§ 6.20 p.m.
§ Lord Molloy rose to call attention to the pressures on the staff of the National Health Service; and to move for Papers.
§ The noble Lord said: My Lords, I have for almost two decades been closely associated with the Confederation of Health Service Employees. In consequence, I have become pretty well known by 1220 and have known very well the other great national health organisations representing practically all staff. The list is quite formidable. I have been approached by the College of Speech Therapists, the Royal College of Psychiatrists, the Confederation of Health Service Employees, the Royal College of Nursing, the Health Visitors Association, the British Medical Association, the Royal College of Surgeons, the Royal College of Obstetricians and Gynaecologists, the Royal College of General Practitioners and the Royal College of Midwives, all of whose members are experiencing grave pressure together with tension and anxiety which in some cases is bringing about a collapse among staff.
§ All the leaders of those great organisations within our National Health Service have echoed and agree with the words of the General Secretary of the Confederation of Health Service Employees, Mr. Hector McKenzie, when he said that, after 40 years of successful operation, it would be complacent and foolish to believe that the National Health Service would not benefit from some form of reform. Improvements must always be sought for the efficiency and effectiveness of health care and the effectiveness of the service itself. That approach has been accepted by all the organisations that I have mentioned, so it is not just a silly, stupid, anti-government attitude. If they were not concerned about the stress experienced by their members and the tension under which their members work, they would not be worth their salt.
§ The Confederation of Health Service Employees covers nurses, midwives, ambulance personnel, all ancillary staff, mental health nursing staff and other ward personnel. Sir Roy Griffiths' report on community care recommends that there should be a Minister for community care, but the White Paper Caring for People does not say that. Perhaps the noble Baroness who is to reply to the debate will tell us why there is no Minister for community care and why—this is a serious point—the plight of young district nurses in relation to post-operation responsibilities is now becoming exceeding difficult.
§ The Confederation of Health Service Employees welcomes that part of the White Paper which establishes clear responsibility for all people requiring care and support, but it is impossible to fulfil that obligation without sufficient funds. The Confederation simply says therefore "Give us the tools. We have the inspiration and we shall do the job".
§ The Royal College of Nursing and the Confederation of Health Service Employees believe that poor medical equipment is still extant, that there is inadequate overtime compensation for nurses and—I find this point very moving—that there is a lack of support for nurses in their other capacity as mothers. I hope that that point will be considered.
§ The Royal College of Nursing set up a working group to consider the issues concerning our nurses in the National Health Service. It found that certain key areas lead to increased pressures on nursing staff. The Royal College is also perturbed at the fact that patient throughput has drastically increased. In consequence, according to the Royal College of 1221 Nursing, deaths and discharges have increased from 5,400,000 in 1979 to 6.5 million in 1988–89. Many patients are therefore in hospital for a shorter time and are sometimes pushed out almost as ill as they came in in order to fit in with the Government's scheme of abolishing care and compassion and of saving money. That great Christian ideal of the National Health Sevice is now under attack from the Administration. The RSM says that that places great demands and increases pressures on nurses. The more difficult things and more poignant things they have to do increases the pressure. The RSM also says that, as patients leave hospital more quickly due to a desire to increase throughput, in consequence stress on community care becomes very heavy.
§ It is very distressing to have to read something which we can perhaps never understand. A young nurse or doctor may have been looking after a patient in hospital after an operation. That is where the work of the nurse is fundamental; but, because of that policy, the patient may be turned out and may then die. The Royal College of Nursing and the Confederation of Health Service Employees tell me that that is a most shameful effect in this day and age and in this country. When the person who operated on the patient and the person who nursed and comforted him realise that he is dead, it has an effect on the young person whom we call a British nurse.
§ The Royal College also believes that recruitment and training under that system is in jepoardy, yet every 1 per cent. reduction in the wastage of qualified nursing staff would save the National Health Service over £100 million a year. I hope that the noble Baroness, Lady Hooper, will note that point. Many qualified nurses leave the job. They do not want to be nurses any more. They are saddened by and fed up with their sufferings. If we can stop 1 per cent. resigning, that will save £100 million a year. I beg that the voices of the Confederation of Health Service Employees and of the Royal College of Nursing should be heeded.
§ I now turn to the difficult question of the opting out of hospitals in accordance with the Government's two-part strategy to commercialise the National Health Service. The internal market competition plus the existence of independent suppliers will create havoc. All the great organisations believe that the proposal is undemocratic. It reduces patient choice and quality of care. Our National Health Service will no longer be a national service. How many people in each hospital will decide whether to go outside the NHS? The general public have a right to know who will make the decision when a hospital decides to go outside the NHS. The great organisations as well as ordinary people claim that they have a right to know who will make those decisions.
§ Lord McColl of Dulwich
My Lords, does the noble Lord realise that there is no question of a self-governing hospital acting outside the NHS? It will not move outside the NHS. Just because the noble Lord said it three times does not mean to say 1222 that it is true. It is not true. Those hospitals will stay within the National Health Service.
§ Lord Molloy
My Lords, I note what the noble Lord said. I now have to decide between what he has just said and what the Royal College of Nursing and the Royal College of Obstetricians and Gynaecologists said. And there is the recent episode in Guy's Hospital. Perhaps it may help if I read out a statement made by Professor Harry Keen of Guy's Hospital, which was widely reported.
§ Lord McColl of Dulwich
My Lords, Professor Keen has been a life-long member of the Labour Party and has communist connections and he is therefore very much opposed to these changes.
§ Lord Molloy
My Lords, I have been in Parliament for a quarter of a century and that is the most distasteful and disgusting statement that I have ever heard. If anyone in my party were to say, "He has been a member of the Tory Party" it would be a shameful thing to say. I do not know whether the noble Lord has been elected to any office in this parliament but I have never heard any noble Lord say to me that something said is invalid because he is a Member of the Labour Party or the SDP or a Liberal—a member of any party. I have not heard that said before in a very long time.
Let me go on to make my point. It was reported that there was secret junketing at luxury hotels in London. To speed NHS hospitals—and let me say it slowly—to opt out of local authority control (I do not expect an answer from the Minister immediately although I expect the matter to be investigated) at a cost of £20,000 per meeting without knowledge of hospital staff or doctors involved. The Government refused to publish any agenda, minutes or costs involved.
I want to know who did the organising for that junketing. This has infuriated distinguished members of the medical profession, like Professor Harry Keen, who is also chairman of the NHS Support Federation and a consultant at Guy's Hospital. Is it an offence to be chairman of the NHS Support Federation? Is it an offence to be a member of the Labour Party and be a consultant at Guy's Hospital? Thank God! This is not yet a communist country. I am bound to say that all this is somewhat redolent of government inspired hints of some form of corruption or at least sharp practice.
