Lords Sitting of 13 February 1991

Preamble
The House met at half-past two of the clock: The LORD CHANCELLOR on the Woolsack.
Prayers—Read by the Lord Bishop of Salisbury.

The Gulf: Military Costs
Lord Borthwick Lord Borthwick asked Her Majesty's Government:
What is their policy for financing military operations in the Gulf.
The Parliamentary Under-Secretary of State, Ministry of Defence (The Earl of Arran): My Lords, a substantial part of the costs have come from the reserve through winter and spring supplementary estimates. In addition, some of the costs have been met from the original defence budget and from contributions from other nations both in kind and in cash.
Lord Borthwick: My Lords, I thank my noble friend for his Answer. It is very interesting but not quite what I was looking for. My attention was drawn to something earlier. Can the Minister confirm that the UN Security Council should be responsible for collecting funds for the war rather than private or official individuals going round with the begging bowl?
The Earl of Arran: My Lords, that is not the case. It is the responsibility of individual member states of the coalition forces in the Gulf as to how they fund their requirements.
Lord Kennet: My Lords, can the noble Earl say anything about Saudi Arabia having to borrow from international institutions for the first time in its life in order to meet its quarterly commitment to the United States of 13.5 billion dollars especially in view of the fact that the United States is still financing Israel?
The Earl of Arran: My Lords, I cannot comment on that; it is an internal matter for Saudi Arabia. However, Saudi Arabia has been very generous to this country from the point of view of the material aid it is providing for our forces in the Gulf.
Lord Boyd-Carpenter: My Lords, are we receiving financial help from any of our colleagues in the European Community other than Germany?
The Earl of Arran: My Lords, as my noble friend indicated, Germany is providing £275 million. I understand that other countries are being approached. Obviously I cannot say who is being approached at what time.
Lord Mellish: My Lords, bearing in mind the enormous debt owed by Belgium and Holland to this country is it not time that instead of talking about it they did something about it? What does the Minister say about that?
The Earl of Arran: My Lords, the noble Lord has asked the same question before. I answered in regard to Belgium and Holland; I have nothing further to add.
Lord Molloy: My Lords, can the noble Earl assure the House that with regard to finances for our troops in the desert, not one single penny which can be garnered will be overlooked so that we can respond to their endeavour in a way which will be most practical?
The Earl of Arran: My Lords, as my right honourable friend the Chancellor of the Exchequer indicated, there are no limitations on the funding for our troops while they are in the Gulf.
The Lord Bishop of Manchester: My Lords, can the Minister say whether the cost of financing military operations includes the cost of reconstruction following the war in Kuwait and Iraq?
The Earl of Arran: My Lords, that is a Question for another day.
Lord Williams of Elvel: My Lords, when the Question was raised previously in your Lordships' House the noble Earl will recall that I asked about negotiations taking place between Her Majesty's Government and both Saudi Arabia and Japan to ensure that we received our fair share of the funding they were prepared to provide for the operations in the Gulf. At that time he replied that negotiations were still continuing. Can the Minister give the House any indication as to how those negotiations have progressed?
The Earl of Arran: My Lords, those negotiations are still in progress.
Lord Bruce of Donington: My Lords, will the noble Earl give the House an undertaking that all these questions and other matters associated with them will be borne in mind in the course of the intergovernmental conference that is taking place within the EC? The conference is alleged to deal with the progress that might be made in conceivable circumstances towards achieving economic and monetary union in Europe.
The Earl of Arran: My Lords, the conflict in the Gulf encompasses very wide scope. I am sure that all such points of view will be discussed and taken into account.
Lord Mackie of Benshie: My Lords, will the Government bear in mind that we went into this venture, I hope, on a point of principle and that we are prepared to pay the money? While contributions will be accepted we will not go round begging for money.
The Earl of Arran: My Lords, we are very grateful for the contributions that we have received. As I said, there will undoubtedly be additional costs. The contributions that we have already received will be taken into full account by my right honourable friend the Chancellor of the Exchequer.
Lord Borthwick: My Lords, I regret that my question was not quite answered. I asked who was responsible for collecting money. We went to war but not under our own name. We did so under the

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protective name of the United Nations Security Council which actually declared war. We joined in the war. Does not my noble friend agree that that organisation is responsible for collecting cash and not individuals from various nations?
The Earl of Arran: My Lords, that is not the case. As I said in my original Answer, it is the responsibility of each nation which has coalition forces in the Gulf.

Exchange Rate Mechanism
2.43 p.m.
Lord Stoddart of Swindon Lord Stoddart of Swindon asked Her Majesty's Government:
Whether they will remove sterling from the exchange rate mechanism of the European monetary system.
The Parliamentary Under-Secretary of State, Department of Social Security (Lord Henley): My Lords, no.
Lord Stoddart of Swindon: My Lords, is the noble Lord aware that that is a most disappointing Answer? Is it not a fact that the promise of sharply reduced interest rates before we joined the ERM has proved wrong? Does the Minister agree that it is a fact that the Government are now in a situation where they cannot cut interest rates by the amount required and are therefore endangering the real economy? Does the Minister further agree, as some distinguished economists remarked in The Times today, that we are in danger of having a 1930s-type slump with mass unemployment?
Lord Henley: My Lords, I am sorry that the noble Lord finds my Answer disappointing. He is probably not aware that at 9.47 this morning we announced a reduction in interest rates of a half per cent.
Lord Stoddart of Swindon: My Lords, that is too little and too late.
Lord Barnett: My Lords, will the Minister tell the House why it is that those countries within the exchange rate mechanism have for so long had a much better economic performance than we have?
Lord Henley: My Lords, that is why we went into the exchange rate mechanism—so that we could reap the benefits of that mechanism.
Lord Harmar-Nicholls: My Lords, is my noble friend aware that the exchange rate has nothing whatever to do with one's competitiveness in being able to earn the money to have a good exchange rate? Does he now agree that we joined on terms which are not satisfactory to us? Surely we should do something about the situation even if we do not withdraw from the exchange rate mechanism.
Lord Henley: My Lords, I do not accept what my noble friend said. There have been allegations that we went in at the wrong time. But as we explained when we went in, we thought that that was the right time to join and that is why we did so. I feel that any change
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now in the exchange rate—in other words, a realignment—would weaken our credibility. It is very important that we stick to the rate and convince people that we intend to do so.
Lord Grimond: My Lords, will the Government have time to study the letter in today's edition of The Times from some very eminent Conservative economists, including a recent adviser to a recent Prime Minister, which deals with this matter and which also stresses the essential need to reduce the interest rate?
Lord Henley: My Lords, I have studied that letter. As I said, we had already reduced the interest rate this morning by as much as it was prudent to do so.
Lord Jay: My Lords, does the Minister understand that at present the forces of depression have been allowed to grow so strong in this country that a small cut in the bank rate, without a drop in the exchange rate, will not turn the tide?
Lord Henley: My Lords, I am sorry that the noble Lord thinks that. The allegation of the risk of a depression must be put into context. The current situation of the 1990 GDP for manufacturing output and employment shows that a number of firms have already reached record levels.
Baroness Seear: My Lords, does the Minister agree that we debated all these matters at considerable length yesterday and that it is really a waste of your Lordships' time to do it all again the day after?
Lord Henley: My Lords, I certainly agree with the noble Baroness.
Lord Bruce of Donington: My Lords, will the noble Lord give the House an indication that, when the Government made the decision to reduce the minimum lending rate by a half per cent., they had already seen the text of the letter to The Times to which many noble Lords have referred? Can the Minister say why the Government do not accept the sensible situation of applying for a realignment within the existing exchange rate mechanism to a point where the pound might be valued at about 2.60 deutschmarks and about 1.55 to 1.60 dollars so that the economy can be put on an even keel and so that we may compete properly on an even playing field internationally?
Lord Henley: My Lords, the cut in the interest rate was not in response to the letter in today's edition of The Times. The cut was a measured response to the current market conditions.
Lord Annan: My Lords, does the Minister agree that the question asked by the noble Lord, Lord Jay, has great cogency? Are not the Government making the same mistake as they made four years ago when interest rates were raised by a half per cent., then by a half per cent. and then by a half per cent. with the result that inflation was not stopped? We are doing the same thing again; we are reducing the interest rate by only a half per cent. when we are facing a major recession.
Lord Henley: My Lords, I do not accept what the noble Lord, Lord Annan, has said. As I said, we judged it right to make a reduction of a half per cent. We shall make further reductions as and when we are able to do so. Interest rates are set at a level needed to keep sterling within its ERM band and thus to bear down on inflation. We feel that it would be a mistake to cut interest rates to provide a short-term stimulus.
Lord Williams of Elvel: My Lords, is the noble Lord aware that after the reduction in the base rate this morning sterling firmed within the ERM, which was contrary to expectations? Will the Government now take the other step and reduce the base rate by another half of one per cent.?
Lord Henley: My Lords, as I said, we reduced the rate by a half per cent. and we shall reduce it further as and when we are able to do so.
Baroness Phillips: My Lords, does the Minister agree that perhaps the previous Prime Minister, being a woman, was right after all and should not have been sacked?
Lord Henley: My Lords, that goes somewhat wide of the Question on the Order Paper.
Lord Stoddart of Swindon: My Lords, is the noble Lord aware that the Government show remarkable complacency about this whole business? Do not the Government realise that unless we have an urgent and substantial cut in interest rates the economy will slide into a real slump with high unemployment? Will the Government do something about that?
Lord Henley: My Lords, I am sorry that the noble Lord accuses me of complacency. I totally reject what he has said. We shall cut interest rates further when we are able to do so.

