at all. That was a point referred to by the noble Lord, Lord Seebohm. If additional resources are made available to local authorities, they now come either through the revenue support grant from Government or by increasing the poll tax locally. The Bill comes into force in April of next year. Can anyone imagine that extra resources for community care will be made available next year? We read that billions of pounds of revenue support grant will have to be thrown at the poll tax to keep it at the same figure as this year. Local authorities will be under the most intense pressure to keep the poll tax down.
1379 In that situation, I should like to ask the Government where the money is intended to come from to fund the new proposals and to meet the existing level of unmet need? The refusal by the Government to protect the community care budget by ring fencing has been strongly criticised by every organisation in the field, and indeed by the social services committee in another place in its third report on community care and the funding for local authorities. It is also criticised by the Association of Metropolitan Authorities, the district and the county councils.
There is a further problem. There will be every incentive for health authorities which have overspent to relabel the sick and disabled people in need of community care and try to shift them on to the community care budget. The Association of Metropolitan Authorities estimated that local authorities will inherit a deficit on the funding of residential care of around £ 90 million, which will increase to £ 700 million by 1994–95. I repeat that with all the problems of the poll tax, the pressures on the revenue support grant, the deficit in the cost of residential care, the refusal to provide funding for the setting-up of an administrative infrastructure and the refusal to ring fence the community care budget, where will the money come from to provide the level of community care which we all agree should be provided? We certainly wish to table some amendments to deal with that.
I turn now to a number of specific aspects of the Bill. The area of disability was mentioned by the noble Baroness, Lady Masham, and others. The Bill contains the worthy aims for the disabled of promoting choice, independence and the monitoring of the quality of care. That is the intention, and the simple question which has been asked so many times before is: why will the Government not implement all the sections of the 1986 disabled persons Act? If the community care proposals are to work, there must be a right to assessment, a right to be represented, and a right to appeal. We look forward to the Government amendments mentioned by the Minister regarding the complaints procedure. We shall also be tabling amendments dealing with that aspect of the Bill.
Section 3 of the 1986 Act provides the framework for involving disabled people in the decisions about the services that they need, and which in fact can result in cheaper provision. Why are the Government so reluctant to build in the rights of consultation and access to services for the users of those services? In other fields of activity we are constantly told that the consumer is king. Why is that not the case in the provision of community care?
There is great concern about the deliberate discrimination between local authorities and the private sector in the provision of residential care. Perhaps I may repeat the point I made at Question Time today. A recent excellent independent report, an analysis of home care trends and costs by the London Research Centre, has calculated that there will be a need for 81, 000 more places in residential and nursing homes in England alone in the year 2000 and that less than 10 per cent. of elderly people will 1380 have sufficient income to pay for private residential care without some form of public support. In the light of those figures it is extraordinary that the Bill is introducing a deliberate financial disincentive for the placing of the elderly and the infirm in local authority homes and deliberate financial incentives for placing old people in the private sector.
The voluntary organisations are extremely concerned about the failure to require the registration of small residential homes; those with fewer than four beds. The Bill would seem to be the ideal place to deal with that problem.
There are no proposals for any form of regulation of private domiciliary or day-care agencies, though there is for residential homes. That could be more than an anomaly. It might provide a loophole for the unscrupulous or the inefficient to profit at the expense of the elderly, the infirm and the disabled. We shall seek to improve the Bill in that respect.
Your Lordships will be aware that there are many aspects of community care, but with the lack of time and the lateness of the hour I will leave them for the moment but will certainly wish to deal with them at later stages. However, I should like to return to the point made by so many of your Lordships regarding the time for evaluation and assessment. I urge the Government to listen to those pleas very carefully and seriously.
We were asked by the noble Lord, Lord Nugent of Guildford, to detail what the Labour Party would do. I make clear that it has been stated in another place that some parts of the Bill will be repealed by an incoming Labour Government unless a satisfactory system of evaluation and assessment is found and accepted. There has been widespread concern right throughout the debate that the Secretary of State is rushing in at a dangerous speed before any evaluation system has been established and before there has been adequate preparation in terms of training, information technology and resources. As the noble Lord, Lord Carr, said; more haste, less speed.
