The HIV/AIDS Epidemic

HL Deb 05 February 1991 vol 525 cc1108-54

5.7 p.m.

Lord Kilmarnock rose to call attention to the current state of the HIV/AIDS epidemic worldwide and to the measures required to limit its spread in the United Kingdom; and to move for Papers.

The noble Lord said: This is the third debate that I have introduced in your Lordships' House on the subject of HIV and AIDS. The last occasion was 3rd February 1988; therefore, a further review of the subject is appropriate if not overdue. I am grateful to the Chief Whip for making the time available.

I assume that most noble Lords present, and members of the Government in particular, are aware of the global and national picture. I shall keep my statistical remarks short, but I must briefly set the scene. At the end of 1990 the World Health Organisation estimated that about 1 million cases of adult AIDS had occurred worldwide. There were an estimated 8 million to 10 million cases of adult HIV infection across the globe. It is estimated that more than 5 million of those infections have occurred in sub-Saharan Africa where heterosexual transmission is the predominant mode of spread. Globally, heterosexual transmission by vaginal intercourse accounts for the largest number of infections.

The World Health Organisation predicts that by the year 2000 approximately 25 to 35 million people will have been infected with HIV, including 10 million children. On average children born with HIV become sick more rapidly than infected adults so that most of those 10 million will be dead before the decade is out. Many children born to infected mothers are not themselves infected but face a different problem. They will be orphaned and will require support, care and education. I believe that the right reverend Prelate the Bishop of Southwark will touch on that subject in relation to the horrendous figures in Uganda. I believe the Overseas Development Agency is playing an important role; I shall be grateful if the Minister will tell the House about that. Will she also tell us the level of support provided by the Government to the WHO global programme on AIDS and say whether it will be continued at a comparable level?

Worryingly, HIV is spreading to areas not thought previously to have been much affected; that is, the Middle East and South East Asia, especially Thailand. Thailand saw its first AIDS case only in 1984. Prostitutes and injecting drug users have been the main channels there. India is also becoming seriously affected. More than 100,000 US citizens have died from AIDS since the disease was first recognised in 1981 and approximately 1 million in the United States are currently infected by HIV.

Projections of cumulative AIDS cases within the EC to the end of 1991 lie in the region of 60,000 to 78,000. Comparisons with other European Community countries show that the United Kingdom, with 55 AIDS cases per million of population, comes well behind France, Italy and Spain and well below the EC average of 99 per million. That is a cause for congratulation but not complacency. According to the last set of quarterly figures released for the United Kingdom on 21st January, the cumulative total of AIDS cases reported is 4,098. Of those, 2,256, or 55 per cent. are known to have died. The cumulative total of HIV positive reports for the United Kingdom is 15,166 which is likely to be substantially less than the true number of infected people.

Within those raw figures, there lurk some interesting developments which we must watch carefully. First, the number of new cases of AIDS reported in the fourth quarter of last year—namely, 300—is less than for the previous quarter. At the same time, one should note that the average survival time from the onset of full AIDS has increased from 10 to 20 months. That is probably due to earlier and increasingly sophisticated use of therapeutic drugs, principally AZT. That has important implications for the pattern of treatment and the distribution of funds to which I shall refer shortly.

The next point is that in the UK, Europe and the USA, the proportion of cases acquired through heterosexual intercourse is increasing every year. In the UK alone the most recent CDSC figures indicate that the number of heterosexually acquired AIDS cases rose by 85 per cent. from 145 to 268 and accounted for 9.6 per cent. of newly reported cases in the UK in 1990. During the same period the total of positive HIV tests attributable to heterosexual contact rose by 50 per cent. from 829 to 1,247. It is also significant that over 1,500 women have now been reported HIV positive in the UK. Cases of AIDS in women increased during 1990 by 78 per cent. from 114 to 203.

As your Lordships will be aware, there has been some controversy in the press and the media as regards the heterosexual figures. They have been assailed as insignificant or misleading. I have no intention of being apocalyptic. One has to be clear that they represent a gradually increasing proportion of overall totals which are mercifully less than originally forecast.

There is an argument that the threat to heterosexuals is much increased by the presence of other sexually transmitted diseases—the so-called co-factors—which are prevalent in sub-Saharan Africa and to a lesser extent here. That is true. However, it should not blind us to the fact that transmission can and does take place without such co-factors. The All-Party Parliamentary Group on AIDS produced a pamphlet which gives a dispassionate and objective view. I shall be happy to send a copy to any noble Lord who has not received one. Obviously the conclusion one reaches is an important determinant of the messages sent to young people and the population at large.

Having outlined the general and national picture, I wish to turn to some specific problems. There are a number and I can touch upon them only cursorily. However, I believe that other noble Lords may develop some of them more fully. I shall ask the noble Baroness one or two questions.

First, as regards the strategy and organisation of our AIDS approach, it has always been argued by government that AIDS should be contained within the NHS and that there is no need for a strategic body like the National AIDS Commission in the USA. I remember advancing the contrary view to Tony Newton in a debate back in 1986 at London University, without success. It is true that we are extremely fortunate to have the NHS which enables us to confront this deadly disease. On the other hand, AIDS undoubtedly faces us with issues broader than those contained within our health service. Local authorities and voluntary bodies play an increasing part and there are also problems as regards education, the law, employment and criminal justice which do not fit within the NHS model.

It is true that there are a number of advisory committees, the principal of which are the Expert Advisory Group on AIDS, the Interdepartmental Group on AIDS, Co-ordination of AIDS Public Education and the AIDS Services Working Group. All that is coming perilously near to alphabet soup and none of those bodies has anything like the clout of the now disbanded Cabinet committee of the noble Viscount, Lord Whitelaw. They are merely advisory to the Department of Health.

Without becoming involved in the game of supremos and blueprints, to which we are allergic as a nation, I should like to suggest to the Government that there is at least a case for a national co-ordinating committee drawn from political, academic and community service sources on the lines of the US commission. That may help to avoid some of the shortfall and overlaps which I am sure will emerge in this debate. I do not expect the noble Baroness to hand me such a body across the Dispatch Box but I want her to say that she and her right honourable and honourable friends will look at the matter.

On funding, the British Government's record has been relatively good. It is difficult to make comparisons because one is often not comparing like with like. However, from what I can ascertain, Britain is well up in the European league table, both absolutely and proportionately, in total government resources earmarked for HIV/AIDS. I know that the figures for funds for 1990–91 will shortly be superseded but I give them by way of illustration. For the NHS —that is, for England and Wales—they amounted to £127.5 million; for local authority social services, £9.8 million; for Scottish health boards, £7.8 million; and for special help for Scotland, £7.1 million. That makes a total so far of £152.2 million. In addition, approximately £20 million goes to the MRC, European Community programmes and the Public Health Laboratory Service; £10 million to the HEA; and £1.8 million to the voluntary sector. I shall only remark in passing—I shall return to it later—that central government support of the voluntary sector seems remarkably low at only about one hundredth of the total of £184 million.

So far so good, or fairly good. However, the noble Baroness will certainly be aware of the criticisms levelled by Keith Tolley and Professor Alan Maynard of the York Centre for Health Economics in their paper Government Funding of HIV' AIDS, Medical and Social Care. Without going into details, the basis of the charge is that the present method leads to great disparities between regions; for example, £16,000 per head in South West Region and as much as £70,000 in North East Thames. That is due to the calculation on the basis of live AIDS cases at the end of the previous year. I have referred already to the rise in life expectancy and change in patterns of treatment of AIDS cases. In another paper by Dr. Bentley and Professor Adler, the authors refer to the increased use of anti-retroviral therapy and prophylaxis against opportunistic infections for pre-AIDS treatment. That will alter the ratio of AIDS to pre-AIDS cases. More resources for zidovudine, DDI, CD4 counts, monitoring and the more frequent attendances by pre-AIDS cases will also alter the balance of costs. Those authors say that financial problems will arise if allocations continue to be made on the basis of the number of AIDS cases at the beginning of a financial year. They suggest that projected mid-year numbers should be used instead.

The arguments are rather technical. I shall not pursue them further because the noble Baroness will have them at her fingertips. However, at this point I wish to ask her two questions. Can she assure me that the increased use of therapeutic drugs for both HIV positive and AIDS patients will continue to be supported? She will be aware that the Wellcome Foundation has made two 20 per cent. price cuts of AZT in the UK and has not adjusted fully for inflation for three years. That, with the decrease in dosage, has brought the cost of AZT treatment down to 38 per cent. of its original level. I hope that the Minister can give me the assurance I seek.

Will the Minister also say that the method of allocation of earmarked AIDS funds will be looked at? She will be aware of the letter written to me by her noble friend Lord Strathclyde on 21st December in which he says that the Scottish Office is reviewing the present method of distribution. Of course, the Scots tend to claim that they order things better north of the Border. That is no reason why we should drag our feet here. There are strong grounds for a more sophisticated system of allocation here which takes into account the identified HIV positive population of any region and the pre-AIDS treatment being provided.

While on financial matters, I must revert to the future funding under the new contract system of the genito-urinary medicine clinics which provide an open access service on a confidential basis to all-comers, regardless of origin. They are an essential bulwark in the control of all sexually transmitted diseases. They have been recognised as such since the introduction of the Venereal Disease Regulations of 1914. They saw 1.5 million people last year and their importance has increased since the onset of HIV/AIDS.

I rehearsed the arguments for their protection and continuance at some length during debates on the National Health Service and Community Care Bill. I received some assurances from the noble Baroness, Lady Blatch, on 25th July last year (at cols. 1352 to 1359) but these have not allayed all fears. The Monks Enquiry Report recommended that the clinics should become "designated services" to be provided in all districts, but it is not clear how they are to be funded; nor is it clear whether confidentiality would still apply to patients who had not entered the hospital through self-referral but through the accident and emergency department. When Mrs. Bottomley addressed the All-Party Parliamentary Group on 27th November last year she agreed that there seemed to be a need for further guidance on these issues. I am hoping that the Minister will take that matter a step further this evening.

As always time is the enemy. I shall now rush through a shopping list, neither the brevity nor the order of which in any way reflects the importance of the issues. I hope that other noble Lords and noble Baronesses will put some flesh on the bones. I shall end on a more philosophical theme which seems to me to be important.

The first item on my shopping list concerns the voluntary sector. In the HIV/AIDS field this sector—a cold word, so perhaps I should say that remarkable assortment of human beings—has been unrivalled in the speed, sensitivity, imagination, innovativeness and the effectiveness of its response. At international gatherings people ask, "How did you get this movement? How can we get one too?" It is not an easy question to answer without being swollen-headed. The immediate question is how it is to survive. It receives only one-hundredth of central government funding, as I have already mentioned. It is also supported by health and local authorities. However, as all AIDS allocations for 1991–92 have been cut well below the rate of inflation it is doubtful how far they can continue their support. I believe that the noble Lord, Lord Ennals, will elaborate on that point and I shall say no more except that neither this nor any other social problem in the country could have a hope of solution without the voluntary movement.

The next item on my shopping list concerns the Medical Research Council. It is working on vaccines for prevention, drugs for treatment and the design and monitoring of the epidemiological research through named and anonymised testing. I wish that the noble Earl, Lord Jellicoe, who for eight years until recently was chairman of the MRC, were here this evening. Unfortunately he is abroad; otherwise I am sure that he would have spoken. He told me that when he first went to the Whitelaw Committee for AIDS funds he and his colleagues received what they asked for. Is there another wind blowing? I am not sure. However, there is one important point. The response of British science would not have been possible without the strength of its basic research in virology, biochemistry, molecular biology, immunology and epidemiology. Thus it is not only a question of earmarked funds for AIDS. There is a serious concern that the fundamental sciences which underpin the AIDS programmes and on which the research depends are starting to lag behind due to shortage of funds. I hope that the Minister will address that problem.

The shopping list is getting out of hand. It is amazing how one epidemic, albeit a complex one, can give rise to so many heads of concern and have such a devastating effect in so many walks of life. I would have been tempted to dwell on the drugs scene, which is a key link in the HIV chain, had it not been debated thoroughly the other day in your Lordships' House on a Motion ably introduced by the noble Lord, Lord Rodney. I suspect also that that topic will be covered by one or more noble Lords in this debate.

There is the related question of prisons and prisoners, which I am sure that the noble Baroness, Lady Masham, will tackle. Our country is one of the most retrograde in that respect. It surely must give us pause for thought that in Spain, the country of Philip II, the Counter-Reformation, more popish than the Pope, the government have taken on the Church, issued condoms to prisoners and undertaken a nationwide condom-based safer sex campaign.