I ask the Government to investigate exactly how such things happened? Are they in point of fact truthful and accurate, as I have stated them? There is enough evidence, I submit, that they are worthy of investigation. In opting out, I believe that there will be an agonising choice. Who will be responsible for the staff? Who will be responsible for the cash? Who will be answerable if there is a shortage of both when that opting out takes place?
1223 If, after opting out, there is no profit, will the hospital be closed down? Will there be competition to win business? Will those hospitals specialise in rich patients and compete for business? There will be a danger of cutting the umbilical cord between professional staff at all levels, management and the Government. Will Whitley Council agreements be abandoned? Despite the great professional service to staff and patients, it would be a sad day if the organsiations could not work together under the principles of the Whitley Council. Can universal and equal care always be available when needed? That is another fundamental principle.
I also believe that there is a danger in the two-tier system. Those hospitals which cannot opt out will become cheap and nasty. Will desperation, pain, illness, fear of illness and worry be allowed to work their way through our National Health Service and into the homes of many ordinary people? I believe that there is a very serious risk of jettisoning the superb organisation that we have for consultation between members of staff and officials in the National Health Service and indeed members of the Government.
Many people say to me that what they find remarkable, if not distasteful, is that so much of this conversation does not go on under the auspices of Mr. Kenneth Clarke in the Department of Health. It all goes on in 10 Downing Street. We want to know why.
The BMA claims to have evidence of enormous opposition to the government reforms of the National Health Service. I do not for one moment believe that every single member of the British Medical Association is a member of a political party, let alone a member of the Conservative or Tory Party. I know them too well. They are too much involved in their great medical association which is world renowned. It conducted a poll in which 71 per cent. of those asked showed disapproval of the Government's attitude to the National Health Service and to their White Papers. The chairman of the British Medical Council, Dr. John Marks—who may be a bad person in some people's eyes but I do not believe that he is—said that the Government should recognise that those untried ideas were very unpopular. That is a moderate statement. He simply wants to know whether the Government will recognise or test how these things are making people unhappy.
Like COHSE and the BMA the Royal College of Psychiatrists say that Working for Patients is an admirable and superb document, but that its interpretation is causing stress and strain. There are doubts about the practicability. It was devised in Downing Street and not at the Department of Health. There is a dangerous deregulation of NHS hospitals. The Royal College of Psychiatrists say that training and research is ignored. Last July it met Mr. Clarke who said that very little could be done but that brochures would be issued. As the Royal College says: man cannot live by brochures alone. It is of the opinion that psychiatric patients need extra care and to enjoy extra protection from the Mental Health Act Commission and the Health Advisory Service.
1224 For the mentally ill the national development board together with the present existing arrangements under the Mental Health Act must work together and be assisted financially. Local authorities do not provide "out of hour" services. That contravenes the code of practice of the Mental Health Act. There is also a need for sheltered housing.
Another organisation with which I have had a great deal of contact is the Health Visitors' Association. It consists of very remarkable people who are devoted—just as are our surgeons, doctors and midwives—to serving our National Health Service. They are concerned at the reductions in staff levels, which result in the threat of health visitors' services being closed. In January this year Greenwich Health Authority suspended all routine health visiting services. The health authorities are not recruiting staff; rather, they are trimming back health visiting services. That is causing great strain and stress among the members of the Health Visitors' Association. Their heavy workloads are increasing, as is what they term burn-out, which results in high staff turnover. They also believe that there is a danger of this act, which is being encouraged by government and some local authorities, being a breach of professional conduct. They want these matters to be looked at. I do not think that that is a great deal to ask the Minister. I hope that he will look into these questions.
The Government want doctors and nurses to be able to cost every single service which they provide right down to the last bedpan. The doctors and nurses say that that is what the Government really want, and that it is a hopeless task to undertake. They want hospitals to be run by a board of directors. They want to get rid of national agreements on pay and conditions of staff. I believe that that would be an absurdity. All the organisations believe it also.
The Government want to create an internal market in which hospitals sell their services to health authorities. People working in the National Health Service believe that that is the last thing that is wanted. Members of all the professions who devote their lives and skills to the NHS realise, as do their patients, that silent pain evokes no response. For that reason they are speaking up now and asking for attention.
Those great organisations make no massive demands. They say merely that they are apprehensive, and they speak with great experience and speak fairly. However, they and I are afraid that we could be witnessing the evaporation of our civilised sense of compassion. That sense of compassion was the envy of the world when Aneurin Bevan created the National Health Service. I hope that it will always be the envy of the world and that other countries will follow. When the British undertake something of such calibre—as in the creation of the NHS—not only does it uplift the spirits of the British people but it becomes an example to all mankind.
§ 6.40 p.m.
§ Lord Walton of Detchant
My Lords, when commenting on the problems which continually beset the National Health Service, members of my 1225 profession are all too often accused of purveying unjustifiable doom and gloom. That is so especially when discussing the recurring financial problems and the seemingly insurmountable difficulties associated with the unremitting pressures upon the staff of the service—the topic which is the theme of our debate.
Whether any of those problems will be alleviated by the provisions of the National Health Service and Community Care Bill is a matter of opinion but the Bill is soon to be debated in your Lordships' House. It would not be proper to consider its detailed proposals today. However, while it contains many provisions which I would warmly welcome, there are others about which I have substantial reservations.
I am one of the many in this country who gladly acknowledge the outstanding achievements of the NHS, especially in the field of emergency care. It is a system of health care delivery operating alongside an expanding private health care system with which it can, if both are properly managed, develop a healthy partnership of mutual benefit. The NHS system is one which I personally prefer to that which exists in many other countries which I have visited and worked in, including especially the United States of America. I visit that country regularly and there is no doubt that, while many aspects of its health care system are superb, many are at present in total disarray. I also fully acknowledge that Her Majesty's Government are now devoting more financial resources to the NHS than did any of their predecessors and that more patients are being treated.
Why is it then that health authorities throughout the country are facing substantial financial deficits in the current financial year which they see no prospect of recouping, even within the increased financial allocation recently announced for the coming year? In consequence authorities such as those in Newcastle upon Tyne and our near neighbour at St. Thomas's Hospital—to quote but two of the many examples—have been compelled to announce substantial bed closures with an inevitable consequential decline in patient care and in the clinical teaching facilities available to the doctors and nurses of tomorrow. And why is it that there are still junior hospital doctors throughout the country who are contracted to work unacceptably long hours, some still involving one-in-two rotas?
The first question is easily answered. Many noble Lords will believe that I am simply repeating, parrot-like, views which have been constantly expressed over many years by members of my profession to governments of all political persuasions. But the evidence is irrefutable: despite its rapidly escalating costs the service has for many years been, I fear, chronically under-funded. It gives wonderful value for money but when we spend only 6 per cent. of our gross national product on health—the figure is quite unacceptable—compared, for example, with about 9 per cent. in France and Germany and 12 per cent. in the United States, it is not surprising that the service is unable to meet the increasing demands and public expectations imposed upon it.