National Health Service Expenditure
2.50 p.m.
Viscount Hanworth: My Lords, in asking the Question in my name on the Order Paper I apologise for the fact that it was put down without knowledge that we were to have a major debate on the subject. Nevertheless, perhaps I may just say—
Noble Lords: No!
Viscount Hanworth—that I hope that what I am putting forward will be considered important in the major debate.
The Question was to ask Her Majesty's Government:
What consideration they have given to increases which may be required in National Health Service expenditure by new research developments which lead to more sophisticated treatments requiring more expensive equipment; and what action they propose to take.
The Parliamentary Under-Secretary of State, Department of Health (Baroness Hooper): My Lords, technical developments and ever increasing expectations for health services inform our decision-making
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about the level of spending in the National Health Service. We will be increasing it by more than £3 billion next year, taking planned total spending to £32.6 billion. These levels of expenditure, coupled with the measures we have taken to improve efficiency, mean that the service is able to keep pace with the demands arising from demographic change and medical advances.
Viscount Hanworth: My Lords, I thank the noble Baroness for that Answer but it does not in any way meet the point that I was trying to make. We shall be in trouble in the future—
Noble Lords: Question!
Viscount Hanworth: —because we shall simply not have—
Lord Ennals: My Lords, does the Minister agree with me on two simple points? First, does she agree that to cut back on fundamental research can rarely be a sensible economy? Secondly, while I accept that drug costs should always be kept under scrutiny, does she agree that it is not a sensible economy to reject new medicines if they have proved to be effective?
Baroness Hooper: My Lords, we are well aware of the importance of a research and development strategy. It is to that end that my right honourable friend the Secretary of State has appointed a new director of research. We are awaiting his plans.
Baroness Carnegy of Lour: My Lords, does the Minister agree that much medical research aims to increase the use of preventive medicine? That is likely to ease the costs of the National Health Service rather than increase them.
Baroness Hooper: My Lords, I am happy to agree with my noble friend. Indeed the main thrust of our reforms is in the area of preventive medicine.
Lord Elton: My Lords, is my noble friend aware that those of us who were crying "Question" a moment or two ago during the intervention of the noble Viscount, Lord Hanworth, were not seeking to silence him but merely hoping that he would put his question in an acceptable interrogatory form?
Viscount Hanworth: Thank you.

The Gulf: Merchant Shipping Contracts
2.57 p.m.
Lord Dean of Beswick Lord Dean of Beswick asked Her Majesty's Government:
Whether they are making maximum use of ships of the British merchant navy in the military activities in the Gulf, and whether the personnel involved are provided with the same chemical and biological protection equipment as members of the armed forces.
The Earl of Arran: My Lords, all eligible British shipping companies are able to compete for MoD charters but few companies have put ships forward for use in the Gulf. The safety of merchant seamen entering the Gulf is primarily a matter for the shipping

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companies concerned although we are providing advice and assistance to shipping companies as appropriate.
Lord Dean of Beswick: My Lords, I am sorry that the Minister did not care to deal with the second part of the Question, which is very important. Is the noble Earl saying that the jobs have to be tendered for? The figures I have been given show that only seven ships of the 123 in use by our forces are crewed and registered in Britain. Have we not come to a sorry pass when the Government were warned in your Lordships' House by noble and gallant Lords with extensive sea service and by Select Committees in another place that the merchant navy was being run down to a dangerously low level? Will the Government put that matter right?
On the second part of my Question, is the Minister aware that according to my information no such protection has been afforded the crews of these ships? If that is so, why is the situation allowed to continue? These men are in as much danger as anyone on any of the warships.
The Earl of Arran: My Lords, the noble Lord is not quite correct in the last part of his assumption. The merchant navy ships do not have to advance or sail nearly as far forward as the Royal Fleet Auxiliary ships. Therefore, their assessment of risk is considerably less than those in the front line who are serving the Royal Navy. It is for that reason that we give them advice and also assistance in the form of NBC respirators.
Lord Bruce of Donington: My Lords, are we to understand from the noble Earl's reply that the British merchant fleet is no longer entitled to the protection of the Royal Navy?
The Earl of Arran: My Lords, that is not quite the point of the Question. As the noble Lord, Lord Dean of Beswick, said, a total of 130 vessels have been chartered by the Government for use in the Gulf of which only seven are British flagged. The rate of protection depends upon the assessment in the area.
Lord Colnbrook: My Lords, my noble friend said in his original Answer that British ship owners had not tendered for very many contracts to serve in the Gulf. If the Government decide that they need British ships, have the ship owners said that the ships will be available if required?
The Earl of Arran: My Lords, the Government feel that they already have sufficient merchant vessels for the purpose of serving our troops in the Gulf.
Earl Attlee: My Lords, is the Minister aware that merchant seamen serving on the ships of the Royal Fleet Auxiliary are kitted out with gas masks and anti-bacteriological equipment? Is he further aware that sailing alongside them might be an ordinary merchant ship whose crew can obtain only one basic item, a gas mask? They have to apply to the embassy in Bahrain and pay more than £100 for each gas mask.
The Earl of Arran: My Lords, that is really not the point. As I have mentioned, I hope very carefully, merchant navy ships will not be sitting alongside the RFA. They will be considerably behind the RFA. In
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fact the furthest north they will probably advance is A1 Jubayl. If the British ship owner thinks that they require NBC equipment it is his decision as to whether or not they take that equipment. They do receive NBC respirators which play an extremely important part from the point of view of protection against vaporisation.
Lord Williams of Elvel: My Lords, is it the case that, if the ship owner decides that the crew needs protection, he has to pay for that protection? Is it further the case that the MoD is providing full protective equipment to journalists in the Gulf? If it is provided to journalists, why not to British merchant seamen?
The Earl of Arran: My Lords, as regards the protection of British journalists in the Gulf, obviously they are in a very much more front line area. The rate of risk is assessed to be greater there than it is where the merchant navy is operating—no further north than A1 Jubayl.
Lord Mackie of Benshie: My Lords, is not the most disgraceful point about the Minister's reply that only seven of the ships we need to support our troops in the Gulf are British flagged? Surely, something should be done about the flags of convenience under which British ship owners making money in this way are evading their responsibilities to crews. Is this not a matter of grave concern to the Government?
The Earl of Arran: My Lords, the main reason for so few companies offering vessels is that either the British flagged ships are generally busy with existing charters or that those put forward do not meet Ministry of Defence specific requirements in the current situation.
Lord Greenway: My Lords, does the noble Earl agree that the present situation in the Gulf amply demonstrates the need for a strong merchant navy? Is he aware of reports in the shipping press last week that foreign ship owners who have ships on charter to the Ministry of Defence are urgently seeking British seafarers to replace third world crews who have refused to sail into the war zone?
The Earl of Arran: My Lords, I agree with the noble Lord about the continuing necessity for a strong merchant navy. Indeed, over the past few years, the Government have done much to improve the quality of life in the merchant navy.
Lord Callaghan of Cardiff: My Lords, is it not the case that there is a shortage of British ships and especially of British seafarers? Can the noble Earl tell us what progress is being made as regards the strategic review of our maritime needs which was promised in the joint working party report? Further, can he say when that report is likely to be published and what conclusions it reached?
The Earl of Arran: My Lords, I am afraid that I am not able to answer such a question without prior notice. However, I shall certainly write to the noble Lord on the matter and place a copy of the letter in the Library.
Lord Dean of Beswick: My Lords, does the Minister not understand that many Members of your

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Lordships' House think that it is a very dangerous policy to allow such a huge percentage of our logistic support for this operation to be dependent upon market forces—that is what the Minister said—and foreign companies which have no loyalty to the Crown? Have we not learnt our lesson from the reluctance shown by the Belgians before finally deciding to provide us with ammunition? Therefore, would it not be better for us to do this ourselves? Will the Minister kindly convey that message to the Government?
The Earl of Arran: My Lords, as I indicated in a previous answer, it is felt that the Government have sufficient vessels of the merchant fleet to supply our troops in the Gulf. That remains the case.