While on that subject I want to ask the noble Baroness whether, in view of the cutback in family planning services in many districts, the Government will make it possible for GPs to issue free condoms, particularly where no family planning clinic exists. In regard to kitemarking to ensure the quality and effectiveness of condoms based on British Standards and to keep cowboy suppliers out, I understand that the Government are prepared to look at the problem seriously. I hope that the noble Baroness will confirm that and give me some indication of what is being done.

I would have touched on the question of life insurance, which is an important one in the AIDS world. However, I was relieved to learn from the noble Viscount, Lord Falkland, only five minutes before I entered the Chamber, that he is proposing to deal with the subject. I shall therefore remove it from my shopping list and add it to his. I shall nonetheless listen with great interest to what the Minister has to say. The matter was taken up vigorously with the industry by Mr. Robert Key before he became a Minister, and Mrs. Bottomley has also pursued it. I therefore look forward to hearing from the Government and the noble Viscount on that point.

I have reserved a little breath and firepower for education and prevention, and for my peroration—which must now be ardently desired. Education in its widest sense as performed for the public as a whole by the HEA is the most potent weapon we have against the spread of HIV and AIDS. I understand that the response to the latest series of short TV personal testimonials has increased the average weekly calls to the national AIDS helpline from 8,000–10,000 to 22,000 per week. Is the Minister pleased with that? Will the Government continue to authorise and fund similar broadcasts?

In schools the matter is more difficult. Sex education is only a small part of health education, which in turn is only a cross-curricular theme that has to find an uneasy lodgement in other subjects of the National Curriculum. The noble Lord, Lord Rea, would have liked to attend the debate but cannot. He sent me a note indicating his concern on that point. Governors also have the ultimate say in schools on whether there should be any sex education at all. Has the department, in conjunction with the DES, thought of issuing guidance to governors? To my knowledge there is a parent-governors association which might be receptive.

I wish to address only one other topic. It concerns public health and private morals. This is the most important political issue facing any government in a matter like this. It affects the expenditure society will sanction and the official messages that can be sent out by the HEA, whether in schools or over the broadcasting channels. With the very large costs attached to any HIV/AIDS scenario, however minimalist, it is obviously in the interests of government and taxpayers that every conceivable precaution should be taken. It is clear to me that "safer sex" is not only in the interest of the individual but also of the public. That is a straight piece of utilitarianism well within the British empirical tradition.

However, religious and family mores of an older stamp cannot simply be dismissed. Indeed, the Government have faced criticism of the "safer sex" campaign on the grounds that it encourages promiscuity. I understand that. But I believe it to be ill-directed. The Government are above all the custodian of public health during an epidemic and not of private morals, which are up to individuals. That public health role is one which none but the Government can fill. I am not against continence, abstinence or fidelity; but it is up to the Churches and other ethical bodies to make the case for them.

I am delighted that the right reverend Prelate the Bishop of Southwark will be speaking this evening. I expect him to make just such a case and shall respect him for it. But it is the Government's duty to protect the well-being of the people as a whole, regardless of creed and custom. Creed and custom—the ethical approach, if you like—constitute another track which can and no doubt should be pursued vigorously. But they do not fall within the province of Government, whose duty is to achieve disease control with all the means at their disposal. At the onset of the epidemic the Government took a commendably nonjudgmental and unmoralistic stance. I hope that the noble Baroness will confirm that that is still what animates official thinking.

We have been fortunate in our leadership on AIDS. Mr. Fowler, as he then was, Mr. Newton and now Mrs. Bottomley have all taken the epidemic deeply to heart, as I am sure does the noble Baroness. I am sure Mr. Waldegrave will do the same. All have benefited, and I hope that they will continue to do so, from the wise guidance of the Chief Medical Officer, Sir Donald Acheson and I cannot refrain from applauding the dedication with which Her Royal Highness the Princess of Wales has brought comfort and understanding to AIDS sufferers. Hers is an impressive example. But we still have a lot of work to do. There are still gaps, shortcomings and instances of pure wrongheadedness in our policy. I have endeavoured to point some of those out.

I hope that the noble Baroness will take my remarks in the constructive spirit in which they were intended and answer as many questions as she can this evening. I look forward to her reply and to all the other contributions to the debate. I beg to move for Papers.

5.30 p.m.

Lord Ennals

My Lords, the whole House owes a debt of gratitude to the noble Lord, Lord Kilmarnock, not only for initiating this debate but for the two previous debates which he opened and for his energy and enthusiasm in sustaining the work of the all-party Parliamentary group which provided us with invaluable research material on this subject. I, too, am personally grateful to him.

I have the deepest sympathy for all who are directly involved—that is, the doctors, nurses, carers and family members—but most of all, for the victims of AIDS and HIV. It is not just the feeling of hopelessness which must come to those who are afflicted and suddenly discover that they are AIDS victims, but the fear and rejection by so many members of society. I believe that part of our educational role is to try to gain understanding for those who, whether or not by some act of their own, have contracted this sad disease. I so much agree with the noble Lord, Lord Kilmarnock, that by her constant contact, which has sometimes included physical contact, Her Royal Highness the Princess of Wales has made a notable contribution to this kind of understanding.

Of course we need more education not only in a preventive sense but in society as a whole. The noble Lord, Lord Kilmarnock, has dealt with the overseas statistics. I am also grateful to the noble Lord, Lord Rees-Mogg—I hope that he arrives in time to take part in this debate—who had a notable article published in the Independent on Monday. It looked at the whole world picture. Taking the situation in Britain, the best available estimate I have is that possibly up to 46,000 people in England and Wales had been infected with HIV by the end of 1990. Although homosexual men have accounted for most cases of AIDS to date, the rate of increase is much higher for other groups. In particular, the number of cases attributed to heterosexual intercourse increased by 98 per cent. during 1990; from 135 to 268. Over the same period, the number of cases attributable to the sharing of injecting equipment increased by 100 per cent.; from 80 to 161.

AIDS does not develop until, on average, around 10 years after a person is infected with HIV. Therefore, these figures reflect past rather than current patterns of the spread of HIV for which it is almost impossible to produce a conclusive figure. The rate of increase in reported HIV-positive cases among heterosexuals is rising faster than for any other groups. It was up by 61 per cent. during 1990. As that reflects only those individuals who have been tested, it may also not give an accurate picture of the epidemic. The question of testing is very controversial. My personal view is that if someone has a blood test for some other reason I do not see why that blood test should not also tell them whether or not they have an infection. It is important that people themselves should know. I am not saying that others should be given the results. I am certain that a great deal of cross-infection arises from the fact that people are unaware of their own situation. We still have a massive and growing problem. Broadly speaking, the Government have tackled the situation well; but we should not let down our guard. That is my principal fear. There is much cause for concern.

I have listened, as I am certain other noble Lords have, to conversations among young men and women, boys and girls. A frighteningly high proportion of those involved in casual sex are prepared to take a risk and have sex with a partner without the protection of a condom because, inevitably, they have no knowledge about their own danger or the possibility of infection by their partner. They say, "Sex is fun and it is not likely to happen to me". People always say that it is not likely to happen to them. We still have an enormous way to go in order to persuade young heterosexuals of the risks of having casual sex without the use of condoms. Little do they know that they may already be carriers. It is a wildly irresponsible attitude, risking their own lives and that of their sexual partners.

My main contacts are through the voluntary sector; the Terrence Higgins Trust, Crusaid, Phoenix House, of which the noble Baroness Lady Masham is the chairman and I am a member of her committee; London Lighthouse, which does a remarkably important job; the National AIDS Trust and the Mildmay Mission hospital. All are greatly to be commended. I commend to your Lordships a new book on terminal care for people with AIDS by two people who work at the Mildmay Mission hospital. The London Lighthouse is a national resource for people with HIV. It provides care and support to over 4,000 people a year. As London Lighthouse currently obtains 80 per cent. of its income from statutory bodies, it has a number of anxieties relating to the recent legislative changes in the NHS which are due to take effect in April 1991.

In particular, London Lighthouse is worried about the implications these changes have regarding treatment for people affected by HIV-AIDS and their freedom to choose which service they wish to receive. Its primary concern is to ensure that open access is maintained for all the services when contractual agreements come into force. It is also concerned that as catchment areas develop it may have funding only to provide services to people living within district health authorities with whom it has a contract. Consequently, access to people from districts without a contract will be restricted. Already non-Thames district health authorities have denied their residents access to their services due to the refusal or inability of authorities to pay. I hope that the Minister will look very carefully at this matter. It would be a tragedy if, with the introduction of the contractual system from 1st April, it were made any more difficult for patients to be able to receive the treatment, particularly where it is available to them.

I now say a few words about the voluntary sector. Its response to HIV-AIDS has been rapid and innovative. The diversity of organisations illustrates many needs which have arisen in relation to HIV-AIDS. I am glad that the noble Lord, Lord Kilmarnock, paid tribute to the voluntary organisations. Many of them have good working relations with the statutory sector, but funding does pose a real problem. There is great concern over the ability of projects to maintain services at current levels, let alone expand them to meet new needs.

I draw the attention of the Minister specifically to the fact that the AIDS support grant for 1991–92 has been increased to local authorities by only 4 per cent. and to health authorities by 6 per cent. As the noble Lord, Lord Kilmarnock, said, both of those figures are below the level of inflation. That presents very severe problems to the voluntary sector. Despite a strong funding contribution from some regional health authorities, much of the statutory sector funding available to the voluntary sector has been from local authorities. If the local authorities are pegged then the money is simply not going to be available for the voluntary organisations to do the jobs which they do so very well.

The AIDS support grant to local authorities for 1991–92 means that many local authorities will be unable to cover their own costs and will certainly not be able to fund the voluntary sector. Therefore, on behalf of the voluntary sector I must tell the Minister that there are real dangers which the Government must face unless we are to see a slipping back rather than a stepping forward.

I refer now to the NHS. Although the provision of new resources only began in 1986–87 the major allocation was not made until 1988–89. Hence, many of the services are very new and still vulnerable in a National Health Service which faces major financial and managerial constraints. That is all the more so because of the historic marginal position of units like health education. If these new services are to be consolidated, protected and expanded, earmarked funding must continue. It is important that the Government should recognise that a commitment must be a commitment.

The underlying principle behind the provision of earmarked money for HIV development was that it be ring-fenced. It was not to be used for purposes unrelated to HIV and particularly not to help offset wider NHS deficits. Given the financial problems facing the NHS it has been difficult for some managers to resist using this money for other purposes. A number of notable examples of this have been reported recently, of which the Minister is no doubt aware. This has given rise to some suspicion that the HIV issue has been allocated too much money and that not all the allocation was required. That view must be changed. In that respect, I want an assurance from the Minister on the situation as it affects the National Health Service.

The situation is serious. The policy being pursued by the Government is simply not acceptable. Penny pinching now is endangering the lives of tens of thousands of people in years to come. The local authority associations' officer working group on AIDS, from which department of health funding has recently been withdrawn—I hope we can have an explanation for that—has drawn up a programme of training and development for AIDS co-ordinators and liaison officers with a strategic emphasis which will go some way towards meeting these key officers' training needs. In order to provide the best possible advice and to ensure high quality service provision in their local communities these officers need specific training and development input in a variety of relevant subject areas. One crucial consequence of this withdrawal of NHS funding is that local authorities are increasingly unable to fund important voluntary sector initiatives. Some community charge capped authorities have stated clearly that they will not be in a position to fund any voluntary sector initiatives in this financial year and probably not in the following year. Perhaps I may give Kensington and Chelsea as an example in case the Minister thinks that only Labour authorities face this problem.

Bodies in the voluntary sector are rightly recognised as playing a fundamentally important role in the further prevention of the spread of HIV infection in our communities. Their ability to continue to do so is already beginning to be severely hampered. Their difficulties are exacerbated by their own needs for specific areas of training and development, not least in relation to the importance of developing skills and expertise in contributing to contracts for social care and in developing agreements in relation to the provision of services.

I hope that this debate will cause the Government to think again. Two courses of action are needed. First, there should be an immediate increase in the level of AIDS support grant in line with inflation, or above it, to allow projects to continue to exist; and where projects have not yet begun, to allow them to make a start. Secondly, there should be an increased recognition that joint funding arrangements—the whole future of which is still, so far as I know, uncertain—are nevertheless the key to the continued development of high quality service provision and of education.

The local authorities have shown themselves to be highly committed to making a major contribution to the further prevention of the spread of HIV infection and to the provision of high quality services for those already affected by the virus. This increasingly harsh financial climate is tying their hands and demoralising their workers at a time when all expert advice tells us that the number of people affected is consistently increasing and when many view levels of complacency to be higher than ever. I hope that this debate will bring home to the Government and the House the message that not only is there no room for complacency but that there is room for great anxiety about the extent to which we as a society are fulfilling our obligations. The consequences of any failures now may not be seen immediately—it is perhaps 10 years from now that we will see the folly of our ways—so I urge the Government to continue as well as they started and maintain the pressure for services, and the funding of services, which the cause so urgently needs.