1226 Report after report from the Royal colleges and faculties, which have examined the need for patient services and increased staffing in a wide range of specialities in medicine, have identified serious shortages of consultant posts and of the facilities which burgeoning developments in medical science require and which our patients may justly feel that they deserve. Of course, no developed country, however wealthy it may be and whatever its economic success, can ever hope to provide a fully comprehensive health service offering openly all that medicine and medical science can provide completely free of charge and funded entirely from direct taxation.
But when in this country one enumerates just a few of the remarkable developments in patient care which modern medical science has wrought in a few years—including, for example, nuclear magnetic resonance imaging; kidney, lung, liver and heart transplantation; joint replacement; the crushing of gallstones and kidney stones without surgery; the increasingly effective chemotherapy of many forms of cancer; and the use of DNA recombinant technology in the diagnosis and prevention of inherited disease, all of which are complex, time-consuming and very expensive—it is not surprising that, faced with those competing demands, many health authorities, recognising as they must the need to define priorities when allocating resources, are bewildered, even bemused, by the necessity of having to make painful choices between so many worthy alternatives.
One must also add to that every-growing list the needs of a rapidly growing cohort of elderly people, imposing increasing demands upon the service in our hospitals and in the community; the obvious need to improve the facilities necessary in order to offer screening programmes for cancer prevention and for the care and rehabilitation of handicapped and disabled people; and the very reasonable expectations of the public, some of which are being increasingly reinforced by the threat of legal action if the facilities requested are withheld. They all impose increasing demands upon the service and its staff which cannot at present be met.
I should like to quote only a few examples and first mention my speciality. In the UK there are 178 consultant neurologists practically all of whom carry a totally unacceptable workload of clinical care and responsibility. That is one-twentieth the number of consultant neurologists per unit of the population available in the United States. Even Finland, with a population of 4.5 million, has 400 neurologists. A similar pattern exists in neuro-surgery and in innumerable other specialities in the UK.
In many parts of the country the number of, for instance, cytologists, cyto-geneticists and medical laboratory scientific officers available to examine cervical smears or to help in the pre-natal diagnosis of Down's syndrome, to mention only two examples, are inadequate to cope with the workload.
Of course the list is endless and I accept that the solution is not at all easy to find, especially when staff in all grades, and recently medical secretaries, are being lost to the service in increasing numbers 1227 as a result of the infinitely greater financial rewards they can command in the private sector.
In the face of such a situation it was somewhat less than helpful to read a few days ago that, if he was quoted correctly, the Secretary of State suggested that this year over-spending by health authorities has been due to mismanagement. In fact, financial allocations have failed to supplement fully nationally agreed salary increases for all grades of staff or to take full account of inflationary price increases. Repeatedly, health authorities have been told to find the shortfall from so-called efficiency savings, just as they have so often been told to find the much-needed funding for additional consultant posts, all too few in number, from within their existing resources. And, of course, the unremitting pressures upon junior medical staff in our hospitals simply cannot be relieved by any trick of administrative sleight of hand when the clinical work is there to be done and ongoing responsibility for patient care must be shouldered.
Of course, the problem could be met if the number of junior medical staff could be increased to share the load or if, above all, consultant numbers could be increased so substantially that a greater share of the on-call and emergency duty could be assumed by consultants rather than their juniors. We must all acknowledge that the ability to work long hours when necessary and to offer continuity of clinical care to sick people is an essential part of the training and experience of young doctors. However, such prolonged periods of unremitting responsibility must not occur too frequently and must be compensated by adequate periods of rest and relaxation if powers of concentration and working efficiency in the face of all the arduous demands of modern medicine are to be maintained.
The problem cannot be solved by increasing the numbers of registrars and senior registrars. For as long as overall consultant numbers in the service are unfortunately constrained in the face of increasing demand through financial stringency and lack of facilities, registrars must be reasonably assured of being able to succeed eventually to a consultant vacancy.
Recent surveys and my own personal experience have clearly demonstrated that NHS consultants are for the most part working much longer hours than the hours for which they are contracted. If their numbers were very substantially increased and the facilities were available for them to carry out the work which they have been trained to do, I know that they would willingly do what they could to reduce the hours being worked by their juniors. An increase in the number of registrars being trained to fill the increased consultant vacancies then available would follow with further sharing of the clinical load.
Therefore, whatever the outcome of our forthcoming debates on the NHS Bill, I am afraid that in the end it comes down to a question of money. We need many more consultants as well as staff in non-medical grades in our NHS. Health authorities need to be able to plan ahead with an assurance from central government that nationally agreed salary increases will be fully supplemented, 1228 as will the inflationary price increases for food and supplies.
In my view it is essential that some of the increased financial allocations, for which I recognise fully that the Secretary of State has had to fight very hard should be made available to fund much needed new developments instead of being used simply to plug the yawning gaps which some previous chronic underfunding has created. A new baseline or starting point is, I believe, necessary.
I know full well how bitterly the Treasury is opposed to any form of earmarking of income from taxes, but how I wish that we could have an index-linked income-related health tax to establish a much firmer financial infrastructure for our service. I believe that, if fully informed, the British public, who are deeply concerned about the NHS, might well accept that. Can we not find a means of revitalising the technique of funding, both in the short term and long term, our much-loved National Health Service in order to relieve the pressures which for many years the staff have shouldered cheerfully and willingly? I fear that the signs of growing frustration leading all too often to the resignation or early retirement of invaluable members of staff are all too readily evident at present.
§ 6.53 p.m.
§ Lord Auckland
My Lords, two subjects have been debated in your Lordships' House on frequent occasions over the past decade or so. One is the National Health Service and the other is transport. I do not believe that your Lordships' House need make any apologies for that because they are both vital subjects.
The wording of this Motion poses a number of difficulties because I venture to suggest that ever since 1948 when the National Health Service came into being there have been pressures on it. Admittedly today we are treating some 50 million people under our National Health Service, and when tourists come here that number is frequently increased. Therefore, I believe that when we consider this Motion we must put those figures into perspective.
We have here two problems: diagnosis and cure. It is not difficult to diagnose pressures on staff in the National Health Service. It is not difficult to diagnose pressures in many walks of life nowadays. Cure is much harder. There are pleas for more money to be injected into the National Health Service. I do not quarrel with that but I believe it is fair to point out that more money is now being injected into the National Health Service than at any other time and more patients are being treated. The real problem is where that money is going. That is one of the problems which we shall debate when the legislation on the White Paper is before your Lordships' House in the next few months. I do not propose this evening to embark upon a discussion on the White Paper. I believe that that is for much closer discussion and scrutiny which your Lordships' House will have a duty on all sides to give to that White Paper.