Business
3.2 p.m.
Lord Denham: My Lords, with the leave of the House, I should like to say a word about the length of speeches in today's debate standing in the name of the noble Lord, Lord Ennals, to which your Lordships have agreed to apply a five-hour time limit. On the principle that the mover is allowed 20 minutes and that the Minister should rise to reply not less than 25 minutes before the scheduled end of the debate, no other speech should exceed nine minutes. I believe it is right to point out on this particular occasion that should any noble Lord speak at greater length, he would be doing so at the expense of other speakers.

Brighton Marine Palace and Pier Bill [H.L.]
Read a second time, and referred to the Examiners.
Commercial and Private Bank Bill [H.L.]
Read a second time, and referred to the Examiners.
Harris Tweed Bill [H.L.]
Read a second time, and referred to the Examiners.

Planning and Compensation Bill [H.L.]
Viscount Astor: My Lords, on behalf of my noble friend Lady Blatch, I beg to move the Motion standing in her name on the Order Paper.
Moved, That the amendments for the Report stage be marshalled and considered in the following order—

Clause 1

Clause 27

Clause 2

Clause 28

Clauses 3 and 4

Clause 29

Clause 5

Clause 30

Clause 6

Clause 31

Clause 7

Clause 32

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Clause 8

Clause 33

Clause 9

Clause 34

Clause 10

Clause 35

Clause 11

Clause 36

Clauses 12 and 13

Clause 37

Clause 14

Clause 38

Clause 15

Clause 39

Clauses 16 to 18

Schedule 1

Clause 40

Schedule 7

Clause 19

Clause 41

Clause 20

Clauses 42 and 43

Clause 21

Schedule 2

Clause 44

Schedule 8

Clause 22

Schedule 3

Clause 23

Schedule 4

Clause 45

Schedule 9

Clauses 24 and 25

Schedule 5

Clause 46

Schedule 10

Clause 26

Schedule 6

Clause 47

Schedule 11

Clause 48

Clause 60

Clause 49

Clause 57

Clause 50

Clause 58

Clause 51

Clause 59

Clause 52

Schedule 12

Clause 61

Schedule 14

Clause 53

Clause 62

Clause 54

Clause 56

Clause 55

Schedule 13

Clause 63

Schedule 15

Clause 64

Schedule 16

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Clauses 65 and 66

Schedule 17.—(Viscount Astor.)

On Question, Motion agreed to.

NHS: Long-term Objectives
3.3 p.m.
Lord Ennals Lord Ennals rose to call attention to the current state of the National Health Service and to consider its long-term objectives; and to move for Papers.
The noble Lord said: My Lords, perhaps I may say first what an honour it is to be opening this debate and how delighted I am that so many distinguished Peers from all parts of the House are taking part. It shows the extent of the concern and awareness of the difficulties in the National Health Service. I am especially looking forward, as is the whole House, to hearing the maiden speech of the right reverend Prelate the Bishop of Exeter. He is chairman of the Hospital Chaplaincies Council and, as I said, we are all very much looking forward to hearing his speech.
The debate takes place at a most difficult time for the National Health Service. The Government are assailed by problems from all sides. I should like to concentrate on some of the challenges. Most of them have been created by the Government but some are the consequence of scientific success. I should then like to share with your Lordships the plans which now stand ready to be implemented by an incoming Labour Government whenever the Prime Minister decides to go to the electorate.
Today's debate cannot be separated from the one which took place yesterday on the economy and the mismanagement of the economy by the Government over so many years. However, because I shall be saying some harsh things, I should like now to say a friendly word about Mr. Waldegrave. It is refreshing to find a Secretary of State who is prepared to listen, who has a charming bedside manner and whose priority does not seem to be to bash the head of anyone who cares to argue with him. Therefore, I wish him well, although so long as he pursues his predecessor's policies he will not receive much support from this side of the House.
We hold our debate in the shadow of a war which has rightly obliged the National Health Service to be prepared and ready to face the possibility of casualties from the Gulf. It is the prayer of all of us that no major demand will be made upon it. However, its doctors, nurses and other health workers will be ready to face an emergency, as indeed is always the case. Whatever happens, no one should use the argument of the Gulf crisis to explain the appalling situation of ward and bed closures and the postponements of operations on a massive and devastating scale. The Gulf crisis is separately funded.
Similarly, the Government cannot be blamed for the current period of bad weather. They may be blamed for the extraordinary way in which they have handled heating allowances in the past few days, but we cannot blame them for the weather. I suppose we could blame the Soviet Government for the weather as
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it seems to come from that direction. However, the Government must accept responsibility for any excessive death rate which may occur as a result of this very cold spell.
The gap between the rich and the poor in Britain seriously widened in the Thatcher years. That was a direct consequence of government economic and social policies. I give as an example the rundown of child benefit, which is now at its lowest level since this Government came to power. The benefit which was supported by all parties across the House is now seriously undermined. It is a sad betrayal of the principles for which I am afraid the present Prime Minister must share some responsibility.
As we hear of old people dying in this cold spell, either at home or sleeping on the streets, let us recall the fact that the British winter death rate is twice that of almost every other Western country. It is bad compared with countries which are accustomed to hard winters, but it is equally as bad when compared with countries such as France, Germany, Italy and the Netherlands. A recent study of winter mortality shows that, while 10 other Western countries see a 10 per cent. increase in deaths during the month of January, the comparable figure for the UK is 19 per cent. I believe that that is a reflection, as the Black Report showed 10 years ago, that people experiencing poverty suffer from poor diet and from bad housing. They are the main causes of higher mortality and the main reasons why old people suffer, especially under the present weather conditions. Indeed, it is a sad story of a decade of cuts.
In the last debate in this House on the National Health Service when the new legislation was before us I urged the Government to postpone the new untried reforms until the National Health Service was ready to deal with them but to press on with the plans for community care. We are now seeing the tragedy caused by the fact that the Government did exactly the opposite.
I shall concentrate on the National Health Service; my noble friend Lord Carter will deal with the frankly cynical decision by the Government to postpone the implementation of the urgently needed reforms in community care. I say "cynical" because the funds needed to provide decent services in the community are now to be used for straight party political purposes to reduce the worst excesses of the poll tax demands. That was a monstrous decision. It reflects no credit on the new Prime Minister or on the new Secretary of State that the community care provisions contained in the Bill have been postponed. However, as I said, my noble friend will deal with that aspect.
What has been the consequence of the Government's decision to bash on with the new NHS reforms? The Secretary of State decided that every health authority must balance its books by 1st April, regardless of the effects upon patient care. Almost every health authority in the country has been forced to cut programmes.
The report of the Association of London Authorities, based upon the results of a survey of