5.45 p.m.

The Viscount of Falkland

My Lords, I should like to address the question of the connection between HIV testing and the life assurance industry. There are two main reasons why people should seek a test to find out whether they are HIV positive. The first is obvious: should they turn out to be HIV positive they would quite rightly wish to take steps to make sure that the disease does not spread to others. The second reason is that recent advances in medical science have made it possible to delay the development of HIV into AIDS by the use of certain drugs and it is therefore necessary for the HIV positive result to be obtained at an early stage.

Those who have taken an HIV test which was negative will encounter delays if not difficulties if they seek to fill in a proposal form for life assurance. Those who are HIV positive are bound not to get the life assurance cover they seek. Those who have been for a test in any case, whether it is negative or positive, are in serious difficulties. If they are negative, the companies will inevitably require them, because they have taken the test, to answer further questions. It is the subject of the further questions which at this stage is a little worrying.

I have before me a fairly standard additional form from a leading insurance company. The form is short and brief. The Terrence Higgins Trust would describe it as crude. It is called a lifestyle questionnaire. Those who have taken a test, even though it be negative, are required to say whether they are part of five clearly defined groups: a homosexual, a bisexual, an intravenous user of drugs, a haemophiliac or someone who has sexual partners who are connected with any of those groups.

The noble Lord, Lord Ennals referred to an excellent article, written by the noble Lord, Lord Rees-Mogg, which appeared in the Independent. I do not see the noble Lord in the Chamber but I hope he will be here later. It was full of information and was extremely interesting to read. An important point relating to the attitude of life assurance companies was made early in the article: 60 per cent. of those who suffer from AIDS contracted their disease from heterosexual sources in the first place.

The article went on to state that there is authoritative evidence which shows that by 1993 at least two-thirds of new AIDS sufferers in this country will have contracted the disease from heterosexual contact rather than from homosexual contact. Therefore, not only is the insurance companies' line of questioning about one's lifestyle brief and crude: it is also not based upon reality. Many of those who are vulnerable are not covered at all because they have provided the additional information required and this in turn leaves an important gap in their lives.

As I said, if you are in a high risk group, you will not be able to obtain insurance cover. However, if you had not taken the test in the first place, and admitted so doing, you would not have had to fill in the extra form. I suggest to your Lordships that the people who are most at risk are those who are most discouraged from taking the test. Of course, there is another option: one can always lie on the insurance form. Such a course of action should be avoided at all costs. I say that because anyone who does so runs the risk of losing any premiums and benefits which may have accrued.

As noble Lords will be aware, insurance companies can consult your doctor when you apply for the insurance cover. Of course, you have to give your permission; but if you do not do so, again, that will affect your proposal. In such a situation your doctor is bound to pass on any information he has about you and about what is termed your "lifestyle". The same applies to any other doctors whom you may have consulted and whose names you are required to put on the form.

The present situation is unsatisfactory. That fact has been confirmed to me by many doctors. I am informed that doctors will often advise against taking an HIV test because of the damage which it may cause financially by prejudicing the chances of obtaining life insurance. Indeed, I was discussing the matter only today with someone with two female friends who had both consulted their doctor. Each one had been given such advice and, at the same time, the doctor concerned had advised each girl that he would keep their conversation off the record so as not to prejudice any chances of getting life insurance cover.

As I said, the situation is extremely unsatisfactory. I should very much like to hear the Government's view on the matter. I say that because, without labouring the point, there are many people who are at risk and who are being prevented and discouraged from taking tests which may save lives in the long run. In my view, the matter needs to be addressed as it has been in the United States, although I dare say that the situation there is somewhat different. Indeed, the Association of British Insurers believes that the reason one is not asked the question, "Have you had an HIV test?" but is asked instead, "Are you HIV positive?" in the United States is because Americans all have blood tests throughout their lives, whereas in this country one generally has a blood test only when something appears to be wrong. For reasons of which I am unaware, although other noble Lords may well have the answer, it is actually against the law in the United States to ask the question, "Have you had an HIV test?" It is interesting to note that the asking of such a question is not against the law in Canada. However, that country has opted to go the American way. People are asked, "Are you HIV positive?" They are not asked, "Have you had an HIV test?" That is done voluntarily because it is felt to be more satisfactory.

I shall leave the matter there. I hope that I have focused your Lordships' attention on this particular area. I also hope that I have not upset the insurance industry by what I have said. Indeed, I dare say that the industry runs its affairs very competently. However, it seems to me that it has taken an historical view of the disease which is extremely limited and which concentrates mainly on experience in this country. The early experience of the disease related largely to homosexuals. Enormous and admirable efforts have been made by the homosexual community to ensure that such people are less at risk, as the noble Lord, Lord Rees-Mogg, pointed out in his newspaper article. That is the group of people which has made the greatest efforts to ensure that the disease does not spread in its community. I see that the noble Lord, Lord Ennals, wishes to intervene. I am happy for him to do so.

Lord Ennals

My Lords, I have followed with great interest the remarks made by the noble Viscount. I wonder whether he can give his own view on one aspect of the matter. It seems to me that it is one thing to have a test which is available to the insurance company, but it is another thing to have a test which is available to yourself. Can the noble Viscount give the House his view on that complicated issue?

The Viscount of Falkland

My Lords, I must be honest and say that, before speaking in the debate, I had been concentrating rather exclusively on the insurance aspect of the matter. However, because of the discussions which I had with various people before entering the Chamber, I am under the impression that many young women are very conscious of the change in thinking which has now been recognised. I refer to the fact that heterosexual contact now seems more and more to be the cause of the disease. But that view is not held among young men. They seem to have gone into conventional thinking along the lines that it is only homosexuals who are at risk.

When a young women is entering a new relationship she may be worried about a previous boyfriend. She may have had one or two affairs, but this is a sign of the age in which we live. She may consider that a previous boyfriend was promiscuous and she may wish to reassure herself and the new man in her life in this respect. It is only fair that she should feel quite secure in the knowledge that she can go and take the test in order to find out about her state of health without prejudicing herself as regards obtaining life insurance cover.

5.58 p.m.

The Lord Bishop of Southwark

My Lords, I want to make my way into the debate via Uganda. It is clear that Uganda is one of the countries on the African continent worst affected by AIDS and HIV infection: the latest estimate is probably about 1.3 million out of a population of some 20 million. Yet, despite the obvious differences, I believe that there is much to be learned already from the responses which the Churches and other organisations in that country are trying to make to the problem.

What follows is based mainly on my conversation with someone who has recently returned from a visit to Uganda and who is himself a Ugandan priest now working in the diocese of Southwark. He spent a week in the diocese of Namirembe, which is a large diocese severely afflicted by AIDS and HIV infection. He was able to talk with the bishop and others who are directly concerned. After much discussion I understand that the Ugandan Churches, along with the government, have come down in favour of widespread testing. Noble Lords will be interested to hear that test centres are being set up, in particular near churches. Persuasion and not coercion is stressed, but of course against a background of growing awareness about the extreme seriousness of the epidemic in that country.

Testing is confidential. It is recognised that a positive result will have serious consequences for the individual concerned and for members of his or her family if they are told. The Bishop of Namirembe has appointed four counsellors. On one occasion my informant saw 60 people waiting to see two of them. By our standards, that is an impossible case load, but one has to do what one can in a country with so few trained resources; and at least the need is recognised. The overriding argument in favour of testing is that the situation must be faced openly, and that will only be so when people begin to realise their own responsibility and involvement and develop a sense of urgency in coming to terms with what is happening.

Much agonising has gone into the debate about what we call safer sex and the use of condoms, as one might imagine. Church leaders there, as here, are not in the business of encouraging promiscuity; we are in the business of encouraging chastity, self-discipline and faithfulness to a partner. But Church leaders there, as here, also try to be realists. We are well aware that not everyone accepts the Christian ethic, and in Uganda there is also a legacy from polygamy which makes faithfulness to one wife more difficult. The culture is hostile to male contraceptives, and there is the question of cost and reliability.

The outcome of the Churches' debate in Uganda is an interesting one. It has been to propose to government and others that condoms should be made freely available only to those who are HIV positive. I doubt whether that is a realistic way forward, but at least it is a serious attempt to send out a signal which is consistent with the view that the best way forward is to teach and practise chastity and not to encourage promiscuity.

My informant told me that he was amazed by the way in which the Churches are trying to meet the desperate needs of orphans and children who are HIV positive or dying of AIDS. I understand that the time gap between being positive and getting the disease is much shorter with children. They have day clinics which in that diocese are being funded by grants from the German Lutherans, who provide food, clothing and other help to enable the children to be cared for as much as possible by the extended family if their own parents have died or are too weak to cope.

The significant point about that development is that children are not being swept out of sight in some remote institution, as happened, for example, in Romania. Villages divided by civil war and other sufferings are coming together again in a common recognition of need and acceptance. They remember after all, some of them, what happened to lepers. There is an upsurge of loving concern in many villages which gives cause for hope in face of the fear that AIDS induces.

In this country we are still in a different situation from Uganda, but there are useful and important parallels to be drawn. If the disease progresses here, the case for widespread testing must be strengthened. How else shall we learn how serious is the situation that we face and take the steps necessary, both individually and corporately, to meet the threats that may emerge?

The importance of counselling is plain to see. A wealthy community can afford to put far more resources into appropriate training and numbers than a third world country; but the interesting point about the Ugandan experience is that such counsellors need to be easy to reach. They have to be voluntary. They have to do their work in a way which makes them accessible to people of varied background and culture and be able to counter the common misunderstandings about the spread of the disease. Sometimes our counselling becomes so professional that it is not readily in touch with many ordinary folk.

In this country', public education has focused almost entirely upon the safer sex route, with its implicit assumption that that is the only way worth considering. The Church of England Board for Social Responsibility in its submission to the Social Services Committee of another place in 1986 made it clear that: It is the teaching of the Church that all individuals should practise chastity before, during and outside marriage … Pairing and bonding are normally part of human nature, and promiscuity is contrary to it". That is not to deny in any way that sex is fun. But we all know that there is more to be said. I am very much aware of the difficulties, especially the point made by the noble Lord, Lord Kilmarnock, about the responsibility of government for health rather than for morality as such. But I believe that there are still many people who would welcome a more positive emphasis on that alternative way of preventing the spread of AIDS, because that is what we are talking about tonight, especially perhaps in guidance for health education in schools. I shall be interested to hear whether the Minister can comment on that point.

Finally, we should note how strongly the Ugandan Churches are trying to foster open and honest recognition of what is happening and are working with and through their local communities to care for and accept the victims of HIV infection and AIDS and not to turn away from them in apathy or condemnation or because they think that someone else should cope. They know that there will be no large government funds available in that country, and I guess that sooner or later we shall have to come to terms with the fact that ours too are limited.

One of the suggestions that we have often heard—I believe that it is important—is that there need to be more special hospices, such as the Mildmay Hospital or the London Lighthouse. That may well be right, so long as we recognise that AIDS sufferers also need to stay in the community and at work for as long as possible—and that relates to the insurance issue. It is vital for them and for us that we do not fall into a 20th century version of the rejection of lepers. The Churches still have an important role to play in this, probably not widely understood as yet, and it is good that in many places the local churches, usually acting together and ecumenically, are beginning to support advisers, advice centres and support groups such as Time for Support in Manchester.

In my diocese, Brixton Prison has a small hospital. I am aware, because I have seen it, that an extension has been built to house AIDS patients. Judge Tumim's recent report on the prison and the hospital did not encourage us to think that the level of care would be very great, given Home Office constraints on funding and staffing. When people are dying of AIDS, is it necessary for them to end their days in a prison hospital? Could there not be a hospice for dying prisoners, with simple security, where relatives might have greater access for those last few weeks and months and where reconciliation with one another and with God might be easier and more humane?

6.8 p.m.

Lord Butterfield

My Lords, I begin by expressing my gratitude to the noble Lord, Lord Kilmarnock, for bringing the debate to the Floor of the House. In the same breath, perhaps I may apologise to him and to the noble Lord, Lord Ennals, for being late in reaching the Chamber. I inquired in a certain office and was given the information that the debate would probably start at about 5.30 p.m. I stepped into the Chamber at 5.31 p.m. I apologise to your Lordships for being late.