In the 31 years which I have spent in your Lordships' House I shudder to think how many 1229 Royal Commissions, Blue Papers and Yellow Papers there have been on the health service, chaired by very distinguished and well-meaning people. The real tragedy is that, under all governments, not a great deal always emanates from that. I believe it is fair to say that in 1990 all parties are committed to the National Health Services. I do not believe that there can be any argument about that. Like most noble Lords, I have family concerned with the National Health Service. My youngest daughter is a staff nurse and I had an uncle who was secretary of Kingston Hospital when the National Health Service came into being. I am the president of the friends of our local hospital in Surrey. In fact, I should have been at a meeting there this afternoon but I felt that this debate was more important.
I was interested in the observations which the noble Lord, Lord Walton of Detchant, made about Finland because that is a country of which I have some parliamentary knowledge, and I am involved in non-financial business there. I have visited no fewer than five hospitals in Finland: two in Helsinki, one in Tampere, one in Rovaniemi, and one in Kemijärvi. I was with a parliamentary delegation to Kemijärvi. We asked about certain pressures there. There were some 35,000 people on the waiting lists. There was a 12-month waiting list for a hernia because there is a big paper mill nearby. There are the usual problems of a place which is 300 or 400 miles from the capital city as regards referrals. Requests are made for referrals to Rovaniemi but in fact cases are referred to Helsinki.
I have been to Australia, New Zealand, the West Indies, Scandinavia and Eastern Europe. I always make it my duty, if I can, to visit a hospital in those countries to see what happens and to try to talk over some of the problems and pressures they have. I believe it is true to say that there is not a country in the world where there are not pressures on the health service. There are staff shortages, nursing shortages and, not so much in the cities but in the rural areas, shortages of doctors because everybody likes to gravitate to the capital city.
I do not believe that that problem is necessarily confined to this country. However, turning to this country, I recently visited one of the leading London teaching hospitals in the company of the head of the anaesthesia department of that hospital. We found some disturbing factors there. The dialysis unit is threatened with partial closure because it cannot obtain trained staff. There is a shortage of technicians—I think that is the correct word—for the operating theatres and operating lists have had to be cut. Those are some of the problems experienced by a London teaching hospital. In the district hospitals the situation is more serious. Again, the diagnosis is easy; the solution is much more difficult.
I should like to put to my noble friend the Minister a question of which I have given notice; it specifically concerns teaching hospitals. The cost of housing in London and the South East is very high—that remark may be a masterpiece of simplicity. However, housing costs are a positive disincentive to finding staff, particularly those who are married with young children. Perhaps the Government could look 1230 seriously into this problem, because I believe that waiting lists could be cut if staff could be found. It is not an easy matter. There are professions other than the health service which have similar problems.
Health is vital. I believe it is absolutely essential that something is done to prevent the shortage of trained technicians in, for example, kidney dialysis units. I speak with some experience because three years ago I had my gall bladder removed, under the health service, in my local district hospital. I was in hospital for nine days. At the same time my brother had a kidney transplant in Glasgow Royal Infirmary. He was in hospital for seven days. Those in this House who are doctors will know full well how long we would have been in hospital 10 years ago. We therefore have to see in proportion the considerable advance in techniques in medical treatment, the many more people being treated and the pressures which are put on the doctors, technicians and nurses as a result of the need to master new equipment. That is where the pressures lie, and they will lie there under any government.
It is very unfortunate that the health service has become embroiled in the cockpit of party politics. I have always felt that. It is inevitable, but it is sad because one party can vie with another as to the number of hospitals it will build and how many nurses it will recruit, but the old lady waiting for her hip replacement operation will not thank a Labour Government, a Conservative Government or any other government if politicians squabble. We are all to blame.
It is all too easy to diagnose pressures and analyse why they exist. One only needs to walk round a hospital to recognise them, let alone work in it or be a patient. Last year there was a television series concerning two hospitals in Portsmouth which showed the enormous strains under which the junior doctors worked. I hope that the review of junior doctors' working hours is carried out rapidly. Again, it is not an easy problem to solve. It is easy to diagnose, but not so easy to cure. However, it is a matter of urgency.
Perhaps I may say in conclusion that the cures are not easy, but unless something is done with regard to waiting lists and recruiting suitable staff for these hospitals the problems will escalate.
§ 7.5 p.m.
My Lords, I rise to speak as one of the National Health Service hospital patients who has not yet died, despite the harrowing conditions so graphically described by the noble Lord, Lord Molloy. I say to the noble Lord at once that I experienced those conditions and will return to them in a moment.
It is the first time in my experience in a debate such as this that I have found more speakers below the line on the speakers' list than above it. There are reasons for that. In this Chamber we have debated the National Health Service so often recently that noble Lords are reluctant—and rightly so in my opinion—to rise and repeat the same points over again. I share that reluctance and shall try not to err in that direction.
1231 That dilemma should not be regarded as implying any criticism of the Motion of the noble Lord, Lord Molloy. The noble Lord, Lord Molloy, has been indefatigable in raising the problems of National Health Service staff, particularly nursing staff, but we are now asked to look at the problems of all staff. They all have problems and all work under intense pressure. Indeed, as the noble Lord, Lord Auckland, implied, in the early years the National Health Service only kept going because of the dedication and devotion to duty of its staff, who were under intense pressures in those days. However, times have changed. I suspect that dedication to duty alone is no longer an adequate motivation for the maintenance of the service as we would wish to see it.
I do not intend to say anything about the National Health Service and Community Care Bill, save that uncertainty about its provisions has been and is being demoralising to all staff, particularly as many of them do not have much say in how the provisions of the Bill are to be implemented. For example, the decision as to whether a hospital is to opt for self-governing status rests almost wholly with senior consultants. They are probably the people who know best, but the outcome of a decision to opt out or stay in is, in my opinion, likely to be very much better if all staff play some part in the decision process.
As many noble Lords know, I recently spent some time in one of our major teaching hospitals, the Manchester Royal Infirmary, where I was trained and in which I had a carcinoma removed—successfully, I hope—and treatment for a neuralgic condition, which condition has left me with a minor speech defect, in respect of which I crave noble Lords' indulgence.
The Manchester Royal Infirmary has no choice but to opt for self-governing status. That is my opinion. I may be wrong; I have been wrong before. I was wrong when I said to your Lordships three years ago that the best way to improve morale in the National Health Service was once again to appoint a single Minister of Cabinet rank to be responsible for the health service and nothing else. We now have one, but morale has not gone up; it has gone down. I have been wrong before and I may be wrong this time.
The Manchester Royal Infirmary—a hospital with a wonderful history—has produced some outstanding people; Sir Geoffrey Jefferson, Sir Harry Platt, the late Lord Platt, and many people who have made a major contribution to medicine. However, the hospital at the moment looks like a battlefield. The old and dilapidated hospital is being demolished while the new one is erected within it. Because of staff shortages and other difficulties all sorts of odd devices are employed to get by. For example, they have things called "week-day wards". I was in one. It is a ward where everybody is sent home on Friday, if they are fit to be sent home, and then brought back on Monday. If they are not fit to go home they are put in another ward for the weekend—a ward where no one knows anything about them at all. I 1232 was left on my own in splended isolation with no one within 100 yards of me.