We cannot ignore the views of those who work in the National Health Service, all of whom think that the timetable has not been properly worked out. It may be that we need a phased programme over three to four years as mentioned by the noble Lords, Lord Smith and Lord Nugent. It is crucially important that we get this right in Committee and on Report. The Government must give urgent thought to evaluation and staging so that some sensible compromise can be found.
We are fortunate to have had some outstanding speeches from those in the medical and nursing professions, such as the noble Baronesses, Lady Cox and Lady McFarlane, and the noble Lords, Lord Hunter of Newington, Lord Walton of Detchant, and Lord Smith, all of whom speak from vast experience.
I return finally to the central problem of resources for community care. Without sufficient resources the plans for community care will certainly fail. Sir Roy Griffiths, commenting on the major difference between his proposals and those in the White Paper which are now in the Bill, said: 1381I had provided a purposeful, effective and economic four-wheel vehicle, but the White Paper has redesigned it as a three-wheeler, leaving out the fourth wheel of ring-fenced funding".I can assure the Government that, in regard to community care, as this Bill proceeds through this House we shall be doing our utmost to put that fourth wheel on again.
As regards the National Health Service proposals, we believe profoundly that the market place is a peculiarly inappropriate mechanism for allocating health and community care. We shall be doing our best to inject into the Bill the concept of a public service which is the foundation and bedrock of both the health service and community care.
§ 11.24 p.m.
§ Lord Henley
My Lords, it is many hours since I last rose to respond to a point made by the noble Lord, Lord Carter, at Question Time. It is now eight-and-a-half hours since my noble friend Lady Hooper opened the proceedings on this Bill.
I begin by welcoming the stout defence by the noble Lord, Lord Ennals, of the rights, privileges and prerogatives of this House and by saying that I look forward, as do my noble friends on the Front Bench, to many hours in Committee, on Report and at Third Reading. However, I should stress that many hours have already been spent on this Bill in another place. Two days were spent on Second Reading; 109 hours were devoted to the Bill in Committee and a further 23 hours of debate were spent at Report stage on the Floor of the House. I also join all other noble Lords in congratulating both maiden speakers. I am sure that I speak for everyone in the House when I say that we very much hope that we shall hear a great deal more from both of them, particularly during the very many hours at Committee stage, Report stage and Third Reading which I suspect we shall be having.
It has been a very useful debate. What I have found interesting about it is that there has been much general agreement from all sides of the House. I am not trying to include the two noble Lords on the Front Bench opposite. They were in agreement on some aspects. I think it was my noble friend Lord McColl who said that on about two-thirds of the Bill there was much agreement.
Our proposals for making further improvements to our health service build on this Government's impressive record over the past 10 years. Spending on the health service stands at £ 26–3 billion in 1989–90 and will increase still further to £ 29–1 billion in 1990–91. That represents an increase of 42 per cent. over and above inflation since 1979. Equally important, those growing resources have been well used to fund higher levels of care than ever before. In the 10 years from 1978 to 1987–88 the number of inpatients treated rose by 22 per cent. from 5–4 million to 6–6 million and the number of day cases from 562, 000 to 891, 000, an increase of 58 per cent. Those patients have been treated by a workforce that has been increased to provide better standards of care. There are 67, 000 more nurses and midwives working in the NHS today than in 1979.
1382 These developments over the past 10 years have helped bring about real improvements in the health of the nation.
I have set out this record because I believe it is one that any government would be proud of. There is no more powerful response to the charge that we are not committed to the health service. Our commitment to the founding principles of the health service is the starting point of the reforms we are discussing today. We are convinced that the National Health Service is the right health system for this country. The public affection and support for it is well justified. Our reforms therefore build on and improve the existing National Health Service. To suggest, as the right reverend Prelate the Bishop of Manchester suggested, that we cannot be committed to it just because we also see a role for the private sector, is not true.