I want to speak in the debate because there are two sides of my life which are deeply concerned with the subject. One is that I have spent a good deal of time in education, and there is a major health promotion and health education challenge in this terrible epidemic that we face. The second is of course that my first degree was in medicine. I may stray into the clinical vocabulary as I have not written out all my words in detail. If they become rather torrid I hope your Lordships will excuse me. It is not my intention to try to shock or offend.

I want to begin, as I am sure the noble Lords, Lord Kilmarnock and Lord Ennals, probably emphasised, by saying what a great change has come about in this epidemic. When it started I am sure from my personal observations that there was a good deal of prejudice about those suffering from acquired immunodeficiency state diseases because of the link with homosexuality, which runs against the grain for many folk. But it is terribly important that we all leave this debate clear in our minds that it is no longer correct to consider the epidemic in those terms.

The World Health Organisation stated firmly in a publication on 15th December: heterosexual transmission of the human immunodeficiency virus that causes AIDS is becoming the predominant mode of spread". I wanted to go on to say that there are projections—and we have no reason to doubt their accuracy—that the number of people who may he suffering from this dreadful condition (I will tell you in a moment why I regard it as so dreadful) is going to be of the order of 25 to 30 million in the early part of the next century. I am sure that that figure has probably already been drawn in, but I do not apologise for re-emphasising it.

If you are immunodeficient you are very susceptible to a whole range of infections. In connection with this debate I was talking on Sunday to an English nurse just back from a spell in New York. She said, "There are two things I would tell you, Professor. One is that we are now seeing many women with AIDS in New York, and the other is that the number of patients with tuberculosis as a result of AIDS is rising and rising, and that is a very uncomfortable sort of case to have to nurse".

There is a further point that I should like to make. One of the things that happens to you when you are a retired professor is that you perhaps see more of your students. I am going to describe two things that former students have said to me. First, a lady doctor reported to me the sort of distressing cases which have been drawn into this terrible web. She knows of young mothers from the Middle East who were delivered and had a small haemorrhage at the time of delivery. Their obstetricians, anxious to provide the best level of service, topped them up with a little transfusion of blood, a bout 150 millilitres. Unfortunately a lot of the blood in the Middle East 10, seven, five years ago came from New York and was contaminated with the virus. Therefore, as a result of what was hoped at the time to be good medical practice, this doctor has seen several young mothers in London in the terminal stages of AIDS with all the resulting problems of degeneration of the central nervous system. There is a lesson there that we need to learn.

Not long ago I was in the Soviet Union. The doctors there were all worrying that so many children—several hundred in one epidemic—in small hospitals and in orphanages had been infected by repeated use of the same needle. The prediction is that there are going to be probably 10 million orphans worldwide within the next 20 to 30 years. The mothers and fathers, brothers and sisters, will die and leave them as a dangerous and serious social and political problem.

Those youngsters are bound to become streetwise. I cannot believe that they will not have hard children's hearts. It is one of the things that I worry about. I hope that we do not find among them some who are prepared to step on anybody in their way to success in their lives as they would judge it. Of course one fears that some of them may follow a military career and lead countries to war.

That touches a point that I should like to make quickly. I am full of admiration for our Secretary of State for Foreign Affairs, Mr. Hurd. He is right to worry about conferences after the Gulf War is brought to a conclusion, and it is to be hoped that that will be soon. Perhaps I may say, however, that there are some of us in this Chamber—and I believe that the right reverend Prelate the Bishop of Southwark will be one of them—who will be pressing that before the end of the century there will be more international conferences about what is going to be needed for the survivors of this epidemic. I suggest that we need to worry particularly about those 10 million orphans.

The second part of Lord Kilmarnock's Motion concerned the measures required to limit the spread in the United Kingdom, and I should like to talk about that for a few moments. First, I must on your Lordships' behalf offer our congratulations to the many people who have been so busy and successful in combating this epidemic in this country. The Chief Medical Officer and the Department of Health deserve our thanks and congratulations. Many people have come forward to help there—it is usually young men at this stage—in the terminal stages of the disease.

The world medical fraternity has stepped up its efforts as have our pharmaceutical companies too. I know that there has been difficulty about the question of insurance, and I have been led to believe that a joint survey is being conducted by the Association of British Insurers and the Department of Health. Perhaps the Minister will tell us in due course if that is so and how it is getting on?

We know that the numbers in this country are alarming. For example, in Edinburgh one pregnant woman in every 250; in Dundee one in every 1,500; and in London one in every 2,000 is HIV positive when she comes to the clinic. Those are pretty alarming numbers.

Lord Winstanley

My Lords, will the noble Lord allow me to intervene for a moment? I find most interesting the figures he has just given about the number of pregnant women who are HIV positive. How is this known? Presumably blood tests were carried out. What consent was given specifically by all those women for the test for HIV?

Lord Butterfield

My Lords, I am afraid I cannot answer that. These figures came to me through the offices of the Medical Research Council, which I should also like to congratulate on its wonderful efforts in this epidemic. I believe that it has become the custom to test pregnant women in clinics in case there are problems with blood transfusion needs. I believe that is the basis for the testing. The figures are alarming.

I should just like briefly to talk about the question of prevention. There is a great and wonderful story in my profession about Professor Bywaters, who was once asked by his students about safe contraception. He said, "There is only one safe oral contraceptive and that is a firm, `No'". Whether we are going to be able to bring about that level of continence among young people is one of the great challenges which face us. There is no doubt that people are keen on condoms. Perhaps I may mention that I have heard from health educators in Japan, which I visited recently, that the approach adopted there is to encourage the girl partner to put the condom on her young man. This apparently increases the chances that condoms will be used. The girl's excuse for it is that she is twice as likely—if the pair do not know their HIV status—as the boy to contract the disease from promiscuous intercourse.

Lastly, I would not wish noble Lords to leave the Chamber without being made aware of the work on vaccination which is going on in this country. We can hold our heads high and I am grateful to my friends and colleagues in the Medical Research Council and elsewhere in the research world for the information that I shall give briefly.

In this country we have a great tradition as regards vaccination. Edward Jenner started vaccination in the grounds of Berkeley Castle and I think his first boy was vaccinated in 1796. The question now arises: how shall we find something like the vaccinia virus, the cowpox virus against smallpox, to use against the AIDS virus? Our clever young men and women will know about the proteins in the HIV virus.

As examples of the devotion shown by our young research workers who are committed to the problem, I shall mention two points. First, there has been successful vaccination of a small number of monkeys through collaboration with the Zoo. Secondly, now that it is known that protection can be obtained with fragments of the virus protein, certain people, young men at St. Mary's Hospital and a professor at the University of Cambridge, are allowing themselves to be inoculated every month with one of the proteins which might be a useful vaccine. They expect their blood to be taken and the antibody to be separated, labelled and given to patients with AIDS. It is labelled so that estimates can be made of the rate at which the antibodies are being used up. At the moment, no one knows whether the antibodies are low in AIDS patients because they are used up more quickly or because the T-cell, the immunological defence, is unable to make the antibodies.

I apologise for running over my time but I wanted noble Lords to know of the strenuous efforts being made by all those at the research interface with the AIDS problem. Their efforts are a reminder to us of the size of the problem we face and how important it is that we recognise that we shall have great responsibilities in Southern Africa, parts of the Sahara and the Far East. We may have responsibilities for health there as great as the challenges we are meeting in the Gulf war.

6.23 p.m.

Lord Colwyn

My Lords, I also must apologise for being late for the start of the debate. When I telephoned the House at half past four I was told that the debate would start at about 6.15 p.m. That would give me time to attend the all-party football committee annual general meeting at six o'clock and also hear the opening speeches. As it happens, I have missed all those speeches and I am now missing the football meeting.

Telling people that AIDS is always fatal is both untrue and misguided. It ignores the fact that many patients have experienced significant remissions and now lead normal lives. It is also an entirely negative approach for, as I propose to show, AIDS patients must be able to live in a wholly positive atmosphere in which their self-healing capacity is encouraged and enhanced.

The AIDS virus, as we have heard, reduces the efficiency of the immune system, particularly the T-4 helper cells which organise the killer cells of the body's defence mechanisms, leaving the victim susceptible to infections which are normally naturally controlled. Your Lordships will know of my interest in the natural methods of healing. I declare an interest as president of the Natural Medicines Society, joint president, with the noble Lord, Lord Ennals, of the All-Party Parliamentary Group for Alternative and Complementary Medicine, and a patron of the Research Council for Complementary Medicine. I also acknowledge this evening the help I have received from papers by Branko Bokun and Chris Thomson.

It must be logical to spend some time and money on research into how to improve the efficiency of our natural defence systems. Even if scientific research eventually finds a cure for AIDS, without improving the efficiency of our immunity, other lethal viruses or different forms of AIDS could become active.

We all carry thousands of innate or acquired viruses in our bodies which remain inactive if our immune system is in good shape. Could it not be that AIDS develops when someone's immunodeficiency, perhaps caused by another infection, descends to a particularly low level, to the point where it becomes incapable of any defensive action? Perhaps our defence mechanisms have a sliding scale of deficiency and at a certain point on that scale, varying between different individuals, we become susceptible to certain infections.

In our present environment we are permanently subjected to all manner of micro-organisms which often lie dormant for our whole life, if our immune system is in good order. There is no doubt that it is possible to catch and carry AIDS for many years, perhaps even a lifetime, without any ill effects if our immune system works correctly. Millions of people carry the herpes virus in a quiescent state, only showing symptoms when the immune system descends to the level of its deficiency at which herpes becomes active.

Scientific researchers invariably insist that most carriers of AIDS will develop the disease and die within five to seven years. There is no proof but as that kind of statement produces panic and stress, the chances are that it is true. Panic and stress lower the immunity to the disease and death is more likely. Fears and anxieties stimulate the hypothalamus, increasing the activity of the sympathetic nervous system. The more protracted this alert state, the more damage is created to the immunity. When the state continues for long periods, as it would invariably do when individuals are told that they have the AIDS virus, various hematological abnormalities occur, of which the most common is the reduction in the number of leucocytes—the very cells responsible for the body's defence against pathogens.

I believe that male homosexuals are more susceptible to AIDS not due to their sexual promiscuity—although this may help to spread the disease—but because of the factors that are part of their lifestyle: anxiety, agitation and restlessness produced by the instability of their state of existence created by mental attitudes. In general, male homosexuals have a lower immunity than average, thus making them more susceptible than others to opportunistic infections.

Drug addicts, by the nature of the abuse to their bodies, develop immunodeficiency, which exposes them to many infections including AIDS. In any society, there will always be young people who develop irrational anxieties. They mainly stem from successful parents or a community where success is praised and failure is a stigma. At an age when they face reality, responsibilities and the values created by healthier and tougher generations, these youngsters instead develop anxieties and fear of failure, which is diminished by the use of drugs.

Like any escape, drug addiction increases fear and anxiety which in turn reduces the efficiency of the immune system. Those who suggest giving addicts free sterilised needles and syringes in order to prevent spreading AIDS do not understand the psychology of drug addicts. Sharing the needle consolidates togetherness and belonging, which are far more important to those people than anything else.

Could the rapid spread of AIDS in central Africa—where signs of the anxiety and stress in the western style of life and its cures using drugs, alcohol and sex, are becoming more evident—be due to the fact that the imitation and adaptation to this new lifestyle is particularly strenuous?

The main agent which facilitates the spreading of an epidemic is the fear of that disease. Fear reduces immunodeficiency dramatically. Dramatised statements from the media cannot but spread AIDS, opportunistic infections, AIDS related complex or cancers. Vague speculations and forecasts can create such terror among the virus carriers as to transform the speculations into truth. The real truth is that AIDS virus carriers could live to a normal age if they concentrated on keeping their immunity at its optimal range.

People are becoming increasingly frightened at the first sign of physical or mental disorder. More people are rushing to their doctors in search of the quickest and most effective drug remedy, prescribed in most cases to please patients. Many strong drugs, particularly antibiotics, inhibit the body's immunity, and certain drugs, particularly the corticosteroids, positively reduce the immune reaction.

I am in possession of papers which show that HIV patients and patients with AIDS-related complex can be helped dramatically by treatment with a combination of mainly natural therapies. The current edition of the Journal of Alternative and Complementary Medicine gives details of an American trial which has shown 100 per cent. survival and no progression to full blown AIDS in 16 HIV-positive patients over a 12-month period. That compares with a 93 per cent. survival rate and 28 per cent. progression to full-blown AIDS in a study of patients using AZT therapy. I am also aware of the beneficial effects of treatment with sodium ascorbate, or Vitamin C. A recently published paper from the Linus Pauling Institute confirms reports from doctors who are having considerable success treating AIDS patients with large non-toxic amounts of Vitamin C. I am trying to show that it is inherent immunity which is the vital factor in AIDS.