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London's community health councils, gives a district-by-district summary of the current financial situation and recent cuts and closures in each of London's district health authorities and reveals that NHS spending cuts in the 1980s resulted in the loss of a quarter of hospital beds in London—more than in any other part of the country. It revealed that waiting lists for treatment in London are longer than in other regions; that eight of the 10 inner London health authorities are having to make cuts in excess of £1 million in this financial year; and that elective surgery and orthopaedics have been hit especially hard.
When the Secretary of State decided that those cuts were to be made, I do not know whether he knew the consequences—so far 3,500 beds have been closed temporarily. My fear is that many of them will never reopen. There are at least two great London hospitals which are now in peril as a result of those decisions by the Government.
The immediate consequence is that waiting lists have soared to their highest level, and more and more patients and their families are waiting longer and longer for an appointment with a consultant and for admission to the reduced number of beds. Increasingly, patients are having appointments to see their consultants and to be admitted to hospital cancelled. In March last year, the waiting list figure was 963,000. That is about 50 per cent. higher than the average list when I was Secretary of State from 1976 to 1979. The figure must now be over 1 million, but no doubt when she replies the Minister will tell us what the figure is. Consultants in operating theatres are obliged to work below capacity, not because of NHS inefficiency but because of serious underfunding of the NHS.
The latest turn of the screw is the implementation of the NHS reorganisation which is extremely costly in terms of staff—administrators and accountants—and administrative costs. Perhaps the Minister will tell the House what is the latest estimate of those extra costs. I want to know because I believe that that is funding that should have gone to patient care. Had it gone to patient care, we should not have had some of the crises which now exist in the NHS. The funding of the new scheme is part of the new funding for the NHS. As I said, it should instead have gone to looking after patients' needs. With pay increases, and the funding of the higher levels of inflation —a higher level of inflation exists within the NHS than in the public sector generally—there will be little left for improvement.
Perhaps I may quote from the recent report of the Health Database 1990 by the Chartered Institute of Public Finance and Accountancy. It shows that the 8.4 per cent. increase in resources made available for hospital and community health services revenue in 1990–91 does not allow for any growth in services after taking account of the underlying deficit brought forward. The increase needed in hospital and community health services revenue in 1991–92 is estimated to be £1.5 billion—10 per cent.—after taking into account additional cost improvements and income generation.
Out of that new money, there is to be no improvement in the quality of service. The Minister will no doubt recite figures to show that each year funds for the NHS have increased. Of course they have. That is no big deal. It has happened 46 years running—since the first year of the NHS. No government have ever spent less on the NHS—even in real terms—than they did the previous year.
What is now happening in the NHS as it prepares for reorganisation? There has been an influx of new managers, many of them with little or no knowledge of the health service. I insist, from 25 years experience in the NHS, that we cannot run the service as if it were Marks & Spencer or ICI. Some appalling decisions have been taken over the heads of doctors and nurses. Let me give just two or three examples. Breast cancer screening, which could save 1,250 lives a year, has been cut to save money; thousands of long-stay mental patients have been discharged from long-stay hospitals, landing up in prisons or sleeping rough, because the Government will not provide money for good community care; mental hospital beds have been cut by 40 per cent. in a period of just two years; and hundreds of patients on kidney dialysis have been refused modern drugs to save money.
In my day as Secretary of State, we may have made many mistakes—there is no Secretary of State who did not—but it was the doctors who decided what treatment was needed by patients. In the future it may be nurses as well, but not managers. Managers are called upon not to take clinical decisions or to determine who should be treated but to be responsible for the management of the service. The new Tory-style NHS with its opted-out NHS trusts, its injection of business management techniques and restraints on GP clinical budgets, is designed to change all that, and is doing so with a vengeance. Cost-cutting accountants are now in the NHS driving seat.
Since the debate in Parliament last year and the programme of implementation, the plans have gained few friends. Everything that has happened has confirmed views that there should have been pilot projects, as were recommended by this side of the House. Support came from a small minority of consultants who were told that NHS trusts would bring in more money. They have now been told that extra funds will be strictly limited. There was also some real support from managers who knew that they would have more power. A recent survey by the National Association of Health Authorities and Trusts shows that most have now concluded that the new system will not bring the expected improvements. They have complained that the pushing through of reorganisation is seriously disrupting the work of the NHS.
Without doubt, the most disturbing development is the decision of the North East Regional Health Authority that it will reduce waiting lists by striking off the lists patients with painful varicose veins, wisdom teeth and other conditions for which doctors think they need treatment. IVF of course is out. That is the thin end of the wedge. Since the Secretary of State, Mr. Waldegrave, must have given his approval

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—if he did not, no doubt the Minister will say so in her reply—other regions may follow suit. How long will it be before other treatments are prohibited by health authorities and NHS trusts? When will we find that hernias and ingrowing toe nails are off the list? We can think of a number of conditions. What is the answer? How is one to have them done? They are to be done privately. Of course everyone can have their work done privately if they have the money to pay for it.
I say again, in my time as Secretary of State it was doctors and not managers who decided what treatment was necessary. We have the term "clinical freedom". That decision by the North East Regional Health Authority, unchallenged by the Secretary of State, confirms my worst fears—that the NHS is being prepared gradually for privatisation, and that the Government now need to look at a new set of priorities.
I most warmly commend to all of your Lordships, to whichever party you may belong, to read the new Labour Party health policy document entitled A New Start for Health. It is just what is needed. We should know what our opponents think. If the party opposite has some good proposals for the NHS I should like to have a copy so that we may study them. Of course funding is important. We cannot provide an adequate service without gradually devoting a higher proportion of GDP to health care, as other countries do. The problem is that the Government seem determined to reduce that proportion. Our answer is not just more money: who knows what financial crisis there will be when we come to power.
We must change priorities. Our major aim is to seek a better balance between curing disease and prevention. In co-operation with local authorities, we will give higher priority to policies to reduce health risks, to encourage healthier lifestyles, to support reliable screening programmes, to give a boost to natural and complementary medicines. I very much welcome the fact that we have a positive policy towards complementary medicines. This again is a subject which I know several of your Lordships will take up during the debate.
We will launch a national health initiative to tackle the causes of ill health, both mental and physical. Each regional health authority will have its own strategy for improvement of health in its own region, with clear targets and regional budgets for health promotion. Those targets will be adapted to local circumstances and will then be embodied in performance agreements between the local and regional authorities. Such strategies will ensure that every health authority which becomes responsible for family health services as well as hospital community services is working to agreed priorities, including the need to achieve the most effective use of resources. We know that it can be done.
Attention was recently drawn in the Guardian newspaper to the Merseyside region which achieved a dramatic drop in its waiting lists without resorting to shutting the hospital door. Every consultant was given a target which was continually monitored.
Last October, the Audit Commission showed how 300,000 extra patients could be treated each year without extra resources if more doctors would switch to day care surgery. Nationally, day care treatment accounts for about 17 per cent. of all surgical work in the National Health Service. However, in the United States it accounts for 50 per cent. Surveys show that patients prefer it and medical teams have more opportunity to develop routines closer to the needs of patients. Liverpool is the only regional health authority carrying this out but it could be done by every other region in the country. There will be a strategic policy board with responsibility for implementing the performance agreements and setting and overseeing the achievement of local targets.
In conclusion, we wish to establish a new partnership to create a better health service. It will be a partnership with the many professional groups within the National Health Service: consultants, nurses, midwives, and the professions complementary to medicine. We will establish a dialogue with them on the basis of consultation and agreement on our policies. We will have a basis of a partnership with local authorities and voluntary organisations. All of those are having a hard time getting on with this Government.
We will have a partnership internationally to seek to achieve the WHO objective of health for all by the year 2000; a partnership with the people whom the National Health Service exists to serve. Once again, health service management must include close links with consumer groups, including the community health councils. We know that when we come to power we will have a huge task. However, we have great faith in the wisdom of the British people. We will give them back their health service which the Government have hijacked. My Lords, I beg to move for Papers.
3.24 p.m.
Lord McColl of Dulwich: My Lords, I rise to bring you good news about the National Health Service with which I have been closely associated for the past 40 years. My memory is extremely good; I remember everything that happened during those 40 years. However, I have noticed on numerous occasions that time has taken the pain out of the memory for the noble Lord, Lord Ennals. Time has also taken the memory out of memory.
I bring to your Lordships the good news that we have more nurses and doctors today in the National Health Service than ever before. We have more personnel per bed than ever before. Last year we treated 7½ million people, which represents an increase of 2 per cent. on the previous year. Incidentally, in March 1990 the total figure for waiting lists was 5 per cent. lower than in 1979. The noble Lord, Lord Ennals, should take note of that figure. The three years during which he was Secretary of State—we must be fair to him—were the three unhappiest years in the whole 40 years of the National Health Service. Those of us who are old enough will remember the