I was not receiving preferential treatment. I do not believe that I ever do receive it. Indeed, it might be useful if I told your Lordships of my wife's experience many years ago when she attended a National Health Service hospital for a minor operation. She was in a National Health Service bed. I was a Member in another place at the time. A battleaxe of a hospital sister told my wife, "Mrs. Winstanley, it is no good expecting special privileges because your husband is an MP". Quite rightly my wife said, "I would not dream of asking for them". About two hours later the same battleaxe of a sister came to my wife and said. "Oh, Mrs. Winstanley, I did not know that your husband was a doctor. We are putting you in a side ward". Surely that says something about the pecking order in the National Health Service!
My experiences in hospital have left me with the impression that all staff are under intense pressure and that morale might be better if so-called junior staff had a little more say in what is happening now and what will happen under the Bill when it becomes an Act. We have that extraordinary example of a ward being emptied at the weekend, with patients being put into another ward. The nurses loathed it. I am not suggesting that it could be avoided. That hospital, as I said, is in a terrible situation. I believe that it could be restored to a different situation but—and this is my personal opinion—it will need to opt for self-governing status. That is an argument for another occasion.
I return specifically to staff. We have spent much time in your Lordships' House debating the Bill presented by the noble Lord, Lord Rea—the Junior Hospital Doctors (Regulation of Hours) Bill. A fat lot of good that did us, or indeed the junior doctors. Frankly, the situation is unchanged though I understand that there is hope on the horizon. I am told that a conference is to be held for all interested parties sometime before Easter. I believe that that conference has been announced by Mrs. Bottomley. I hope that when the noble Baroness replies she will be able to say a little more about the conference and whether we may hope for any solution.
I recall the late Lord Trafford saying not long ago in this House that there was no reason for junior hospital doctors to work these absurd hours and if they did the fault lay with the consultants. Lord Trafford was wrong. The consultants could help but the noble Lord, Lord Walton, is absolutely right that there are not enough consultants. Unless we have more, that problem of ever-lengthening junior hospital doctors' hours will remain with us virtually for all time.
When the noble Baroness gives the House some news on that aspect perhaps she can also say something about the present situation in regard to the recruitment of hospital social workers. These are very important people indeed. I remember raising the matter in this House with one of the predecessors of the noble Baroness, when hospital social workers were not being recruited because of a dispute between the Department of Health and the various 1233 local authority associations regarding an agreement about sharing of costs. Where are we now in that regard? Unless we recruit and retain sufficient hospital social workers there is no doubt at all in my mind that the burdens on the citizens advice bureaux, which we debated earlier today, will be doubled. I hope the noble Baroness will be able to say something about that.
I now turn to a group of workers that is too frequently overlooked; but not overlooked by the noble Lord, Lord Walton, I am delighted to say. I refer to hospital clerical staff and medical secretaries. Many are so overworked and underpaid that they leave. When staff are pushed almost to breaking point—perhaps it would be more apt to say leaving point—surely the time has come to take action.
The problems within the National Health Service in regard to secretarial services are little publicised but are of great concern. The market for secretaries must be as close to a perfect market as any, but with the NHS offering salaries between 30 per cent. and 50 per cent. below the commercial equivalent it is hardly surprising that the service finds it hard to recruit and retain competent staff for long. Newly trained secretaries may stay for six months or so, until they have enough experience to command much higher salaries elsewhere. Large amounts of money are wasted on continuous advertising for staff.
More regularly, posts are simply not filled. Some organisations in the NHS scrape by by using up to 80 per cent. of temporary secretaries. An NHS salary intended to pay for 36 hours of secretarial work each week is, however, sufficient only to pay a temporary secretary for 20 hours. The result is either massive overspend on budgets, and therefore cuts in clinical services, or a secretarial staff that is far too small to carry out the demands made on it. That is coupled with much more highly paid staff, such as consultants, having to hand write letters and carry out other duties which should be done by the secretaries they do not have. If general practitioners cannot get letters from consultants about patients whom they have referred to the consultants, then general practice will be in great difficulties. That situation must be remedied.
Having mentioned general practice, perhaps I should say a few more words about it before I sit down. My wife is presently suffering from shingles. Your Lordships will gather that my family is a heavy burden on the National Health Service at the moment. Hard luck; I have done enough for the service in the past. I am not revealing any improper clinical details or breaching professional confidentialities because my wife is not my patient. The general practitioner whom I called in—a very able chap who was a trainee with me a long time ago when he first started—examined my wife and confirmed my diagnosis. He prescribed some extremely expensive tablets. When I looked at the cost of them I thought that if I had shingles I would rather have the money than the tablets.
I asked him how he justified prescribing such tablets. He did so by saying that, as I knew—I had not forgotten—one of the dangers of shingles is the 1234 development of what is called post-herpetic neuralgia. It is a condition which can continue for years afterwards. It is hoped that treatment early enough with these anti-viral preparations will substantially reduce the incidence of post-herpetic neuralgia. If so, it will save the National Health Service a great deal of money, but the prescriptions are expensive.
It is intolerable that in the future general practitioners will have to wrestle with ambiguities of that nature; working out how to balance the benefits between one course of action and another. Again, that is an area in general practice where there is a great deal of uncertainty. The general practitioner who treated my wife said to me, "Tell your pals in the House of Lords that there are three kinds of general practitioner: those who have just come in and wish they had not; those who have been in for years and are now getting out; and all those in the middle who have no idea what to do".
There is a decline in morale among general practitioners, partly because of uncertainty about the way the new deal is to be carried out. It is a pity there has to be so much uncertainty. The noble Lord, Lord Ennals, well knows that before the new Bill there were provisions to deal adequately with extravagant prescribing. They existed. They were never used properly and never enforced. We do not need this new mechanism of budgets.
And they cost a lot, my Lords, as the noble Lord said. That is another aspect that must be considered.
I conclude by saying that all people who work in the National Health Service are under intense pressure. They always will be. The noble Lord, Lord Walton, is absolutely right—at the end of the day it comes down to money. Not enough is being spent. Every week we are told that more money is being spent and I believe that, but it is immediately apparent from looking at some of the old hospitals that not enough money is being spent. The Government cannot get away from that. Do not ask me where they will get the money, but they must get it somewhere.
§ 7.19 p.m.
§ Lord Ennals
My Lords, I first thank my noble friend Lord Molloy for introducing the debate. He is a great campaigner for the National Health Service and he should receive the credit that he deserves.
I also want to refer to other speeches. I should like to say a few words about the noble Lord, Lord Auckland, who said he has been in this House for 31 years. His service to the NHS has been over a longer period than that. It is quite remarkable that whenever your Lordships are debating health the noble Lord, Lord Auckland, is with us. I pay my tribute to him as I do to the noble Lord, Lord Winstanley. It is courageous of him to be back after the treatment that he has had. We are glad to see him well again. He is much better than he thinks he is. He owes a great deal to the National Health Service and he is a dedicated supporter of it.