I have been a member of the All-Party Parliamentary Group on AIDS for several years. I have failed to persuade its members to take any notice of, or to invite presentations from, complementary practitioners working with AIDS patients. Perhaps my noble friend the Minister will have a sufficiently open mind this evening to take serious note of what I have said and to bring my remarks to the attention of her right honourable friend in another place. I should be most grateful for some indication in the winding up speech of my noble friend of the Government's feelings towards the matters I have raised.

6.30 p.m.

Baroness Masham of Ilton

My Lords, first of all I must apologise because, like the noble Lord, Lord Kilmarnock, I have a very bad cold, so if I suddenly stop speaking it will be to breathe. Perhaps I shall ask the noble Lord, Lord Colwyn, for some of his treatment.

I am most grateful to the noble Lord, Lord Kilmarnock, for giving us the opportunity to debate this subject this evening. Much has happened since 1983 when there was the first Question on AIDS in your Lordships' House. As far as the noble Lord and I have been concerned, this matter has always had very high priority.

If we turn back to 18th March 1985 when there was the first debate on an Unstarred Question on the subject in this House, the Minister answering said that in 1985 there were 132 confirmed cases, of which 58 had died. AIDS is now the greatest cause of death in New York City. In very many countries of the world the problem is greater than it is in Britain. I have known two people who have died of AIDS and one who is now dying. It will not be long before many more people will know somebody with AIDS. It is difficult to explain what it feels like to know that someone whom one loves has AIDS. When one fully realises, it is a sorrow that one has to hold and manage as life has to go on. The AIDS virus creates much emotion. There is a strange cloak of silence that comes down which can be lifted only on rare occasions. Many people have now gone through the mourning process, having shed many tears in private.

As chairman of the all-party parliamentary group, the noble Lord, Lord Kilmarnock, must be congratulated on his dedicated hard work. I have the honour to be one of the group's vice-chairmen and should like to pay tribute to the research workers and others who have served the group and to the helpful information which results from having such a group in Parliament dealing with this important matter.

There is no doubt that the British Government have done a great deal to try to prevent the spread of this cruel virus. Many very difficult decisions have had to be taken. Most people take a responsible line, but there are always a few who may spread the virus on purpose because of a grudge and a bitterness against society. Knowing what the results of AIDS can be, I would say that there is no greater priority than to try to do everything possible to stem the spread. Surely one of the biggest problems is that there must be many people who do not know that they are HIV-positive, who perhaps even shut out the thought of any possibility; they just do not want to know, especially if there are no benefits to knowing but only disadvantages. Now, with the increase in women finding themselves HIV-positive there is a fear that their children might be put into care or on the risk register. These people need help from those they can trust and they need to be where they will feel safe.

I have the honour to be a council member of the London Lighthouse. I am a new member, having joined in September. I also have connections with the Mildmay Mission hospital, which the noble Baroness, Lady Hooper, has visited, and with ACET, AIDS Care Education and Training. These organisations are all doing vital work, giving people with AIDS a safe place where they are understood and looked after as human beings or giving them care and support in their own homes.

On an estimate of 85 per cent. occupancy, it costs about £260 per day for a resident at the Lighthouse. Home care is much cheaper. ACET estimates that it costs around £10 per day. During 1990–91 it received 320 referrals in London, of which 157 were for full home care. One of the ever-increasing problems is that organisations such as ACET have to negotiate with 30 to 60 authorities in London alone. That is why ring-fence money is vital. ACET also provides help elsewhere: in Scotland; with the devastating problems in Africa; and with education programmes in Romania.

With the ever-increasing number of AIDS cases some organisations are reaching crisis point. The World Health Organisation estimates that the current level of infection is 8 to 10 million and the projected level by year 2000 is over 20 million.

Working in the field of AIDS may have its sorrowful and difficult side but there are some quite exceptionally good and dedicated people who are providing models of care which could be used in the community in respect to other groups such as severely physically disabled people and cancer patients. There is a wonderful section of volunteers working for both the London Lighthouse and ACET as well as for many other projects. The use of volunteers in any organisation means that if it is to work well they must be reliable; the support for them must be good; and they should be well managed. For AIDS sufferers, having paid staff and volunteers working side by side seems on the whole to work very well.

The challenges posed by HIV and AIDS demand a well co-ordinated response from all sections of the health service as well as from the social services and the non-govermental organisations. The nursing contribution to that response is already significant but it has not yet reached its full potential. The role of the nurse as carer is already well defined, but the role of the nurse as educator, informing the public about HIV, could be further developed. More nurses need educating. At present only one AIDS course unit for nurses exists offering a basic introduction to HIV and its epidemiology, and to issues of sexuality and prejudice and bereavement counselling. That is a good start but the course is available at only 36 centres in England.

So far 3,000 nurses have undertaken the course. There are 28,000 district nurses and health visitors throughout the UK. HIV poses the greatest single challenge to public health this century. Some people who become ill with AIDS may move around the country, perhaps to relatives in rural areas where people with AIDS might not be expected to live. HIV demands a high degree of awareness among nursing staff. It is not restricted to so-called high risk groups. The ability of the virus to strike any person regardless of sex or age means that the disease can spread through all sections of the population. Community nurses, occupational health nurses or practice nurses need to be properly prepared to meet that challenge.

Perhaps the Minister will be able to tell your Lordships how community nursing teams will be organised. Will they be monitored and evaluated by family health service authorities? How will collaboration between local authorities work? With the involvement of local authorities, FHSAs, health authorities and voluntary agencies and the need for confidentiality there are question marks. Good practice must be worked out so that there is a clear strategy and framework for the provision of community health services in general and wider access to education and training for staff specifically on AIDS.

Last week I attended the launch of a book Terminal Care for People with AIDS at the Mildmay Hospital. It has been produced by Ruth Sims, a nurse, and Veronica Moss, a doctor, and should be of great help to GPs, nurses and other carers. The book was mentioned by the noble Lord, Lord Ennals.

There is concern about future funding for some people who are HIV positive, who come to this country, particularly from Italy, Spain, Brazil and Africa, and who then become ill and need treatment and care. Perhaps they come here because we have better facilities. Perhaps the World Health Organisation could hold a contingency fund so that the country which cares for those unfortunate people can be reimbursed. My noble friend Lady Hooper is expert in Spanish and has a special relationship with Spain. Does she agree that that suggestion is worth considering? Otherwise, who will provide the necessary funds?

There is concern about the way in which prisoners with AIDS are treated in our prisons. I have been told that prisoners who have been taking drugs for the virus have been moved to other prisons without their drugs and without the knowledge of the doctor whose care they are under. The health service and the prison service should work closely together. Can the noble Baroness reassure the House that prisoners will not be moved from one prison to another without their medication? I agree with the right reverend Prelate the Bishop of Southwark that it would be much more humane for prisoners with AIDS to be allowed to go outside the prison walls and to die in hospice-type care when the time comes for them to die.

I am sure that the Minister will tell us that the Government have given a great deal of money to deal with AIDS. That is true, but health care has become very expensive indeed. The AIDS dilemma moves very fast. There is still a great deal to do and learn. It is important that there is co-operation and a helpful attitude among those working in the field. When there is a shortage of money there may be the danger that the problem will be denied.

The spread of AIDS by injecting drug users has been and still is a great problem. The good needle exchange schemes seem to be paying off. Liverpool has one of the lowest figures for HIV in the country and should be congratulated. I chair an organisation called Phoenix House which rehabilitates drug addicts. HIV has not helped morale. We are now establishing a safe house for people with AIDS called the Fountain House.

All of those facilities cost money. It is encouraging that there are generous people raising money for so many needs. Tribute should be paid to organisations such as Crusaid and the people from the arts world who have done so much. As has been said, Her Royal Highness the Princess of Wales, through her frequent presence at events and centres for AIDS, helps to keep up much needed morale. Her Royal Highness Princess Margaret has also helped.

I end with a plea to the Minister. Recently it has been reported in the press that in the USA three patients caught AIDS from their dentists. It is important that the Department of Health looks at that question and makes it known how the infection was spread as there will be many worried people. The report in the Evening Standard was vague about how the infection was spread. Every precaution should be taken to stem the spread of AIDS.

6.46 p.m.

Lord Rees-Mogg

My Lords, I should like to join with other noble Lords who have apologised for missing the first few speeches in the debate. Like them, I thought that I was early for a six o'clock debate but found that I was late for a five o'clock debate.

I am very grateful to the noble Lord, Lord Kilmarnock, for introducing the debate. I should like also to express my thanks to several noble Lords who have referred in friendly terms to my article in the Independent.

I am very conscious that this debate is taking place at a time of crisis in the Gulf and of the contrast between the two crises. It is certain that even this year the number of casualties the human race will suffer from AIDS will be a multiple of the number of casualties the human race will suffer from war. Whereas we know that this war will end within a reasonable time, we have to look forward to an AIDS epidemic which in all probability will kill increasing numbers of people through many, if not all, of the decades of the next century.

It is remarkably difficult to understand what is happening. The AIDS virus seems to have a psychological advantage because of the average 10-year delay between infection with HIV and contraction of the full-scale disease. If even now people were thinking rather of the infections taking place in 1991 than of the deaths, which amount to perhaps only a tenth of those infections, some of which were contracted as far back as the late 1970s, there would be much stronger public awareness of what is happening and a much stronger public reaction. I believe that we shall need a public reaction appropriate to the 1990s and not, as we have now, a public reaction which is only as alert as the infections of the early 1980s have made it.

Last week I went to the World Health Organisation and had a meeting with Dr. Merson, head of the appropriate department. I have also had an opportunity to have discussions with various experts in Britain, including Professor Anderson. He is a very distinguished world authority on AIDS and the HIV virus. There are certain conclusions which seem to me to be pretty generally agreed. These conclusions have been referred to in the debate, and in some cases I am repeating what other noble Lords have already said.

The first conclusion is that we are indeed dealing with a long-term, worldwide, pandemic disease. In America and in Europe the disease originally tended to have homosexual transmission. This undoubtedly misled the public in the United States and Europe into believing that it is primarily a homosexual disease. It is no such thing. At least 60 per cent. of present cases were contracted by heterosexual contact, and that percentage seems certain to continue to rise and is likely to end up at 80 to 90 per cent. or more.

The second point which I believe is universally agreed is the truly terrible situation that exists in Africa. The disease spread through central Africa and is now spreading through western Africa. The problem is not so serious in Islamic North Africa—the Arab lands—or in South Africa. However, the effect is devastating across central and western Africa. The situation there is that the rate of infection with HIV has already passed the 5 million mark. Nobody knows for sure how many HIV infections there are in Africa. The estimate is 5 million. But it is worth bearing in mind that that estimate has had to be doubled in the last three years, and a rate of doubling in three years offers a truly grim forecast for the future.

The World Health Organisation believe that approximately one in 40 of all adults in that part of Africa are now infected, and the rate of infection is approximately equal as between men and women. As a result of transmission from mothers they expect that 10 million children will be infected with HIV in the course of the 1990s. Of all the current statistics, this strikes one as perhaps the most tragic. On top of the 10 million children in Africa infected with HIV, almost all of whom will die within five years—because the disease takes a much more rapid course in children—there will be 10 million left as orphans. This is happening in a continent which is already poor and which does not have the resources to deal with this disease or indeed with its other existing medical problems. There is a real danger that as the disease, which started mainly in the cities, spreads to the villages irreparable damage will be done to the social structure of these African nations as the very people who are running these societies are destroyed.

It is also agreed that the disease is beginning to spread to that part of the world which so far has hardly been infected. As we all know, the disease exists across North America and Western Europe. It does not feature very much on the other side of what used to be the Berlin Wall. It is very prevalent in Africa; it is seriously prevalent in the Caribbean; and it is prevalent, and getting worse, in Latin America. But it is now beginning to spread into the main land mass of Asia. The first evidence of it apparently came from Thailand, which seems to have been infected by its tourist trade and through the tourist brothels.

The infection has also spread to India. Tests which have been done on the population of prostitutes in many of the major Indian cities—Delhi, Calcutta, Madras, Bombay, and so on—show that rates of infection of between 30 and 70 per cent. are to be found in those groups. In India, as in Africa, there are large numbers of labourers who leave their villages either as single men or leaving their wives behind, and who have a strong tendency to use those prostitutes while they are in their work status before returning home. There are said to be 4 million such men in Bombay, and 50 per cent. of the 100,000 prostitutes in Bombay are said to be HIV positive.

In addition, we have the first warnings coming from China. We now have the disease marching forward into the land mass of Asia. Asia contains 60 per cent. of the world's population. In terms of AIDS cases, it has less than half of 1 per cent. at the moment. Therefore, I think we must expect that on the most favourable basis Asia is going to become infected in the 1990s in the same kind of way, though not necessarily to the same degree throughout, as Europe was infected in the 1980s. Asia is approximately 10 years only behind us.