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winter of discontent when it was even difficult to have one's relatives buried. We do not wish to return to those unhappy years.
It is true that we spend 6.1 per cent. of the gross national product in this country on the health service, and that is lower than the European average. However, if we were to pay the 1 million employees in the NHS at European rates of pay, it would increase the figure to 8 per cent. and that would be above the European average. The problem is that if we put more money into the NHS, it will be difficult to get it to the patients; it can so easily be absorbed in other ways.
Thus, in spite of all the doom and gloom that we have heard today, matters are not so bad as they are made out to be. The doom and gloom merchants do nothing for the 1 million employees in the NHS, except to demoralise them and make recruitment more difficult. Also, the doom and gloom merchants simply terrify some of the 7.5 million patients whom we treated last year.
I wish to look a little further at the way in which morale in the NHS can so easily be diminished. One of the most difficult objectives is to achieve financial control. There has been a long history of personnel overspending their budgets. In the late 1960s, the late Mr. Richard Crossman found himself in the lift with the secretary to the board of governors of Guy's Hospital. He recognised him and said, "You are overspending your budget". Mr. Harry Burfoot, who it was, said, "Yes, and that is what I intend to go on doing because I consider it part of my job". I recount that conversation not as a criticism of Mr. Harry Burfoot or Mr. Richard Crossman—it was just a way of life. When I returned to that story previously, the noble Lord, Lord Ennals, found it impossible to believe that the conversation had ever occurred. It did and it serves to illustrate that there was and is a problem with people keeping within their budgets.
It was the noble Lord, Lord Ennals, who quite rightly brought in cash limits in the 1970s—to be precise, 1976. I suspect that it had something to do with the International Monetary Fund at that time. Whatever the reason, we ought to give him credit for bringing in those limits.
During a previous debate the noble Lord said that if he had ever been faced with a district health authority that had not stayed within its budget, he would sack it. He went on to say that he had sacked it, and as a result the commissioners were brought in. That is another example of the memory of the noble Lord, Lord Ennals, not being quite as good as it should be, because he did no such thing. It was the noble Lord, Lord Jenkin of Roding, who did it a year or so later. I do not suggest for one moment that the noble Lord, Lord Ennals, is deliberately trying to mislead the House; I believe he genuinely feels that what he said is the case and that it was he who did so. Nevertheless, he did not. I say that because it is difficult to get the point over that financial control is all important. Even today, those resource management initiative hospitals that overspend are still being bailed out. Those who keep within their budgets are penalised by losing their savings. A resource
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management initiative on its own cannot work because there are no incentives for good behaviour and no disincentives for bad behaviour. The tradition of overspending, especially overspending someone else's money, seems to be ingrained in the British way of life.
I personally know that it is perfectly possible in the NHS to live within one's budget. At Guy's in my directorate we have lived within our budget for six years. The credit for that goes to the manager of the directorate, who is also the nursing officer. Nurses make good managers. She has lived within her budget of £3 million for the past six years and has managed to save some money. One can imagine how demoralised she would be if someone attempted to take away those savings. That is what people sometimes try to do.
Hardly a day goes by without some rumpus about the closure of hospital beds. There are many aspects to this problem. As the noble Lord, Lord Ennals, has said, nowadays a lot of day case surgery is being undertaken. If one has the same number or a slightly increasing number of surgeons and one is keeping patients in hospital for only a short time, clearly one does not need as many beds as in the past. There have been headlines on this issue in the newspapers. Robin Cook has stated that 20 per cent. of acute beds have been closed in the past 10 years. That does not appear to be good news at first. However, he should have told us how many beds were closed in the previous 10 years. Since 1965, 7,000 beds have been closed every year, irrespective of the government in power. I hope we can reach an agreement in the House that in future no one will ever say that this or that government are closing a certain number of beds. The number of beds available has shown a straight line decline irrespective of the government in power.
Waiting lists are a strange phenomenon. To a surgeon they are like a virility symbol. Ira surgeon has a long waiting list, it means he is an important surgeon. That idea has been around for a long time. The true value of a surgeon is the amount of work he gets through. Some of the people on waiting lists have forgotten why they are on them. When some of them are asked to come in, they have either forgotten why they are on the list or they have had the operation performed some time in the past.
Noble Lords: Or they may have died.
Lord McColl of Dulwich: My Lords, it is perfectly true that they may have died. That gives rise to a great headline "Patients dying on waiting lists". However, if one asked those patients what they were dying of, they would mention some other condition. That too is a relevant fact. I read an article in a Sunday newspaper which stated that patients were dying on waiting lists. I wrote to the author of the article, and he informed me that he could not give me any details because his article was more concerned with polemics than with facts.
Unfortunately it is a characteristic of the British people to denigrate their own institutions. I wonder whether it would be possible for noble Lords to try to triumph over their British environment and be a little

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more positive about the National Health Service. Perhaps we should congratulate NHS employees on improving the quality and quantity of their work when there are fewer beds available and when they are rewarded with a rate of pay which is well below that of their European Community colleagues. Encouragement costs nothing.
3.34 p.m.
Lord Winstanley: My Lords, I am grateful to the noble Lord, Lord Ennals, for giving us an opportunity to debate this vital subject which is of immense importance to each and every one of us. I agreed with almost everything that he said about the current state of the National Health Service. However, I did not altogether agree with some of his remarks which had nothing to do with the current state of the National Health Service. I thought he went further than the immediate subject we are discussing and I regret that some of those remarks were said in a way that I believe was calculated to turn the discussion into more of a party political contest than should be the case. With so many experts on this matter in your Lordships' House, we should have an informed discussion about the National Health Service and what we should do about it rather than indulge in a party battle.
I am not so naive as to suggest that we can keep politics out of the National Health Service. Certainly when I speak in your Lordships' House I do not speak non-politically, particularly when I remember how one defines that phrase. In years gone by when I sought votes to enter another place I knocked on doors and people used to say, "I am sorry, doctor. We are not political; we are Conservatives". I hasten to say that I am not non-political and I am not being non-political. However, I believe my fears were rather borne out by the kind of response which the words of the noble Lord, Lord Ennals, triggered in the noble Lord, Lord McColl. When one considers the immense expertise in hospital work of the noble Lord, Lord McColl, one would have expected him to use up some of his nine minutes explaining to us precisely how he thinks the National Health Service trusts self-governing status will work for hospitals.
I deny that it is a question of hospitals opting out of the National Health Service. A hospital that becomes a NHS trust is still in the National Health Service. However, I should like to hear how trust status will work from someone who is intimately connected with the detailed working of these matters. I regret that the noble Lord did not explain that. However, he talked about the record of the previous government. I notice that the Motion we are discussing comprises two subjects—the current state of the National Health Service and its long-term objectives.
I hope that the long-term objective of the National Health Service is to do everything that is necessary for every patient, be they men, women or children, at the time of need without charge. I hope that that will continue to be the objective of the National Health Service. The noble Lord, Lord McColl, said he had been connected with the National Health Service for
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40 years. I go back two-and-a-half years further than that and I can declare that the National Health Service never has achieved the objective I have spoken of. That objective was not achieved on 5th July 1948 when the service was established. The objective I have mentioned is impossible to achieve given the way in which medicine constantly develops, thereby creating rods for its own back.
Every week we keep alive at immense expense people who formerly would have died—they require a great deal of care from the National Health Service —and constituted no expense or trouble to anyone. I shall give an example of that. Let us consider the huge and expanding science or discipline of human organ transplants. If we were ever to say that every man, woman or child who could conceivably benefit from a human organ transplant was entitled to have such a transplant, we should then have to accept that no one would treat people for haemorrhoids, bronchitis or any minor ailments. The whole National Health Service would be turned over to operations involving advanced technology.
We have to consider that position. The National Health Service cannot do everything for everyone. There have to be priorities. As has been rightly said, the National Health Service cannot use up all the resources available. Other government activities also require resources and some of those activities such as housing or the environment are not unconnected with health. The National Health Service will merely have a share of available resources. That share will never be large enough and that means we must have certain priorities. It also means that sooner or later we shall have to carry out cost-effective studies into the activities that our hospitals and our doctors perform almost daily to find out what is worth doing.
I am not talking about ceasing to perform minor operations such as removing in-growing toe nails or varicose veins. However, we should start to reconsider some of the more costly and resource consuming activities of the National Health Service. We must consider whether we can devote such a large proportion of our resources to activities which on the whole benefit only a small number of people.
Nine minutes is not a long time to deal with a subject such as this. I shall therefore move on at once to say how very much I look forward to hearing the maiden speech of the right reverend Prelate the Bishop of Exeter. I have a special interest in that one of his distinguished predecessors as Bishop of Exeter, Hugh Oldham, many years ago founded the school at which I was educated. Now that the Manchester Guardian is called the Guardian I say that I was educated at the grammar school. The grammar school was founded in 1515 by Hugh Oldham, Bishop of Exeter.
The noble Lord, Lord McColl, concentrated to some extent on hospitals and there has been much talk about waiting lists. I should like to use some of what little time remains to me to talk about general practice. I believe that our system of the family doctor general practice is almost unique in the world. If it perished, the situation would be very serious and the nation would suffer greatly.