Our reforms of the health service and of community care focus firmly on quality. In the NHS, the effect of contract-based funding will be to reward those providers of services who deliver effective, timely and high quality health care. Quality means not just the effective treatment of patients but also takes in a high standard of medical and other staff training and an innovative programme of research. This emphasis on quality is mirrored in our community care proposals where the new role of local authorities as purchasers of community care services will give greater flexibility in arranging care for individuals in the most effective way.
Our reforms strengthen the hand of the user of health and community care services. Health authorities will need to take account of the views of GPs— surely the best spokesmen of the patient— in placing any NHS contracts. Our proposals for GPs to become fund holders will give family doctors the scope to tailor the services they offer to the specific needs of patients on their list. In the field of community care, our aim is to provide a range of services to accord with individuals' requirements rather than to expect them to adapt to existing patterns of care. Our proposals aim to put people's needs where they belong, at the centre of decisions over care provision.
Finally, the reforms in the Bill before the House will help provide a service that makes the most cost-effective use of resources. I cannot be alone in regarding cost effectiveness as a virtue, not a vice. In fact, I am not alone. The point was stressed by my noble friends Lord Carr, Lord McColl and Lord Nugent. As my noble friend Lord Carr said in responding to the right reverend Prelate the Bishop of Manchester, it is not just a duty but a moral duty. It is our duty to make sure that money is used to bring the maximum benefit. Devolving greater responsibility to local level— whether NHS trusts or GP fund holders— will help in this respect. In community care, our proposals will remove perverse incentives which have led to people being accommodated in residential homes when they could be better and more cost effectively looked after at home.
I am not sure that I shall be able to respond to all the points raised by noble Lords. However, certain matters were raised again and again to which I 1383 should very much like to respond. I start with the community care proposals. For some reason our proposals were raised in speeches of noble Lords towards the end of the list of speakers. I do not know whether this was deliberate or happened just by chance, but as the half-way point of the debate passed, I wondered whether anyone would mention community care at all.
The noble Lord, Lord Seebohm, was worried about how little there is in the Bill on the community care proposals. My noble friend Lady Hooper spoke at some length on this issue some eight and a half hours ago. In framing the Bill we have aimed to include only those items for which legislative provision is essential. I have no doubt that if we included everything which has been suggested, the Bill would be nearly as long as the White Paper itself. To have done that would have been severely to have curtailed the freedom of local authorities to plan and manage their own services. We have powers of direction which we can use to reinforce guidance. I prefer to rely on that rather than on writing inordinate detail into the Bill.
Two other items arose in regard to community care. Many noble Lords referred to resources. The White Paper says that the Government recognise that local authorities will need adequate resources to enable them to discharge their new responsibilities. Net expenditure has risen by some 37 per cent. in the 10 years to 1989–90, more than enough, we feel, to allow for the demographic changes. The new funding system will encourage cost effectiveness and accountability. Funds will be transferred from my department, the Department of Social Security, and final decisions will be taken on resources in the public expenditure survey. I am sure that noble Lords would not expect me to anticipate the outcome of that survey but I repeat that the Government recognise more than anything the need for adequate resources.
My noble friend Lady Faithfull was worried that we had not taken into account the fact that local autorities have to look this year both to the implementation of the Children Act and the community care proposals. We have taken account of the agenda facing local authorities in drawing up proposals for implementing the White Paper on community care. This is one of the reasons why we expect an evolving system rather than the big bang, to which my noble friend Lady Hooper referred in her opening speech.
My noble friends Lady Cox and Lady Faithfull, the noble Lords, Lord Seebohm, Lord Hastings and Lord Carter, and the noble Baroness, Lady Seear, all mentioned ring fencing. The Government believe that decisions about community care resources should be made locally by local authorities accountable to their own electorates. There is no suggestion that local authority expenditure on community care has lagged behind that on other services. We therefore do not wish to disrupt a system which seems to be working well. Indeed, our proposals for community care plans and for the 1384 assessment of care needs are designed to make it work better. In short, we see no need to give special status to the community care funds.