This world problem is going to have to be met by world measures. We have shown—rightly, I think—what a world response through the United Nations we can make, to meeting a political and military crisis of aggression, but is that not disproportionate to the world efforts being made to confront what is a much greater threat to mankind?

I should like to add a couple of reflections about the situation in this country. There is a misconception among the public, fostered to a degree by some of the sensational press, which does not always give us the most accurate information, that somehow we are at the centre of affairs in this matter. We are not. We are part of a particular phase of the epidemic, and we are part of the European part. We match the pattern of northern European countries, and we have a percentage of HIV infection very similar to that of Belgium or Germany. Fortunately, we are considerably below that of southern Europe, where, because of shared needles, there has been a more serious epidemic. We are relatively fortunate in the development of the epidemic so far in this country. From the point of view of world health we are not a particularly sensational case.

So far, we have taken only the first steps which are natural and appropriate to deal with so dangerous and lethal a disease. I believe that we must undertake further public health education, particularly in the schools. It must be right that every schoolchild on a national basis should be fully informed about the risks that he or she will have inevitably to face in adult life. In my view they should be informed on a basis of science. They should be told the facts. They should be told the steps which can be taken to make their own lives more safe. Those steps include limiting their sexual partners. The only real safety will be fidelity to their sexual partner. Nevertheless limitation is of vital importance. Unless we have adequate health education in schools, we shall have unnecessary cases of this disease as it spreads from its initial homosexual orientation into the heterosexual community.

I am completely convinced that if we knew where we already stand, attitudes toward testing, counselling of those tested and tracing would be radically different to those which exist at present. I do not believe that the medical community, though itself divided, will be willing, as the percentage of HIV infected people in the population grows, to go on treating everybody alike, tested and untested. One already hears of cases of people doing medical work who are extremely reluctant to treat high risk patients who have not been tested if they do not know whether they are dealing with the active disease. Therefore I am certain that during the 1990s we shall have to move in a thoroughgoing way toward testing, counselling and tracing. I believe that, if we have to make that move, the earlier we bring ourselves to make it, the better it will be. We must remember that because of the delay inherent in the latency period of the disease in HIV and AIDS, it is always 10 years later than we think.

7.2 p.m.

Lord McColl of Dulwich

My Lords, I should like to add my thanks to the noble Lord, Lord Kilmarnock, for initiating this important debate. I must also give my apologies to the House for not being present at the beginning of the debate, which was due to hospital commitments.

My involvement in this subject is as president of the Mildmay Mission hospital, which was a NHS hospital serving the people of Hackney until it was closed in 1982, being surplus to requirements. The hospital was allowed to reopen three years later as an early version of the self-governing hospital. Thereafter we had much closer co-operation with health authorities. In 1988 within the hospital we opened a hospice for those dying of AIDS. It turned out to be the first of its kind in Europe.

Mildmay deaconesses first cared for people dying of cholera in 1866. The hospital today is particularly well suited to that kind of work—treating people with AIDS who are considered by some to be like the lepers of old. Many have been thrown out of their homes, sacked from their jobs and even rejected by their friends. There have been many distinguished visitors to the hospital; they have been deeply moved by the plight of the people there. They have also been impressed by the dedicated and superb care that is given. The attitude of most distinguished visitors is noticeably changed when they meet people who are living with AIDS.

The hospital provides continuing and terminal care for those with advanced disease. Many patients are admitted apparently dying. But when their infections are treated and the symptoms controlled they recover and leave the hospital, although often returning later having suffered a relapse. So the establishment differs from the usual type of hospice where active treatment would not normally be appropriate.

Respite care is another important aspect of the work. The aim is to have as many as possible of the patients nursed at home. A smaller percentage may need rehabilitation after suffering the effects of a stroke as a complication of the disease. Such patients respond very well to intensive rehabilitation treatment.

Education is another important activity of the hospital. It trains other National Health Service personnel and people from abroad in how to deal with AIDS patients who are being cared for at home as well as those in hospital. There is an ever increasing number of mothers who have AIDS and of children with AIDS. The hospital tries to cater for that need but facilities will need to be improved. It has been reckoned in New York that within a few years it will have 78,000 children with AIDS. The mothers are reluctant to come into hospital and leave behind their children as the children would have to go into care.

We are very grateful to the many people from all parts of the country who have loyally supported the hospital. We are particularly grateful to the Member of Parliament, Mr. Peter Shore, who has been an absolute tower of strength throughout the years with all the help that he has given. We also thank the regional health authority and the Department of Health which, as usual, are being constructive and practical in helping to make the hospital the success that it is. But very much more remains to be done.

I underline what my noble friend Lord Butterfield said about the Chief Medical Officer, Sir Donald Acheson. He played a crucial role in alerting the country to the danger of AIDS at a time when very few people were taking any notice. He went on and on until they did take notice—all credit to him.

As the noble Viscount, Lord Falkland, said, there is a stigma attached to having the HIV test, even if it proves negative. The Minister for Health is working hard to put that matter right. Some people have difficulty obtaining life insurance just because they have had the AIDS test. The fact that it was negative and that the reason for the test was a blood transfusion given at a time when donor blood was not being tested does not seem to carry any weight.

The tragedy of the disease is that many people need not develop it at all provided that they change their behaviour. Sadly, even if behaviour in many developing countries were to be changed overnight, those countries will still lose one third of their populations. In some countries the number will be even higher. That is the same order of mortality which obtained during the plagues in the Middle Ages. Changing the behaviour of mankind seems to be exceptionally difficult. It is imperative that much more effort and funding are put into developing further the excellent work of the Health Education Authority. More money must be found for research and for supporting the caring work of the many institutions which are involved and which will be needed increasingly in the future. Education is of great importance. However, as was said by the right reverend Prelate the Bishop of Southwark, there is more to the issue than education. There is a spiritual dimension which we ignore at our peril.

7.10 p.m.

Lord Winstanley

My Lords, I, too, sought advice from the usual channels about the time at which the debate would start. However, unlike certain other noble Lords, I did not heed the advice and was able to be in my place to hear the entire speech delivered by the noble Lord, Lord Kilmarnock. Other noble Lords may learn not to be as credulous in the future.

The noble Lord, Lord Kilmarnock, has been indefatigable in his efforts to spread knowledge of this serious disease not merely in this House but among Government circles and elsewhere. He is right to turn our attention to the subject when we are pre-occupied with other lethal events elsewhere. I wholly agree with the noble Lord, Lord Rees-Mogg, that however many lives are lost in the Middle East it will be as nothing compared with the number of lives lost as a result of this disease. In saying that, I do not ignore the words of the noble Lord, Lord Colwyn. He told us that natural defences might re-emerge to combat the disease, that it does not necessarily have to be fatal and that the virus might modify itself in time, as has been the case in respect of many other viruses.

I was delighted to read the article in the Independent by the noble Lord, Lord Rees-Mogg. I was delighted not only by its contents but because it appeared in the Independent which is not the usual publication in which his words appear. The fact that they have suggests a move to more liberal attitudes than those which he has previously held. The article covered the subject extremely effectively, as did the speech of the noble Lord, Lord Kilmarnock. However, both omitted to disclose the extent of the infection in Great Britain. The reason is that they do not know. We ought to know, and it is a matter to which I shall turn presently.

I do not intend to go over ground that has already been covered so well by many distinguished speakers but to ask one or two questions before coming to my main point which concerns testing. Reference has been made to the need for AIDS sufferers to have employment where possible. Does the Government's policy remain the same? When AIDS first became a common talking point and we knew of the dangers I was delighted to hear Mr. Kenneth Clarke—who I believe was then Minister for Employment—state that if someone were to be dismissed from employment due to being found to be HIV positive he or she would have good grounds for taking the case to an industrial tribunal, and winning. I commend his statement but ask the Minister whether that remains the Government's view. If so, will they express it with the same clarity?

A great deal has been said about funds. The noble Lord, Lord Ennals, was right in saying that funds are insufficient and that they must be increased. However, the total amount does not matter; what matters is what is done with them. We must decide on the best way of using the funds that become available for dealing with AIDS. Research is essential. However, in this country a great deal of the research rests on the shoulders of people who have clinical responsibility for the care of AIDS patients. It is not carried out by people elsewhere in the research field who have time to do it. I believe that we are being overtaken by the United States where funds and resources for research are greater. I hope that we are able to compete with the United States on equal terms in discovering an effective therapeutic agent and an effective vaccine. They have not yet been discovered and a great deal of money will be required in order to do so.

Money is also needed for counselling. Many noble Lords have mentioned the importance of the work done by the voluntary sector. The right reverend Prelate the Bishop of Southwark believes that counselling in this country is a little too professional. Perhaps he will forgive me if I disagree with him, though I know what he meant. I believe that counselling cannot be too professional. The right reverend Prelate believes that people need someone with the common touch to whom they can speak. They need to feel that the counsellor is not a professional. However, properly trained professional counsellors will conduct themselves in such a manner that patients will not feel that they are dealing with a professional.

It is important to remember that the shortage of social workers and the inadequacy of their training means that counselling people with AIDS can be psychologically damaging and dangerous to the counsellor. The counsellor becomes attached to a patient and gradually develops a relationship with him as he cares for him through a long illness. When in the fullness of time the patient dies the counsellor moves on to another patient to whom he will become equally attached. Again, that relationship will build and progress for months. That patient will eventually die and the counsellor will again move on. Careful professional training is required to enable a social worker to escape from psychological damage. I hope that the Minister will tell the House that adequate funds will be made available for the training and provision of counsellors.

I hope that the debate does more than merely spread additional knowledge about this important subject. I repeat my thanks to the noble Lord, Lord Kilmarnock, for introducing it. I remember that the first debate on the subject in this House was an Unstarred Question tabled by the noble Baroness, Lady Cox. A number of noble Lords who have spoken today also spoke on that occasion. I said that five questions needed to be answered. For example we need to know the nature and identity of the virus responsible, the method of transmission, and more about the incubation period. Four of my questions have been answered but one has not. It is the extent of the invasion of the virus into British society. We do not know, and will not know, the answer until we have a proper system of testing.

During Question Time in this House recently I stated that when, as a doctor, I have taken blood for testing the patient has first given general consent to the blood being tested. Indeed, one never takes blood without asking the patient for consent. When blood is tested, say, ante-natally, before an operation or for many routine purposes, the doctor does not ask the patient whether he or she is agreeable to a sample being taken. He does not then ask whether he can count the patient's red cells, white cells and platelets. The particulars of the testing are not specified; consent is consent. I believe that we have reached the time when samples of blood having been taken for testing, one must assume that the patient's consent allows the blood to be tested for anything, including HIV.

The difficulty is that several people believe that to test the blood for HIV without having obtained the patient's specific consent would amount to an assault. I do not agree with that. I am not an authority on common law but that view has never been tested in the courts. However, it is a fact that the General Medical Council, the body responsible for medical ethics, has given such advice.

I am sorry that the noble Lord, Lord Walton of Detchant, the distinguished president of the GMC, is not in the Chamber. He was a short while ago. He had that matter very much in his hands at one time. Advice was given to doctors that they must not test for HIV without the specific consent of the patient. I believe that advice to be wrong and that it is high time for it to be amended. I should like to ask the noble Baroness to address herself specifically to that point when she replies. What progress is being made to enable doctors, without fear of any possible legal or other consequences, to carry out tests for HIV on all blood samples taken from patients in all circumstances?

When that is done we shall have a real knowledge of the extent of the problem. We can guess, as noble Lords have done throughout this debate, at what the figure will be by the year 2010. We should know, and until we do know I do not believe that we will make the necessary progress with these vital matters.

I am not quite as wedded to education as is everybody else. I do not honestly believe that education will diminish the popularity of sexual intercourse among the young. I agree with the right reverend Prelate who said that sex is fun. Young people know that. I know that I should prefer them to play cricket and that we were perhaps rather more selective. However, I do not believe that education will do the trick.

Noble Lords may remember that there was an epidemic of venereal disease during the Second World War. There was a massive government education programme. About what could they educate? They could merely educate people not to have sexual intercourse with people suffering from syphilis. That was not an easy educational platform. The real results were obtained when we found a therapeutic agent to cure those diseases or, what was more important, to render the patient non-infective once under treatment. That was the vital step in getting rid of pulmonary tuberculosis. Once patients were under treatment, they ceased to be infective. Having ceased to be infective, the number of cases in society was gradually reduced. Therefore, the first step is to find an effective method of treatment which not merely delays or cures the process of the disease but renders patients non-infective.