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In the family doctor system which we still possess in this country one doctor is responsible for the family. Instead of a number of different doctors each being responsible for different parts of the patient, there is one doctor—the family doctor. That is a uniquely British concept, and it is in danger.
I was in general practice for many years. In the eyes of one's friends and relations once a doctor always a doctor, but I am very much out of date. I thought that I should bring myself up to date on some aspects. I spoke to a doctor who is now in active practice. It so happens that he started in general practice as a trainee with me. There has been much talk of waiting lists: I decided to examine those for outpatient appointments. In my recollection they are the ones which cause immense trouble for general practitioners and their patients.
I consulted the doctor who practises in a fairly prosperous suburban area near Manchester. He told me that for neurological outpatient appointments there was a wait of about three months. In orthopaedics the shortest wait for an appointment at any hospital in the area was two months. At the Manchester Royal Eye Hospital, perhaps the best centre for ophthalmic work in the North-West, the waiting time for an outpatient's appointment was one year. That means one year before a general practitioner can get a second opinion free of charge on the National Health Service from a hospital consultant without going to the trouble of calling out a consultant for a domiciliary visit which is difficult to achieve now.
For skin conditions, the wait was three months; for ear, nose and throat conditions, it varied according to the hospital from one month to nine months. That is a very difficult situation.
General practitioners now have new contracts. There was much discussion of that subject when the contracts were first mooted and came into force. The review body has reported recently on salaries. I was disturbed to find that the one part of the review body award which is not to be phased in is the increase in capitation fees. Payment on the basis of capitation encourages increased list sizes for doctors. For the whole of my professional life—and I am sure that this also applies to the noble Lord, Lord McColl —the emphasis was on reducing list sizes. It is therefore very regrettable that the one item which has not been phased is the increased payment on the basis of capitation.
The doctor to whom I spoke told me "When I studied in your practice years ago we did our best to see whether in 24 hours we could satisfy the needs of our patients. Now I find that I am having to do my best in 24 hours to satisfy the needs of bureaucrats in the family health service authority". I could go into that matter at great length but time does not permit.
Health education has been mentioned. I hope that noble Lords will listen carefully to the speeches of the noble Earl, Lord Baldwin, and the noble Lord, Lord Colwyn, both of whom will suggest ways in which we could reduce the burden on practitioners. Health
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education has changed from the days when I was involved. Now we need to teach people that most things get better by themselves. However, we also have to teach them how to recognise the danger signals which indicate the need for special and very expensive resources. That is the type of exercise on which we have to embark.
3.45 p.m.
The Lord Bishop of Exeter: My Lords, in this contribution I aim to draw attention to just one component part of the National Health Service, the hospital chaplain. I thank the noble Lord, Lord Ennals, for mentioning my responsibilities in that regard.
I apologise to your Lordships for the fact that I shall not be able to be present at the very end of the debate. I am very disappointed about that. Until a few days ago the debate was scheduled to be a shorter one and I arranged my subsequent duties in the South-West accordingly.
The hospital chaplaincy is regarded by the service itself as an integral part of the service. The hospital chaplain is appointed not by the Churches but by the health authority. The health authority pays and it is to the health authority that the chaplain is accountable.
The Churches are very appreciative of the opportunity afforded by the health service to offer ministry to patients and to staff. The Churches are very appreciative of that investment, particularly in the training of hospital chaplains. The Churches are also appreciative of the fact that the number of full-time hospital chaplaincy posts has increased steadily year by year over the past decade.
There is plenty of evidence that the ministry of hospital chaplains is appreciated by the public. Public opinion seems to approve of hospital chaplains. The Health and Social Service Journal a few years ago carried an article entitled "Treating Mind, Body and Soul" which read:
"Which group of National Health Service staff has doubled its numbers over the past 10 years, scarcely raising a comment from the public and government? Which group of staff did most patients in a survey say they would have liked to consult while in hospital?
"Answer: hospital chaplains".
I know of one instance in which a health authority was a little slow to appoint to a vacant part-time post. The local general practitioners took action themselves and wrote to the health authority to ask for speedy action.
The favourable view of the hospital chaplain which seems to be held by the public is not surprising. We all know that the healing process is not entirely a matter of physical and technical skills. There is a good word applied to the National Health Service—"quality". It relates to quality of service. That quality is not to be judged only by practical criteria, necessary as those are and right as it is that they are being brought to bear with increasing stringency. Quality of service is also to be judged by less measurable criteria. In the chaplain and the team of helpers that a chaplain often gathers around him or her a hospital has a person who, in the midst of all the pressures of work, can

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stand back and see the patient as a whole person—body, mind, soul—with needs in all those departments.
The chaplain is someone who can be with the patient at a time when the patient is under the considerable stress of a new experience. The patient is away from home and from the familiar resting place at night, away from wife or husband perhaps for the first time in 20 or 25 years and is facing the unknown in surgery. In the hospital chaplain the hospital has a person like the Royal Navy chaplain, who is described as being the friend of all on board. The hospital chaplain is able to go into every department of those great institutions (our hospitals) as a totally non-hierarchical person. The chaplain is concerned as much with staff as patients. Staff are under pressure. The hospital chaplain, especially in making time for staff, can bring to bear great qualities and help different parts of the institution understand each other. The hospital chaplain is being increasingly given a place in the plans now coming to the fore to deal with major accidents and disasters.
Health authorities are required by statute to make provision for the spiritual needs of patients and staff. The view of the Department of Health, I understand, is that it is not a statutory requirement to provide chaplains as a way of making that provision, although in practice it is usually the way. At a time of financial stringency a health authority faces agonising decisions as to what the true priorities are. Some signs are emerging that those pressures are possibly putting the hospital chaplaincy post down the list of priorities. Why, it is asked, cannot the locally-based minister do the work? There are three reasons why in a large hospital that is not possible. One is that the acquisition of the skills involved depends on stability of employment. Another is that a large hospital needs a full-timer as part of the family or team. Lastly, the number of local ministers has halved over a generation. In the year I was ordained I was one of 600 new deacons that year. We are fortunate if we can now ordain 300 new deacons every year.
Hitherto the National Health Service has regarded chaplaincy as an integral part of the service. That is consonant with what we know about health and healing, which are a combination of technical advances, for which all of us are grateful, and meeting the less measurable needs of the human being. I am referring to the non-physical needs of a person, especially when under pressure, and the needs for faith and a purpose in life—a life which can be very delightful but also at times very painful.
3.54 p.m.
Lord Morris of Castle Morris: My Lords, perhaps I may say first what a great privilege it is to be following the right reverend Prelate the Bishop of Exeter. I am sure I speak for the whole House when I say that he has made a most distinguished and thought-provoking maiden speech. As your Lordships may know, he is the son of a doctor (a lieutenant-colonel in the Royal Army Medical Corps) and despite the fact that he graduated from
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Cambridge rather than another place, he has pursued a long and distinguished ministry in the Church at Northampton, Wisbech, Folkestone and as Bishop Suffragan of Willesden. The whole House will look forward to many regular contributions from him in the future.
We are invited by the terms of the Motion to speculate on the long-term objectives of the National Health Service. Philosophically speaking, I suppose there can be no other ultimate objective than the control and elimination of disease. To that end, the logical means is to give priority to preventive medicine and the prevention of disease rather than its cure. Of course that is an impossible aim, but it has been well said that the first duty of the health service is to help the public to stay healthy. It is towards the present embryonic state of a few initiatives to that end that I beg leave to direct your Lordships' attention, with special reference to the situation in Wales.
The Labour Party publicly stated as recently as December 1990 that:
"The most obvious imbalance in our health service is that it offers a first-class repair service to those in ill health, but gives little priority to preventing ill health".
I hope the Minister will comment on that when she speaks.
"Coronary heart disease absorbs an estimated £500 million a year in health spending on emergency treatment and intervention surgery, but only £10 million is allocated to health promotion programmes to reduce heart attacks. Britain has some of the highest rates of coronary disease in the advanced world and is making slower progress in reducing them. Yet poor investment in strategies of prevention has persisted despite examples of good practice, such as Heartbeat Wales or the work of the Health Promotion Authority".
Heartbeat Wales, under the dynamic and indefatigable direction of Professor John Catford, was an inspirational success in an area which for a variety of reasons had a much higher than average incidence of heart disease. That success led to the creation of the Health Promotion Authority for Wales, which published its strategy document Health for All in Wales last month. That document is not vague or cautious. It lists nine specific health goals or intentions, for example: to reduce the incidence and impact of cardiovascular diseases by at least one third; to reduce disability and premature death from cancers by at least one quarter; and to reduce the incidence and impact of chronic respiratory disease by at least one half—and anyone who has known a disabled miner fighting for breath and unable to walk up 10 steps as a result of the humiliating ravages of pneumoconiosis or silicosis must say amen to that.
It is an awesome challenge, but the key to it is the concept of a dynamic partnership between the Health Promotion Authority and local authorities, the education sector, commerce and industry, voluntary and community organisations, the mass media and governmental organisations. Such a concept makes every kind of political, economic, financial and community sense. It is devoutly to be hoped that appropriate funding will be made readily available to support and complete such a visionary initiative. It should have happened 10 years ago, but there is joy in heaven over one sinner that repenteth—even in the