The noble Lady, Lady Kinloss, asked why there is a specific grant only for mental illness. We are particularly concerned that local authorities should improve and increase the services they provide for people with mental illness. That does not belittle concern for other groups. But with none of them is there the need for rapid expansion from a low base as there is in the case of mental illness services. We feel that that justifies the specific grant for these services.
The noble Lady, Lady Kinloss, and other speakers, especially, I think, the noble Lord, Lord Carter, and the noble Baroness, Lady Seear, asked about the implementation of Sections 1, 2, 3 and 7 of the 1986 Act. My right honourable friend the Secretary of State for Health has recently agreed that consultations should begin with local authority associations on the cost implications of Sections 1, 2 and 3. In the light of the proposals contained in the White Paper, we have made it clear that we do not intend to implement Section 7 at present.
I refer once again to the question of ring fencing. My noble friend Lord Hastings asked why Wales was to be treated separately in that it was to receive specific grants while England and Scotland would not. The Welsh Office has long had a successful programme on joint health authority plans for mental illness and mental handicap services which are approved by the Secretary of State and supported by specific grant. That model works well in Wales because of the limited number of Welsh authorities. We feel that it is neither practical nor desirable to apply that regional solution on a national scale in England or Scotland.
My noble friend Lord Hastings also raised several points of detail regarding the operation of the new community care arrangements. I am afraid that there is not sufficient time tonight for me to respond to him in detail. However, I, or my noble friend, will write to him, if possible, as soon as we can. In saying that I should stress that we shall of course try to respond in writing to as many points as we can which I am not able to cover this evening.
The noble Baroness, Lady McFarlane of Llandaff, asked about the involvement of community nurses in the community care assessment. Our proposals in this respect clearly envisage that members of all the caring professions will be involved as appropriate. In her opening speech today my noble friend indicated that we hoped to bring forward an amendment which will make clear the fact that local authorities should bring any apparent health care need which emerges in the course of assessment to the attention of the district health authority.
I turn now from the community care proposals to those regarding the National Health Service. I think that I should begin with the issue which I can describe as piloting. This aspect received a great deal of attention during the debate. The noble Lord, Lord Ennals, was the first speaker to raise it and many other noble Lords said that they wished to see pilot studies in two regions. I have received at least some 1385 support in the matter. My noble friend Lord McColl felt that pilot studies in two regions would dragoon the unwilling and exclude the well prepared and enthusiastic.
In regard to GPs and their practice budgets, I should stress the fact that this process is also voluntary. As my noble friend explained in her opening speech, we are taking an evolutionary approach to implementation with pilot projects built into our proposals. That is not the same as an artificial trial in two specified regions. The analogies with clinical trials are, I think, misplaced. The National Health Service is a single whole that cannot be split into its constituent parts for examination. How, for example, would we identify which two suggested trial regions we should use? How would we agree that the results had national validity? I do not believe that this is practical. Moreover, the Government would be failing in their duty as custodian of the National Health Service if they allowed change to be delayed by three years.
The Labour Government of 1948 which I am sure many noble Lords remember rightly put on one side the ca!l of the BMA for the National Health Service to be phased in. They pressed ahead with implementation, learning from experience as they went. This Government are rightly following the same course in pursuing these changes. I remind noble Lords that at that time the then Minister of Health, Mr. Bevan, talked of phasing in the national health proposals as being stupid nonsense.
§ Lord Ennals
My Lords, does the Minister agree that at that time there was enormous public demand for the service? The whole nation wanted to see a health service. It was totally different from the present situation.
§ Lord Henley
My Lords, I do not see that it is different at all. I do not remember because I was not born, but the noble Lord may remember that the BMA fought the proposals of Mr. Bevan.