Secondly, we must make progress with pioneering and developing a vaccine which will prevent people developing the disease. In order to do that, it is necessary to find out the extent of the problem. Only when that has been done will the necessary funds be made available, particularly in a society which at present is market led.

I know that the pharmaceutical companies are very conscious of the fact that there will be a huge market for a new drug which cures AIDS, renders patients non-infective or protects them from infection. However, we really need to know the extent of the problem.

I do not wish people to feel that there is an element of compulsion about this. I believe that the noble Lord, Lord Butterfield, referred to the Vaccination Act of 1889. That is a long time ago. It was not repealed until the National Health Act 1946. There are a whole number of vaccination Acts which made vaccination compulsory.

Noble Lords may remember that during the Second World War, when there was an epidemic of venereal disease, certain statutes were passed whereby any person who became infected was obliged by law to give the identity of the person from whom the infection had been contracted. The person named was summoned in for treatment. There was a law which provided for compulsory treatment. It was not terribly effective; at least however it was a precedent. So there have been statutes. Is it not time therefore that we looked at this matter? Is it not time that the noble Baroness was able to tell us that a campaign will be carried out—not necessarily a voluntary campaign although that would be more successful than a compulsory one—so that all blood taken for any purpose is automatically tested for the presence of HIV?

If it is tested and an individual sample is found positive, then there is the further problem of what to do with the results. Clearly they must remain confidential and should be revealed only to the patient. Certain steps must also be taken thereafter to protect the patient. Until that step is taken, we shall not have taken a positive step at all. If we take that step, then I believe that very positive results will emerge from this debate initiated by the noble Lord, Lord Kilmarnock.

7.27 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper)

My Lords, this has been a thoughtful and constructive debate. We have been privileged, as so often in your Lordships' House, that so many noble Lords have spoken from personal knowledge and expertise.

The Government welcome the opportunity given to us by the noble Lord, Lord Kilmarnock, to take stock of the situation worldwide as regards the HIV and AIDS pandemic and to report the action which the UK Government have taken in support of the World Health Organisation in its fight to contain the spread of HIV and AIDS through its global programme on AIDS.

We all recognise the sterling work of the noble Lord, Lord Kilmarnock, as chairman of the all-party parliamentary group on AIDS. This group has done much in support of the UK strategy on AIDS and we are grateful to the noble Lord and his colleagues for their efforts to help maintain HIV and AIDS high on the national and parliamentary agenda. Indeed, my honourable friend, the Minister for Health has, I understand, recently written to the noble Lord, expressing her appreciation for the work of the all-party parliamentary group.

Perhaps it would be helpful if I were to remind your Lordships briefly of the elements of the Government's strategy and in broad terms of our approach to them, as the noble Lord, Lord Kilmarnock, asked me to do. Clearly our primary objective must be to curb so far as is possible the spread of HIV infection here and abroad. But in addition the Government have taken steps to ensure that appropriate services are available to meet the needs of people infected with HIV or with AIDS itself. To achieve these aims we have instituted campaigns to educate and inform the public and those whose behaviour may place them at special risk; we have set up monitoring and surveillance programmes to assess the progress of the epidemic within the UK; we have contributed to the research effort both here and worldwide, primarily in the important area emphasised by noble Lords in the course of the debate, to find a vaccine against HIV infection and a cure for the disease itself; and we have given substantial earmarked funds amounting to almost £150 million in the current year to the NHS and organisations within the statutory and voluntary sectors as the Government's contribution towards the costs of preventing the further spread of HIV and of providing appropriate diagnostic, treatment, care and support services.

There are few areas of government that are not concerned with the HIV/AIDS epidemic. For this reason, we have taken steps to ensure the closest co-operation between interested government departments. This is reflected at ministerial level by discussions through the usual arrangements and at official level by an inter-departmental group and a further official group to co-ordinate educational work across government. We also have access to scientific and professional advice through the Chief Medical Officers' Expert Advisory Group on AIDS. I am grateful to all noble Lords who have commended the work of that group.

The UK Government have ensured that the social, legal and ethical issues associated with HIV disease are addressed with care and sensitivity and in the context of the human rights of people with HIV and AIDS and without intervening unnecessarily in the ethical and moral issues to which the noble Lord, Lord Kilmarnock, and others referred. On that I was pleased to hear the views of the right reverend Prelate.

As regards public education and prevention, the UK was one of the first countries to mount a mass media AIDS public education campaign aimed at raising levels of knowledge and awareness among the public at large. I am pleased at the acknowledgment of the success of that campaign and confirm that the Health Education Authority will continue to seek to find the best way of conveying the important message of prevention.

In the field of care and treatment both the voluntary sector and the National Health Service have provided centres of excellence and innovation. Examples have been mentioned during the course of the debate so perhaps I need refer only to those within the National Health Service, which include the Kobler Centre, St. Mary's Hospital Home Care Team and the Newcastle Community Care Centre. The work in the voluntary sector is very much admired and respected by all.

The United Kingdom's strategy and our achievements so far are highly regarded internationally. The public at large, the health service, those who work in the other statutory agencies concerned and the volunteers who have worked tirelessly to assist and care for people with HIV infection, and indeed the Government, can be justified in feeling a sense of pride in our achievements both to prevent wider spread and to provide care and treatment with compassion and understanding for those who are infected or have become ill. In saying that, I do not wish in any way to suggest complacency. There is clearly a need to keep all our achievements under constant review.

Perhaps I may turn to the situation worldwide. The debate has recognised that the HIV and AIDS pandemic continues to worsen, particularly in sub-Saharan Africa, South America and Asia. I am grateful to the noble Lord, Lord Rees-Mogg, for his contribution on this part of the theme. The World Health Organisation has recently completed a detailed review and now estimates that some 8 to 10 million people may be infected with HIV. WHO further estimates that by the year 2000 some 25 to 30 million people may be infected, 10 million or more of them children. So far over 95 per cent. of reported cases have been in younger adults between the ages of 20 and 49 years. As the noble Lord referred specifically to Asia, I should also confirm that the World Health Organisation had previously estimated that the figures would be 1 to 1.5 million infected in that region. In the light of recent data, that now appears to be a substantial underestimate.

We are also aware of the Ugandan situation, on which the right reverend Prelate spoke so knowledgeably. It is important that we draw what lessons we can from the experiences of others.

In helping to combat the global epidemic the Government have so far committed some £30 million to programmes to prevent the spread of HIV and given wholehearted support to the WHO global programme on AIDS which takes the leading role in co-ordinating and implementing international action. AIDS is also high on the agenda of the European Community, which has set up a working group to formulate a Europe-wide strategy. Both within the European Community and further afield the Government have taken every opportunity to encourage international debate and the exchange of information about all aspects of HIV and AIDS. Many noble Lords will, for example, recall that in January 1988 we jointly hosted with the World Health Organisation a world summit of health ministers on programmes of AIDS prevention. That was an unprecedented and highly successful event attended by ministers from 147 countries. In addition we shared in our day-to-day contacts with other countries the experience we gained from our programme of public education and prevention.

I agree that in this very difficult area that programme of public education and prevention is vital. It is particularly true, as has been said, that in the absence of a cure for the disease or a vaccine against infection education and prevention must remain the cornerstone of our strategy. The first phase of the UK-wide public information campaign began in early 1986. That was followed in early 1987 by the highly successful and widely supported mass media campaign which ran under the banner of "Don't Die of Ignorance". These campaigns and those which have since been developed by the Health Education Authority have raised and maintained to a high degree public awareness and knowledge of the risks of HIV infection, how the virus is transmitted and the measures people can take to protect themselves and others.

Noble Lords may recall that in November 1989 the Department of Health and the HEA jointly convened an expert symposium to assess the prospects for the wider spread of HIV in the UK. Three key conclusions were reached at that symposium: first, that all three main modes of transmission were well established—by penetrative sexual intercourse, by drug misusers sharing contaminated injecting equipment, who can of course additionally then pass the virus onto their sexual partners and from mother to unborn infant. Secondly, the symposium concluded that HIV continued to pose a serious threat to the health of the nation. Thirdly, it concluded that the potential for the wide-spread dissemination of HIV in the general population exists, particularly among heterosexuals and injecting drug users. The symposium and the television campaign of expert testimony that followed in early 1990 can have left no one in any doubt of that.

Our figures show—indeed the contributions to the debate this evening show also—that there has been a rapid increase in cases of HIV and AIDS among women. The noble Lord, Lord Butterfield, drew attention specifically to that point. As an indication of this, a recent survey in the Home Counties showed that in inner London one in 2,000 women recently delivered of a child was infected with HIV. In outer London the figure was one in 3,000, and outside those areas, one in 20,000. The noble Lord, Lord Butterfield, quoted figures from Scotland.

Figures have been attained by anonymised screening of Guthrie cards, which are also used to screen new born babies. A leaflet was issued to explain that procedure which emphasises that if the patient concerned has any questions or objections to the baby's left-over blood or urine being used for that purpose, the doctor, nurse or midwife would be happy to speak in confidence. There is emphasis that the wishes of the patient will be respected.

With those increasing figures in mind, it was particularly appropriate that the theme for World AIDS Day on 1st December last year was "Women and AIDS". This country responded magnificently and included many national and local events accompanied by welcome and helpful coverage by the broadcasting and press media. In that context a notable example is the work that Margaret Johnston is carrying forward at the Royal Free Hospital in encouraging women to come forward for help and in giving them access to appropriate services. I also applaud the work of Positively Women, a self-help group for women who are HIV positive. The group's new centre and offices were recently opened by Her Royal Highness the Princess of Wales. I am pleased to be able to say that the Government were able to contribute to the funding of the new premises.

In the latest phase of the mass media campaign, launched shortly after World AIDS Day, we focused on the testimony of people who have become infected. The objective is to increase people's personal perception of the risks so that they will translate awareness and knowledge into personal action. The intention is not to alarm and scare unnecessarily, although I take the point made by my noble friend Lord Colwyn in that respect. That is why we recognise the importance of counselling.

Mass media work is now being supported by HIV prevention work at local level. Health authorities have been asked to work with local government authorities and the voluntary sector to develop prevention initiatives geared to local needs and aimed at encouraging changes in personal behaviour. Coordinators are being appointed in districts to help carry forward that work. Support from the centre will be provided by the Department of Health and the Health Education Authority. In November last year, we convened a national seminar as a first step in the exchange of ideas and information and to help co-ordinators place their work in a national context.

In addition to campaign work at national and local level aimed at the general public, specific campaigns will continue to be directed to sections of the population whose behaviour may place them at special risk and to those where particular educational approaches may be required. To this effect we are discussing with the Health Education Authority the approaches needed to ensure the continued success of our national campaign work. Other governmental departments will also continue to develop educational work connected with their particular fields of interest. This of course includes educational material for children and young people in and out of schools. The Department of Health will continue to work closely with the Department of Education and Science to ensure that up-to-date and appropriate materials are available for use in schools.

We shall also continue to monitor carefully the spread of HIV in the United Kingdom by means including our programme of anonymised serosurveys under the direction of the Medical Research Council. We hope that the results of these surveys will help us in planning services for those infected with HIV or with AIDS and in targeting national and local prevention work. We continue to spend more in the area of HIV and AIDS public education than any other single health promotion programme. This is a measure of the importance we attach, and shall continue to attach, to reducing the impact of this disease on the population of this country.

A number of themes, as it were, came up in the course of the debate on which questions were specifically put. One of them was insurance. Perhaps I may quote my honourable friend the Minister for Health who said in another place recently: We occasionally hear of letters from insurers which imply, or are taken to imply, that the Government require insurers to send supplementary life style questionnaires to applicants for life insurance. This is not the case, and we bring cases that come to our attention to the Association of British Insurers so that it can take the matter up with the company involved. We no longer refer to risk groups, as it is a person's behaviour which determines whether they are at risk of contracting HIV, not their membership of a particular group in society. Our public education campaign messages reflect this".—[Official Report, Commons, 19/12/90; col. 241.] Again, my honourable friend is discussing with the Association of British Insurers the effect of the HIV test questions which insurers ask on the proposal forms for life insurance. We are concerned that these questions should not prejudice public health concerns. The British Market Research Bureau has been jointly commissioned by the Department of Health and the ABT to carry out a survey of public perceptions. The survey is made up of four constituent surveys of experts, advice workers and others, the general public and young adults.

The bureau carried out the interviewing late last year and we have just received the draft report, which will inform our further discussions. A point was made by the noble Viscount, Lord Falkland, about the situation in the United States and Canada as regards insurance. The position of the United States is more complicated because of the need for most people to have private health insurance. Canadian guidelines for insurers are not altogether clear. The guidance produced by the Canadian Health and Life-Insurance Association, which has been sent to us, suggests that insurers can be justified in asking about prior negative tests in this respect.