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present Government—and in fairness it can now be said that there is at last hope for the future for preventive medicine in Wales.
A crucial part of a preventive programme is the provision of efficient screening methods for the early detect ion of known serious conditions. It may surprise some of your Lordships to learn that the Welsh breast screening programme did not become operational until February 1989. Results are available for the first 18 months of screening in south-east Wales where 15,000 women have been screened, and there is a breast cancer detection rate of 0.97 per cent. At 9.7 per 1,000 women screened, the Cardiff screening centre has one of the highest detection rates in the United Kingdom. If that experience continues, some 850 cancers will be detected in screened women during the prevailing round of screening in south-east Wales. It is the objective of Breast Test Wales to identify and invite at least 90 per cent. of the 250,000 women aged 50 to 64 resident in Wales to have an initial mammogram by December 1993, and thereafter every three years, and to achieve acceptance of the screening initiative by at least 70 per cent. of those invited. Those targets are realistic but it must also be said that they are very modest. For many women in Wales it will be too little too late.
But long-term prevention can hardly be better illustrated than from the field of medical genetics. The Institute of Medical Genetics at the University of Wales College of Medicine is absolutely in the forefront of this work. It provides a service for patients and families with genetic disorders in all parts of Wales as part of the National Health Service. Families are seen for genetic counselling. The aim is to give full and accurate information on the risks of a possible genetic disorder in the family and advise on what can be done to help avoid that risk.
Parallel to that clinical work are the laboratory genetic services. New techniques in genetics offer increasing possibilities for the detection of serious genetic disorders. They include the examination of both the chromosomes and the genes themselves. Supporting that is the regional DNA bank. By isolating and storing DNA from blood or tissue of an affected person, tests that benefit relatives may be possible many years after the patient has died. All that research is being constantly fed into the training of doctors of the future since the staff of the medical genetic service are actively engaged in postgraduate teaching throughout Wales as well as with undergraduate teaching in the college of medicine. That is an initiative which the Government will surely smile upon.
One of the principal goals of the Health for All in Wales programme is to reduce obesity and overweight. All the evidence nationwide points to the perils of obesity and inactivity in the incidence of cardio-vascular and other diseases. At this point I come close to home. The daily work of your Lordships' House is not characterised by the vigorous physical activity which generates rude health and —present company excepted—as I look around the Chamber day by day I see that many noble Lords and,
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it must be said, some noble Baronesses are (how may I put this delicately and not call a spade a shovel?) much too fat.
Is it not our duty to take positive health promotion and preventive medicine seriously ourselves? Dare we preach to others what we do not practise? The Westminster gymnasium, which is fully equipped and professionally staffed, has been set up to encourage us to maintain good health by sensible exercise. It is not a conventicle of muscle-bound health freaks sweating and grunting their way to cardiac arrest. It is a sensible way to a healthy lifestyle. It symbolises the best contribution that we can make to achieve the long-term objectives of the NHS. I beg leave to commend it to your Lordships.
4.3 p.m.
Lord Nugent of Guildford: My Lords, I start by thanking the noble Lord, Lord Ennals, for giving us the opportunity today to debate the National Health Service. However, I am not able to thank him for his somewhat slanted picture of the health service, a picture which my noble friend Lord McColl so brilliantly put into more objective perspective.
Briefly, the Government's record over the past 11 years will bear comparison with that of any other government. The funding of the health service has risen by some 42 per cent. in real terms, from £8.1 billion to £32 billion a year. That is a record that no other government can match. As my noble friend said, the number of hospital in-patients treated has risen by 25 per cent. and day cases treated have increased by 100 per cent. With regard to manpower, there are more doctors: 3,000 more GPs is an increase of 15 per cent. and hospital doctors show a 10 per cent. increase. Numbers of nurses and midwives have increased by 8,000, which is an increase of 4 per cent. Pay scales for doctors have risen by more than 36 per cent. in real terms; for nurses and midwives they are plus 41 per cent. That is an impressive record. But dialectic sometimes blurs the view and many of those extra features were forgotten when last year's policy development Working for Patients was announced. The hostile reception, I have to admit, came from across the board.
Perhaps the emphasis on instant transformation to a market economy was a mistake. The good ideas in Working for Patients were lost in the welter of criticism. But the fog of war has now dispersed and, despite what the noble Lord, Lord Ennals, said, the virtues of the new policy are being recognised and are beginning to be adopted. Even the BMA has a kind word to say for the resource management initiative and has produced an excellent commentary on it.
The resource management initiative is central to improving the working of our hospital services. It proposes that consultants and all clinicians should be fully involved in the management of their hospital, so that they share responsibility with managers in a partnership (as the noble Lord, Lord Ennals, called it) for the budgeting and allocation of resources. The executive manager continues to carry ultimate

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responsibility as the accountable officer but management can be devolved to clinical directorates, each under a clinical director, covering the individual specialties in the hospital. Each clinical director will be fully involved in setting the budget for each directorate.
To make that complex structure work satisfactorily it is necessary to install a comprehensive range of computer services and modern information technology. That is expensive. A pilot scheme was introduced five years ago into six hospitals. As a result the structure is now being introduced into 50 hospitals across the country. I have been privileged, through the kindness of my noble friend Lord McColl, who took a leading part in producing it, to see the report on Guy's Hospital. The result of five years' intensive work shows a great improvement in the use of resources for the benefit of patients, the satisfaction of staff and, ultimately, the benefit of the taxpayer in value for money. It also confirms the magnitude of the task. I warmly congratulate my noble friend on the part that he played in it.
However, the BMA reports that extension to 50 hospitals across the country is being considered on an off-the-peg basis founded on the experience of those six hospitals. I hope that that will not happen. I hope that my noble friend will take note. There is no scope for short cuts. Each hospital, with all the complexities of its many strands of activity, is different.
I urge on my noble friend the Minister certain fundamental factors which are essential for success. First, the clinical staff across the board must enthusiastically want the scheme. Success depends on much extra work being done by them. It is essentially a team effort. Secondly, a specialised business consultant will be required to study the working of each hospital in order to design a management and accounting structure to suit it and advise on the appropriate computer system to collect and organise the information and accounts. The staff must then be prepared for four or five years of very hard work to get the system going.
The calibre of the executive manager required to make a success of the combined operation of managers and clinicians is critical. The manager must stand several grades higher than in the present management structure and the salary level must be nearer the award-holding consultants if he is to succeed with the leadership. As we all know, top consultants are high-powered creatures focused primarily on the welfare of their patients. To form and lead the new combined structure the executive manager must be of similar calibre. I say again to my noble friend that without that the Secretary of State had better say goodbye to the whole idea.
American experience with a similar concept is absorbing over 20 per cent. of the total cost. That is alarming; and I am sure that it is unnecessary. In the experience of Guy's Hospital, that did not occur. However, the position must be watched very closely in hospitals which are adopting such a scheme. Some hospitals will opt to become self-governing National
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Health Trusts. Obviously the great teaching hospitals will wish to regain the self-governing status which they lost in 1974. Others may also wish to gain the advantage of submitting their annual requisition for finance from the Secretary of State on the basis of their accurately budgeted accounts. That would rescue them from the present poverty trap suffered by all enterprising hospitals—that the harder they work the sooner they run out of money. We see that happening every year. I believe that the resource management initiative is an essential preliminary to any hospital becoming a National Health Trust.
I conclude that Her Majesty's Government's policy development, Working for Patients, contains some excellent ideas. However, it is not a prescription for instant change, rather a sound basis for organic development over the coming years. I cannot discuss any other aspect of it. I welcome the kind words of the noble Lord, Lord Ennals, about the new Secretary of State. With his first-class intellectual grasp of this great national service which touches the lives of us all, and with his diplomatic approach to the vast body of professionals and technicians of which it is made up, I believe that there is a real prospect of progress for the benefit of patients, staff and taxpayers.
4.11 p.m.
Lord Butterfield: My Lords, I hope that on behalf of the Cross-Benchers you will permit me to add our congratulations to the right reverend Prelate the Bishop of Exeter for his splendid and profound maiden speech. I can vouch for the fact that the work of hospital chaplains is widely appreciated, not only by the patients and their relatives but by the clinical staff who frequently find such psychological support assists their work when trying to help people who are gravely ill.
In the remaining few moments for which I may speak, I hope to show how important it is to harness the fast developing technology. It is not impossible that within the foreseeable future, through such projects as genetic fingerprinting, we may be able to tell those people who are at special risk from cancer of various parts of the body exposed to various toxins that they are at risk. I hope that that will further open the way to people being able to protect their health. Technology has allowed diabetics to take increasing responsibility for the management of their health at home. I am sure the health service will develop that aspect with the passage of time.
As a Cross-Bencher, I do not wish to enter into party exchanges. When I joined these Benches our convener reminded me that one of our purposes was to try to improve things. I must commend the improvements that I have seen in the health service over the past months. No doubt the noble Baroness, Lady Hooper, will be able to widen the definitions of progress. However, it is important that funds are now going into medical audit. There is wider recognition, as the noble Lord, Lord McColl, pointed out, that nurses are excellent managers. There is the possibility that within the foreseeable future they will act as prescribers in the National Health Service.