1235 I wish to say a few words about the noble Lord, Lord Walton, because he is a new boy among us. I believe it was a very wise decision to bring him to your Lordships' House. He is a very distinguished neurologist who is known throughout the world. From the moment that he took his place here he showed that his concern is to put his experience at the disposal of your Lordships on every occasion when he can and when we need it—and long may it be so.
I partly said that because I wish I could say the same for the noble Lord, Lord McColl. When he made his maiden speech, I had the opportunity of congratulating and welcoming him and saying that I thought he would add enormously to our debates if he were here and able to enlighten them with his experience. In the past two debates he has intervened without making a speech. It may be that he regrets doing that, but I believe that the House regrets it even more. I told the noble Lord that I was going to make these remarks in his absence. I plead with him to put his experience, knowledge and wit at the disposal of your Lordships by a considered presentation. It cannot be a considered presentation if one lambasts a colleague by referring to his supposed political origins. That is not a quality which we expect in your Lordships' House.
As has been said, this debate is not about the Bill, though a good deal of reference has been made to it. I wish to follow up one or two of those references before coming to the main subject. It will not be long before you Lordships will be occupied with debates on this extremely important Bill. Whether or not an action was effective before the courts, I find it very unfortunate that before the Bill has been debated in your Lordships' House even for one day, preparations are being made to impose it on the National Health Service, on the professions that work in it and on the public who benefit from the service. That is before the Bill has had parliamentary consideration.
My noble friend referred to what he called secret junketings in NHS hotels. I shall not go into the details of that. However, I find it very distasteful that people who are not part of the National Health Service gather together in conferences, sometimes in hospitals or hotels—certainly at large expense—planning what is going to happen when proposals which have not yet reached your Lordships' House are carried through. That is wrong and it is showing a gross disrespect to Parliament and our system of debates.
It is true that the Bill is before the other place and that it will get here, but as each day goes by more decisions are being taking by groups of people who do not want their names known. They are known as non-executive helpers and people who have been chosen to run opted-out hospitals when the Bill is fully implemented. These measures have not yet been approved and they are opposed by many people in the country. We saw the opinion polls published only two days ago. A Gallup poll based on scientific evidence showed that the public are even more opposed to the Government proposals than when its views were last sought. That opposition is affecting 1236 morale in the health service and it is part of the condition under which people are now working.
It is leading to dissent and not just to uncertainty as referred to by the noble Lord, Lord Winstanley. Dissent is being shown by colleagues who oppose each other, and there has been an example of this in a brief and unfortunate intervention earlier in this debate. Morale is very low and that is partly because of all the uncertainty and the feeling that views are not being considered but pushed aside while decisions are taken in offices and elsewhere. It is not a question of sandwiches in smoke-filled rooms, but decisions taking place in pretty plush hotels.
My noble friend Lord Walton referred to some of the conditions. He referred to junior hospital doctors and to the tremendous pressure under which they work. I am glad that he did so. He also referred to the shortage of consultants. Speaking from my own experience, I agree with him. Consultants are working under very difficult conditions, and they are often working very much longer hours than they are paid to do. We owe an enormous debt of appreciation to all those in the National Health Service. I refer to the doctors and the nurses who provide about one-half of all those who work within the service. In addition, I refer to the professions allied to medicine such as the occupational therapists, physiotherapists, speech therapists, radiographers and chiropodists besides all the others who play such a vital role in the National Health Service.
I have been looking at the evidence put forward to the review body in support of the pay claim for nursing staff, midwives, health visitors and other professions allied to medicine. It is clear that there was worry about the staff turnover. Paragraph 23 of the evidence shows that the turnover rates in 1987–88 ranged from 10.6 per cent. in radiography, to 19.5 per cent. in physiotherapy. Those figures relate to each year. I know of the tremendous pressure to which occupational therapists are subjected. They are now operating at roughly 20 per cent. below their establishment figure because not enough training provisions have been approved by the Government. The independent report prepared by a commission of inquiry headed by Louis Blom-Cooper said that in its view there needed to be an 80 per cent. expansion in occupational therapy in order that it may fulfil its roles in hospitals, with the local authorities and in the community. All of the bodies in the supplementary professions are working under very hard conditions.
My noble friend referred to poor conditions in health service premises. That is part of the evidence submitted by the Royal College of Nursing. Most health service premises are old and rundown buildings. Approximately 81 per cent. of NHS buildings in England were built before 1918. Poor maintenance of NHS property has become endemic throughout the United Kingdom.
A report prepared by the National Audit Office and published in March 1988 states that it is evident that the backlog of maintenance remains a serious problem. It is estimated that £2 billion will be required to clear the backlog of maintenance just in 1237 England. The report criticises the DHSS for having very little centrally-held information as to the present state of NHS property. The evidence refers to poor medical equipment and that much of it in NHS hospitals is dangerously outdated. There is also reference to the lack of childcare facilities with too few creches in NHS offices or childcare facilities for older children after school or during school holidays.
When we say that we want the nurses with their experience to return to the hospitals, the problem is that the conditions under which they would return are grossly inadequate. The nurses with their experience and skills will not return to the NHS unless conditions for them are very much better.
The professions supplementary to medicine are concerned about the importance of pay in connection with recruitment and retention. The staff side said that action must be taken to ensure that the professions remain competitive in the labour market and that this action must include further substantial pay increases. We are seeing skilled people trained by the health service going to other better paid jobs. We saw during the five month ambulance dispute enormous sympathy in the country for ambulance workers. The Government constantly said that they had to keep their pay down to the 6.5 per cent. awarded to other health service workers.
Another of our Sunday newspapers published a report last weekend which showed that Britain's top chairmen and chief executives had awarded themselves salary increases of nearly 28 per cent. over the past year—almost four times the rate of inflation. The report said that a survey of 250 leading companies carried out for the Sunday Times by P-E International management consultants showed that in the year to the end of January the highest paid executive in each of the 250 companies averaged £221,000 a year or 27.8 per cent. above the previous year's level. The report gave one or two examples, including Members of your Lordships' House, whom I shall not mention in their absence.
The staff side said in its evidence to Sir James Cleminson that it had never claimed that better pay was the only factor in recruitment and retention. It recognised the importance of non-pay related benefits, particularly if the substantial number of qualified staff not working in the NHS were to be attracted back. The staff side gave several examples: the opportunity for part-time work, the possibility of part-time staff retaining their grade skill levels; the opportunity for retraining. It concluded that the most immediate need was a substantial uplift in salary levels. If the Government are to pursue a policy which requires of those who work in the National Health Service great restraint on their demands for a higher share and a share at least as high as inflation, we must expect them to give a lead to the country in the private sector as well. Poor working conditions are relevant to the problems faced by health service workers.