That brings me to the other main theme concerning testing. The view of the expert advisory group on AIDS is now that if people think they have been at risk they should consider seeking a test and having counselling. That reflects recent studies which suggest that certain asymptomatic people benefit from early treatment. I was asked why this testing should not be made more routine. The decision to take an HIV test is one that must be considered very carefully. Legal advice obtained by the BMA advised that specific consent to HIV testing was needed in addition to the consent obtained for any other medical intervention carried out at the same time.

The Royal College of Surgeons has issued guidelines this very January. The council says that it would be impracticable and illogical at the present time to call for routine testing of all patients for HIV before each of the 3.3 million surgical operations that are performed in England and Wales each year. Nevertheless, the council strongly endorses the recently expressed view of the chief medical officers that members of the public who consider themselves to be at risk of HIV infection should submit to voluntary testing.

As regards the question of anonymised surveys which I touched on earlier, information is urgently needed in this country about the level of HIV infection in the population. These surveys have been designed to provide invaluable information on the overall prevalence of HIV infection by age and sex among the population as a whole and in different parts of the country and also the rate at which it is increasing in the population at large. We need this information and so do the statutory and voluntary sectors. It is needed to plan for appropriate services and preventive initiatives. Information about the level of HIV in the general population cannot be extrapolated from people who voluntarily seek a named test.

As regards contact tracing, which was raised by the noble Lord, Lord Rees-Mogg, the issue of contact tracing of people with HIV is a delicate one, as the noble Lord acknowledged. There is good evidence that a number of people will not come forward for help if they consider that pressures will be put on them to name their partners. However, there may now be an advantage for people to know whether they are positive or not. It has always been the policy of the staff of genito-urinary medicine clinics to counsel people who are HIV positive on the desirability of informing their partners, but handling must be at the discretion of the staff of the clinics. There can be no doubt that the wishes of the persons concerned are and must remain paramount.

It was also suggested that some doctors might refuse to treat people with HIV positive tests. That is something that we must leave with the General Medical Council, which has indicated that it expects doctors to treat all patients.

I now move to the third main theme, which is funding. I am happy to agree with the noble Lord, Lord Winstanley, that we should be concerned with not so much the funds but what we do with them. I believe it was the noble Lord, Lord Ennals, who referred to the misuse of ring-fenced AIDS moneys by certain regional and district health authorities. I can reassure him that these matters which emerged from the department's scrutiny of AIDS reports have been fully followed up. The authorities in question have taken corrective action. Next year guidance on the use of money will make it quite clear that the virement of money for the purposes of cash management is not acceptable.

Reference was also made to local authority spending being increased by only 4 per cent. That does not take into account the additional help that we have given this year by continuing joint finance money to certain inner London boroughs even though their funding was always due to cease this year. The extra £1 million brings the real additional level of resources to 14 per cent.

We recognise too that the complexity of any future contracting arrangements might affect services for people with AIDS or HIV and therefore we need to ensure that a confidential self-referral system is maintained and that highly expensive services, which in some places are at an early stage of planning and are not yet embedded in the health service infrastructure, are continued and maintained. In response to this we have ensured that the earmarked funding will continue in 1991–92. It will continue to be provided, as now, on a catchment basis rather than on a district of residence basis. A working party will be established to resolve problems of preserving confidentiality and freedom of access to services while operating district of residence-based funding—a very important consideration in this area. This should ensure that AIDS services will be in a strong position to flourish and develop in a system of managed competition.

The noble Lord, Lord Ennals, also referred to the local authority associations' officer working group and the removal from it of central government funding. Funding to this group was provided on a pump priming basis for three years, by which time local authorities ought to have developed sufficient concern for AIDS services to be willing to pay for the group themselves. It is sad that they do not want to do so. We are currently considering a bid from the associations for a revised working group. We want to be certain that the work of this group will be taken seriously through the whole country and will influence those who take managed decisions relating to the delivery of services. Officials will be writing to the associations shortly.

A great many questions were asked. Perhaps noble Lords will bear with me as I try to cover as many of them as possible. On the question of AIDS among prisoners, the Government attach a high priority to measures designed to prevent the transmission of HIV in prisons and other custodial settings. To this end two educational packages have been produced and the video AIDS Inside and Out" for prison inmates has been widely acclaimed. Governors have been urged to use it extensively. The Home Office has also encouraged prison administrations to liaise with health authorities in setting up local prevention initiatives for prisoners, including those on release.

Both the noble Baroness, Lady Masham, and the right reverend Prelate sought certain assurances. I can confirm that my colleagues in the Home Office are concerned to ensure that prisoners who are moved from one prison to another do not experience any interruption in their medical care and treatment. Furthermore, Home Office policy for the management and care of prisoners with AIDS envisages that they will be looked after by the prison medical service at times when they are relatively well and removed to an outside hospital during acute phases of their illness.

The PMS has already received co-operation from NHS hospitals in treating the 21 AIDS patients it has had to date. Eight of those patients have died in custody but all were in an outside hospital at the time of death. Seven other patients were receiving care in a hospital or hospice at the time of their release—in some cases early release—from prison. It seems to me that these figures are an encouraging indication that the services concerned are collaborating successfully to ensure that prisoners receive specialised care when they need it and that when sadly they become terminally ill they do not die in prison. I entirely agree that a prisoner has as much right as any other citizen to be able to die with dignity.

In October 1990 the report of an efficiency scrutiny of the prison medical service was published. Department of Health officials participated in the scrutiny and in the steering group which was set up to prepare an action plan. While the report looks at the whole of the PMS, it also looks specifically at special groups of prisoners, including prisoners with HIV and AIDS, and should also inform our future discussions.

The effect of stress on the immune system was emphasised by my noble friend Lord Colwyn. He also referred to the place of complementary medicines. I have taken careful note of what he said and will ensure that his remarks are brought to the attention of appropriate people in the department.

The noble Lord, Lord Kilmarnock, asked me, on his extensive shopping list, about the availability of condoms via GPs' prescriptions. I can assure him that GPs are able to prescribe condoms within the known budget limits of their health authority.

On the question of dental transmission of HIV—the United States case—we have received a copy of the report of January this year in which the three possible cases of transmission are discussed. We are seeking expert advice on the possibilities it suggests. As for the National Aids Help Line, to which the noble Lord, Lord Kilmarnock, referred, since 1987 a number of successful and well regarded telephone information and advice services have been in place to provide free and confidential information to anyone in the United Kingdom concerned about HIV and AIDS. Most notable amongst these is the National Aids Help Line, operating from London and Glasgow, which is available 24 hours a day, every day. In 1990 it received nearly ¾ million calls. The help line and the other services are an invaluable and essential adjunct to the public education campaign work.

The noble Baroness, Lady Masham, made a number of points about the importance of community nurses and the vital part they can play as part of a co-ordinated response to AIDS. I shall write in detail on the points raised but I should like to make it clear that we in government share her appreciation of the key role of the community nurse in the delivery of effective community care to people with AIDS. My noble friend will also be interested to learn that we have commissioned seven educational videos for nurses in this respect. They are highly regarded.

On counselling, we have funded a joint study by the British Association of Counselling and the University of Durham to report on the availability throughout the country of counselling services for people with HIV or AIDS and to make recommendations as to training and management. The study was started in January 1990 and is due to be published this spring. We shall consider its findings carefully.

On the question of AIDS and employment, guidance was produced in March of last year which refers to the dismissal point brought up by the noble Lord, Lord Winstanley. I can certainly supply him with a copy of the document.

In case I have not covered all the questions raised —that is quite possible since there were so many—I can assure the House that I shall study Hansard carefully and ensure that all the issues are considered within the department or, where appropriate, brought to the notice of other departments, bodies and individuals concerned. Much has been done in this difficult and crucially important area of health but as a result of the debate we are all more than ever aware that much remains to be done.

7.58 p.m.

Lord Kilmarnock

My Lords, I should like to express my gratitude to all noble Lords who have spoken in the debate. I express that gratitude not only to those who have spoken but to those who have listened. We have had quite a large number of listeners, which has been very encouraging indeed. I should like too to apologise for having told noble Lords who excused themselves to me for arriving late that I thought the debate would start at six o'clock, which is what I was informed would be the case. Their lateness is partly my fault.

There was one omission from my shopping list. The noble Baroness cannot reply to it now but I want to put it on the record. I skated over it because I thought I was running out of time. I refer to the tardy settlement of the claim of the haemophiliacs infected by contaminated blood products. I say no more about that because obviously we very much welcome the Government's conversion to the ex gratia payment. But there is also the further point in relation to non-haemophiliacs who were similarly infected through blood products or transfusions. I believe that the cost of compensating them would be in the region of 4 to 5 per cent. of what will be paid out to the haemophiliacs. The principle does not seem to be different. The effect on them and their families has been no less devastating than on the haemophiliacs and their families. I very much hope that the Government will look at that point again.

On the question of insurance, which, as the noble Baroness said, was one of the themes of the debate and which was ably introduced by the noble Viscount, Lord Falkland, and referred to by the noble Lords, Lord McColl and Lord Butterfield, I am encouraged to hear that Mrs. Bottomley is pursuing the matter seriously with the industry. In my view, the situation is most unsatisfactory. I say that because there are many reasons why people may take such a test; for example, responsible young people may wish to take the test prior to getting married, as may someone who has had a blood transfusion, possibly abroad. The fact that taking such a test may be marked against them by potential insurers is a great mistake. I very much hope that the Government will pursue the matter vigorously. I should point out that the matter was solved in the Netherlands by the government threatening to impose legislation. Perhaps a handy little draft Bill stored safely somewhere may be helpful in securing success in the negotiations with the industry.

I agree with the right reverend Prelate, who said that we should not concentrate only on "safer sex". He acknowledged that this is the responsibility of the Government as they are responsible for health, though not responsible for morals. Then, as I expected him to do—and quite rightly —he went on to advocate the other track of chastity and faithfulness. I commend to your Lordships that we should approach the matter on a dual-track basis; that is, that the Government should do their business, which is related to public health, and the Churches and other ethical bodies and individuals should do their business, which relates to private morality. If we approach the problem on that twin-track basis, we are much more likely to succeed. I hope that the Government noted the right reverend Prelate's rather moving remarks on the extension to the Brixton prison hospital and his idea for a hospice for prisoners.

The noble Lord, Lord Colwyn, seemed to be criticising me for not having arranged a meeting for him at which he could air his views on natural medicine. I should like to put on record the fact that, if he chooses to approach me, I shall be happy to do so, provided that he is prepared to speak at such a meeting.

I am extremely grateful for the tributes that have been made to me and to the all-party group. I believe that one such tribute came from the noble Lord, Lord Winstanley. I should point out to him that, according to my recollection, the pre-history of the group was that it emerged from a small causerie of doctors which he himself organised in the very early stages, when we knew nothing of the disease, in order to inform us about it. Therefore, if anyone is the real progenitor of the group, it is the noble Lord, Lord Winstanley.

I was glad to hear the noble Baroness say that the Government are dedicated to curbing the spread of the disease both in this country and abroad. She actually used the word "abroad" and I believe that that probably relates to the work of the ODA in the horrifying conditions in Africa about which we heard from the noble Lord, Lord Rees-Mogg, and the right reverend Prelate.

The noble Baroness set out some of the Government's achievements. She was quite right to do so. I should like to pay tribute to them. As she said, she could not possibly deal with all the points raised during the debate, but no doubt she will write to us on those that were left unanswered. On the education aspect of the matter, I made one or two additional points about whether we could harness the efforts of school governors and parent governors. I hope she will follow them up.

As regards funding, the noble Baroness referred to the fact that no virement of ring-fenced funds would be permitted in future. I welcome that statement. I also hope that she will consider the point I made about looking at a possible new distribution formula for ring-fenced funds. I think that I was glad to hear what she said on the issue of open access clinics in the genito-urinary medicine field. She said that they would be continued and maintained. I believe that the words which fell from her lips were that they would be maintained on a catchment-area basis. Obviously we shall look at that proposal. It is indeed an important matter, to which reference has been made many times in your Lordships' House. We simply must keep such clinics going. I shall read what she has said with care.

I shall not make another speech, as I do not wish to take up any more of your Lordships' time. However, I should like to repeat my thanks to all speakers who have taken part in the debate and all noble Lords who have listened. I should also like to thank the noble Baroness for making a truly memorable effort to meet all our anxieties. I am sure that she will be writing to us to cover all the points which she was not able to deal with tonight. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.

House adjourned at five minutes past eight o'clock.