The noble Baroness, Lady Masham, and the right reverend Prelate asked about chaplaincy services. We appreciate the concern about those services. Chaplains often provide a valuable counselling service in addition to spiritual comfort. It is right that both suppliers and purchasers of the service should take full account of the valuable role of chaplains in planning services for the future. In addition, the Government will look at the future of chaplaincy services in the 1990s, taking account of the changes under the Bill and the wider issues.
The noble Baroness, Lady Masham, also spoke about spinal units. I agree with heron the importance of those units and their work. I assure the House that spinal units and, for that matter, all supra-regional services will be protected by a proportion of the costs being met centrally and the balance regionally. We shall consult interested parties on a system for doing this and will issue guidance in due course.
The noble Lord, Lord Rea, mentioned excessive hours for doctors. He might remember that my first performance at the Dispatch Box was on the Third Reading of his Bill last year. That measure concerned 1386 junior hospital doctors' hours. There is no single solution to this longstanding issue, but I feel that we have made real progress. A major initiative began in 1988. Reports indicate that by September of this year, one in eight juniors will be on one in three rotas, compared with more than a quarter on one in three or even worse rotas before the exercise began. We accept that more needs to be done, but changing the law will not solve the problem. We need a concerted approach.
My right honourable friend the Secretary of State for Health has therefore initiated discussions with representatives of the BMA, the joint consultants' committee and the National Health Service management. These will be wide ranging talks. We want all the parties to commit themselves to a programme of action. This is an excellent opportunity to move forward. I am sure that the House will welcome this further initiative.
The noble Lord, Lord Kilmarnock, in a thoughtful speech, welcomed the prospect of many of our proposals, including some aspects of the National Health Service trusts and funded GP practices. He asked about the whole district trusts. Where these make sense, and the units involved are truly complementary, they will be considered on their merits. The key point will be whether they enhance choice rather than constrain it. As to the family practitioner committee/district health authority mergers, the White Paper saw these as a future possibility. However, in the short-term they would entail significant structural changes and so act as a distraction for all concerned at present.
The noble Lord, Lord Hunter, asked about the practicality of introducing National Health Service contracts. We agree that we have further improvements to make in measuring quality, but we are making progress. Specimen contracts provided as guidance already contain clear specifications on quality. Again, as my noble friend Lady Hooper has said, greater sophistication will develop over time. The development of medical audit will play a part here, and we were pleased to hear of the noble Lord's support.
Finally, I wish to turn briefly to the question of consultation and co-operation between the Government and the professions. The noble Lord, Lord Ennals, alleged that we had not consulted or co-operated with the professions. I agree that co-operation with the National Health Service professions is vital. Since the White Paper Working for Patients was published last year, Ministerial colleagues, senior officials and the Secretary of State have met representative bodies and other groups and leaders of the medical professions on over 100 occasions. Meetings have also taken place with other professional groupings. We have been able to listen carefully to the views of the professions and have taken their points into account in developing the Government's proposals. We are always willing to enter into further constructive dialogue with them about how best to implement our plans. My right honourable friend the Secretary of State has invited representatives of the Royal Colleges for discussion tomorrow.
1387 I appreciate that I have not answered a great many of the points that have been put to me in this long and interesting debate. We are now approaching a quarter to midnight and the debate has lasted almost nine hours. I hope that I have laid to rest some of the misconceptions and assuaged some of the more prominent concerns expressed, but noble Lords will appreciate that we shall have many hours in Committee and at other stages of the Bill to take discussion further forward.
The National Health Service and our social care services have provided a high quality of care over the past 40 years. But it would be a mistake to suppose that they can continue to respond, unchanged, to the constantly changing demands and pressures on them. The provisions in the National Health Service and Community Care Bill seek to build on all that is best in the health and social care services and to create a framework for services that can face the 1990s with confidence. I commend the Bill to the House.
On Question, Bill read a second time, and committed to a Committee of the Whole House.
§ House adjourned at twelve minutes before midnight.