The Minister should take seriously the views expressed by health service workers up and down the country. I return to my first point. The problem concerns not just their working conditions. It is not 1238 simply money, although at the end of the financial year wards and beds may have to close because of under-funding. What is important to them is that their views should be listened to. Nothing is more important in the National Health Service than that those who work in a dedicated way for it know that their work is appreciated not only in terms of the pay they receive but by their views being listened to. I have never known a time since the National Health Service was created when the views of those who work for the service were more obviously rejected—not just not accepted but rejected.
The Government are heading for grave problems if they carry on thinking that they can run a National Health Service on the basis of policies which are not accepted by the vast majority of those working in the service. Each time I have the opportunity, I say to the Government, "For heaven's sake, think again". Otherwise they will create not only worse problems for the health service but, as they seem to be doing, worse problems for themselves. Last weekend I was in central Staffordshire campaigning for the mid-Staffordshire by-election. Although on the doorstep all kinds of other issues such as the poll tax were raised, the health service was still the number one issue in people's minds from a long-term point of view. If the Government take any action to undermine the principles of the National Health Service, they will live to regret it-I do not know whether they will live to regret it, but they certainly will regret it.
§ 7.35 p.m.
§ The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)
My Lords, I am glad of the opportunity to debate this topic because, despite some of the allegations, we believe that we have a record second to none. This is proved by the fact that we now have more doctors than ever before, more nurses than ever before, and, most importantly, a higher proportion of people involved in direct patient care. I say straight away—and in saying this I take seriously the views of health service workers—that I acknowledge that there are pressures on staff. Indeed, there are bound to be in any large organisation. The National Health Service after all employs nearly 1 million staff and has gross expenditure this year of more than £26 billion. It is therefore no exception to this rule. However, we should not necessarily assume that all pressures are a bad thing. They can offer a stimulus to the achievement of greater efficiency and effectiveness. I believe the cash limit to be a discipline of this kind.
The Government's role is to create the overall climate in which adverse pressures can be avoided wherever possible. That is what we have been doing. This year's spending on the National Health Service is more than 38 per cent. higher in real terms than in 1988–98. Next year this figure will rise to 46 per cent. and we shall be spending more than £29 billion, some 12.75 per cent. of all planned government expenditure. Spending in 1990–91 will therefore be some £3 billion higher than this year, more than 6 per cent. higher in real terms.
1239 While on the subject of health service funding, I feel sure that we shall almost inevitably always be in a position in which we could do more to keep pace with improved technology and techniques and the need for modern facilities and equipment. I hope that our health service progresses in such a way that we are always running after and, it is to be hoped, catching up. But the additional funds the Government have provided are intended to be sufficient to allow services to be increased by more than would be needed simply to keep pace with the growing numbers of elderly people, a point specifically referred to by the noble Lord, Lord Walton. The question whether this is enough assumes that the demand for health care is a fixed figure that can be measured. That clearly is nonsense. I see that the noble Lord shakes his head as well. What is important, however, is that the extra funds provided show the priority the Government have given to health service spending within public spending generally.
In connection with allegations of service cuts due to underfunding, health authorities have higher allocations in cash terms than in 1988–89. Some managers have perhaps not been effective under the current system in controlling costs and planning increases in patient care. This demonstrates the need for the reforms proposed in the White Paper Working for Patients. The reforms will enable managers to match more closely increases in resources with improvements in services.
§ Lord Ennals
My Lords, before the noble Baroness leaves the point, has she any comment to make on the morality of proceeding to implement proposals that have not even been debated in your Lordships' House?
§ Baroness Hooper
My Lords, I believe that the noble Lord is referring to the National Health Service trusts. I should tell him that I shall be dealing with them shortly.
I am most grateful to the noble Lord, Lord Molloy, for acknowledging the need for change in his opening remarks. Obviously organisational change always brings with it a certain element of pressure. However, if the changes represent much-needed improvements I believe that the price is worth paying.
The National Health Service and Community Care Bill is currently being considered in another place and no doubt your Lordships will shortly have an opportunity to debate it, assuming that it completes its passage there. The Bill provides for the basis of the new arrangements which are intended to be in place by April 1991.
In implementing our proposals we are aiming for a steady, purposeful, evolutionary period of change during which we all shall, it is to be hoped, learn the practical lessons of experience. To make sure that the improvements are made in the most effective manner we are funding and promoting a great deal of development work within the National Health Service to identify the best ways of putting our plans into operation.
1240 I should point out that the funding and promoting of some of the development work which is taking place is something which has been urged upon us by representatives of the medical profession who wish to have some projects in order to plan the proposals carefully. I can assure your Lordships that the implementation costs will not be at the expense of patient care. This year we have made available £80 million for arrangements which could lead to implementation and next year the additional expenditure will be of the order of £300 million. However, in saying that, I should like to emphasise that the need to have an evolutionary system with practical experience is the criterion in making these arrangements.
The current structures have served us well in the past but, as many people recognise, they are becoming increasingly out of date. Change is essential if the NHS is to be prepared to face the ever more insistent demands of medical progress and demography. I am confident that health service staff will wish to grasp the new opportunities the Government's plans will present—opportunities to have a much greater say in the management of services and the decision-making process. I agree with the noble Lord, Lord Winstanley, that staff should be able to exert more influence. I believe that as a result of our proposals they will be able to exert more influence than ever before in the way in which National Health Service resources are used at local level.
Our plans will end the nonsense by which those clinical teams which should provide the most sought after services are unable to secure the necessary resources to operate to full effect. Why should a popular surgeon have to stop operating in the last few months of the financial year because he has been too sucessful and therefore used up his budget? Success, not failure, will be rewarded in the future. Such changes can only inspire all staff to aim to provide the very highest quality of service for patients and thus enhance their job satisfaction. The Government and National Health Service staff have one overwhelming objective—that is, to give the very best standard of service to all patients, a service which upholds the very finest traditions of the NHS and, above all, puts patients first.
While on the subject of the proposals, and in order to remove some of the uncertainty complained of, I should like to make it absolutely clear, especially to the noble Lord, Lord Molloy, that we have no intention of privatising the National Health Service. National Health Service trusts will be an integral part of the service and of the local health authority's provision. I find it most strange that the court proceedings concerning Professor Harry Keen were mentioned. They made it absolutely clear that the Government were in no way abusing their constitutional rights in making the kind of preparations to which I have already referred.
§ Lord Ennals
My Lords, I am most grateful to the noble Baroness for allowing me to intervene at this point. I do not understand how she can say that what is proposed is not designed to privatise. I say that 1241 because paragraph 14 of Schedule 2 to the community care Bill reads:According to the nature of its functions, an NHS trust may make accommodation or services or both available for patients who give undertakings … to pay, in respect of the accommodation or services (or both) such charges as the trust may determine".In other words, they can sell all of it. Surely that is what privatisation is.
§ Baroness Hooper
My Lords, the reason we are not in any way privatising by introducing the concept of National Health Service trusts is that those units of the health service which apply for that status will do so on the basis that they continue to receive their funding from government. The flexibility which will allow them to have a certain number of private beds in no way suggests that it will be the end of the National Health Service provision for those units. The Government have already made much-needed changes in the structure of the National Health Service workforce. Perhaps I should point out at this stage that we shall shortly have plenty of opportunity to debate the Government's National Health Service proposals.
I return to the subject of this debate. Between 1979 and 1988, as I have already said, the numbers of direct care staff increased by 15.7 per cent. while support staff were reduced by 14.4 per cent. We believe that that is an important trend. I am also very conscious of the need to improve the education and training of staff. In that respect I agree very much with my noble friend Lord Auckland and with the noble Lord, Lord Ennals. A number of initiatives have already been undertaken in this connection; for example, the health care assistant initiative which was announced in January.
HCAs will work in support of professional staff and for the first time they will receive nationally recognised vocational qualifications. We envisage that they will undertake some of the more routine tasks currently being carried out by the professionals. This will have the advantage of releasing professional staff to devote more time to the particular activities for which they have been specifically trained, while at the same time improving the job content and consequently the job satisfaction of those working in support roles. We also have the Project 2000 plans to meet nursing care needs in both institutional and community settings and help to reduce the high wastage of nurses both during and after training.
In relation to nurses I should tell the noble Lord, Lord Molloy, that the pay of nurses and midwives has increased by 43 per cent. in real terms since 1979. The total number of nursing and midwifery staff increased by 13.2 per cent. between 1979 and 1988 and since August 1988 we have been running a recruitment campaign to attract suitably qualified and motivated individuals to the career opportunities offered by nursing.
As regards junior doctors' hours, I should say to the noble Lord, Lord Walton, that the Government remain committed to their long-term objective of an average of 72 hours per week. My honourable friend the Minister of State, as the noble Lord, Lord Winstanley, reminded us, is pursuing the subject 1242 with all the parties concerned. I can assure the noble Lord that we are hopeful of a successful outcome in the matter. I also say to the noble Lord, Lord Walton, that consultant expansion has been over 2 per cent. in 1986–88 alone. I refer to the scheme to fund 100 new consultant posts at £50,000 per post. The first two tranches of these appointments have already been made and we believe that this will help in the fight to cut waiting lists.
An organisation of the sheer size of the National Health Service will inevitably experience some recruitment and retention difficulties. I was glad to hear the noble Lord, Lord Ennals, say that pay is not the only factor in this respect. Nevertheless the Government believe that they can help to reduce these difficulties concerning pay by breaking away from rigid central bargaining in favour of greater local pay determination. We want local managers to be able to use pay as a recruitment and retention tool. The White Paper envisages that National Health Service trusts will have freedom to depart from national pay arrangements, but they will not be forced to do so. We are aiming to build sufficient flexibility into the mainstream National Health Service system to enable it to operate alongside National Health Service trusts. Indeed some trusts may decide simply to follow the national agreements, provided that they have been made sufficiently flexible.
A number of agreements with flexibility provisions have already been introduced. There are relatively new arrangements giving local discretion to supplement the pay of administrative and clerical staff by up to 30 per cent. in Thames regions and 20 per cent. elsewhere. We shall be monitoring the effect of this change. In 1989 some 7,000 nurses and midwives outside London received supplements under a pilot scheme for flexible pay. That scheme is to be continued for 1990 and extended to nurses and midwives in London. Other staff such as senior managers can be paid additional amounts where there are recruitment and retention difficulties. We aim to extend the concept of pay flexibility to other staff groups during 1990–91 so that local managers have much greater scope to manage their affairs effectively.
I believe that local management needs to be increasingly imaginative in the way it responds to the varying requirements of existing and potential employees. There is a decreasing number of young people coming on to the labour market and the demand for skilled employees will become acute as the National Health Service finds itself in direct competition both with other UK employers and with major employers in the rest of the European Community. Our plans must take account of the fact that almost 80 per cent. of the National Health Service workforce is female.
I would say that the National Health Service management executive encourages health authorities to adopt and implement equal opportunity policies covering not only women and people from ethnic minorities but other disadvantaged groups including disabled people. The Government have for a number of years been encouraging more open employment practices in order to secure, retain and encourage 1243 scarce, skilled staff back to work. These practices include the availability of flexible working arrangements such as part-time working, job sharing, flexi-time and the establishment of locally determined retainer or career break schemes. I draw the attention of the noble Lord, Lord Molloy, to that.
On specific points, my noble friend Lord Auckland, raised a problem concerning technicians. A new pay and grading structure for technicians was agreed in September 1989 and health authorities are currently assigning staff to those new grades. These new arrangements can be applied flexibly to meet the needs of management and staff. As regards housing, a scheme is available through Nationwide Anglia which helps National Health Service staff to obtain a mortgage and get on to the housing ladder.
The noble Lord, Lord Winstanley, raised the problem of medical secretaries, They, like other administrative and clerical staff, can be paid supplements in the way I have already mentioned. The noble Lord also raised the question of GPs' prescribing budgets and morale among GPs. There is no question of GPs being unable to prescribe medicines which they consider to be clinically necessary. It is however unsatisfactory that prescribing patterns of GPs vary so widely across the country. The Government believe that doctors whose patterns of prescribing are unsatisfactory should be brought up to the practice of the best. This will be accomplished by peer review.
I believe that the noble Lord, Lord Molloy, asked why there was no Minister for community care. I point out to him that no change is planned in this respect because in the Department of Health we already have a Minister with responsibility for community care—the Minister of State.
In my view there are bound to be pressures when a large organisation such as the National Health Service is changing. The Government are doing their utmost to ensure that changes are smooth and orderly. We have made greatly increased funding available, while giving local managers greater freedom in pay and conditions of service matters and are giving every encouragement to managers to adopt flexible employment practices which are consistent with equal opportunities principles. We shall continue to take steps to make it possible for National Health Service staff to deliver an even better quality of service to patients.
My Lords, before the noble Baroness sits down, has she anything at all to say in response to my question about the appointment of hospital social workers and the dispute about that between the Department of Health and the local authority associations? Has that now been resolved?
§ Baroness Hooper
My Lords, I am sorry to tell the noble Lord that I am not aware of the problem. Therefore if the noble Lord is agreeable, I shall write to him.
§ Lord Molloy
My Lords, perhaps I may briefly say that I have received a note from the noble Lord, 1244 Lord McColl, asking us to excuse his interruption, in terminology which conforms to the highest standards of the House.
I thank the noble Baroness for her full reply to the debate, and I am grateful to my noble friend Lord Ennals and all those who have participated in the debate. I make the plea that there should be greater consultation with all the staff of the National Health Service. I beg leave to withdraw the Motion.
§ Motion for Papers, by leave, withdrawn.