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The noble Lord, Lord Nelson, may touch upon this fact. But there are strong rumours that there will be more clinical research in the National Health Service. The noble Lord led the Select Committee of your Lordships' House which pressed for that, and I am sure 1 hat it is timely.
Perhaps I may say how happy I am to hear, as the Secretary of State pointed out, that the salaries of junior doctors will be to a national scale. One or two noble Lords may have been awake at quarter to one one night when I pressed that we might have a national scale for all clinical workers in the service. The objective is to discourage concentration of especially able people in the new trust hospitals. I shall not develop that to the discomfiture (I should like to hope) of Her Majesty's Government. However, it raises an important point. There is much evidence of variations in class culture between attitudes towards health. The attitude towards smoking varies in different parts of the country and with different classes. The same is true of the attitude towards the consumption of alcohol.
I do not live far from Huntingdon. To me the good thing about the Member of Parliament for Huntingdon who has become our Prime Minister is his statement that his aim is for a classless society. That would be a great help to those of us concerned with health promotion. More recently he has spoken to the Young Conservatives about education. The health service will certainly be grateful for any enrichment of the educational standards that we can achieve in this country.
As was pointed out by the noble Lord, Lord Morris of Castle Morris, the health service needs health education and health promotion. It needs targets of healthiness. I am sure that in the long run we shall find more young doctors coming forward who are anxious to serve that aspect of the nation's life.
It is also important that we in the health service are conscious that it is only one part of an immensely complicated network. The health of the nation depends upon the economic success of the nation. Slumps and unemployment add to the burden of illness. We in the health service are greatly concerned about the food that people eat. That aspect involves the Ministry of Agriculture. It is therefore important to bear in mind that the health service is part of the warp and weft of the nation. That gives me a chance to return to the speech of the right reverend Prelate. In the health service we should never forget that our origins are in the charity that was initiated by the great religious houses.
I wish to spend a few seconds on health promotion. I am the chairman of a health promotion research trust. My vice-chairman is the noble Baroness, Lady Birk. She said that she was sorry that she could not be present. She was kind enough to say that she felt sure that I would speak up properly for the trust, and I shall try to do so briefly. We have run 150 projects. We have uncovered an enormous amount of the most dreadful ignorance. When our report is published in a year or so about the fate of young girls in schools
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when their menses begin, I venture to say that many noble Lords will be shocked by the experiences that those young girls suffer.
We found that it is fairly easy to organise research. It is immensely difficult to organise promotion. In the future high technology must help us all to achieve ways and means of targeting important information to the people who need it. Targeting information will be a vital factor in the health service of the future. I believe that the health service can do great pioneering work to find out the best way to do that.
Those in the health service are aware of that factor. Ann Richardson, Christine Jackson and Wendy Sykes have recently produced a report called Taking Research Seriously. They have seen the importance of targeting information to the people who need it. I emphasise most strongly that they have also seen the importance of an educational service in translating science into language that people can understand.
I tried to write a book about diabetics, which is my subject, and I showed it to a young American school teacher. He said, "My dear professor, there are far too many words with too many syllables for the kind of people you wish to reach to be able to understand what you are saying". I believe that not only will technology provide us with the means of reaching people but it will have to teach those such as me and perhaps other Members of this House the skills of communicating information so that it is understood by those being targeted.
I am grateful for your Lordships' attention. I am also grateful to the noble Lord, Lord Ennals, for giving us the opportunity to talk about this important service and to look into the forward dimension. We must harness the fast-moving technology. We must aim to teach people to protect themselves from what is happening in the world around them. We must also teach people to take care of themselves after diagnosis.
4.21 p.m.
Lord Nelson of Stafford: My Lords, I too thank the noble Lord, Lord Ennals, for introducing the debate at what is, an appropriate moment when important changes are taking place in the National Health Service. I too congratulate the right reverend Prelate the Bishop of Exeter on his excellent maiden speech. I found it intensely interesting.
I shall confine my remarks to research because, as was said by the noble Lord, Lord Butterfield, I was chairman of your Lordships' Select Committee on priorities in research. First, however, I congratulate the Government for tackling the important issue of reviewing the National Health Service. Every large organisation must be reviewed from time to time. The larger it is the more important it is. As times change so do needs, people, and conditions, and one must also change one's ways. It is good that the Government are doing so.
As a result of the Select Committee's inquiry into medical research it reached a number of conclusions. Time will allow me only quickly to summarise them. We found that as regards the research which was being carried out by the MRC, the research charities and the

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pharmaceutical industry within their available resources—and naturally they were insufficient—the work was excellent. It provided a good background for the National Health Service. However, our report also contained a number of criticisms. We were not impressed by the status which was accorded research within the NHS. We were unhappy because insufficient demands for need-led research were coming up from the NHS to be fed into the research programmes. We found considerable conflict in hospitals between the responsibilities for patient care and the need to conduct clinical research in the shortest possible time so as to bring research to a fruitful conclusion. That was particularly so as a result of the pressure on funding. We were also surprised at the paucity of the work being undertaken in the field of public health research and operational research. It was surprisingly small for such a large organisation. We believed that a greater effort in that area would more than pay for itself while providing a useful opening for the training and education of future NHS managers.
After a long time the Government responded to our report. Their reply was encouraging but it did not go far enough. We referred it back to the Government and held further discussions. I can add to the good news referred to by my noble friend Lord McColl because at the end of the day the Government decided to appoint a director of research and development within the National Health Service with a seat on the NHS management committee. We believe that such a person will play an important part in rectifying some of the disclosed weaknesses providing that the post has adequate backing from the department and from the NHS. We welcome the appointment to the post of Professor Michael Peckham who took over the duties at the beginning of the year. We wish him well in the important task that he has undertaken.
In congratulating the Government on taking those decisions I offer a special word of thanks to the Minister for the part that she played. She was extremely receptive to the views expressed by your Lordships during our debate on the report. We owe a lot to her for the fact that this important change has been introduced. It was an added encouragement when recently she announced the scheme of £2 million towards meeting the service support costs of research in non-teaching hospitals.
So much for what has been done arising out of our inquiry. However, there remains one area about which I am unhappy, as are my colleagues on the Select Committee. In our report we drew attention to the unhappiness that we found among research personnel, whether they were scientific, clinical or technical. They were worried about their lack of career prospects. That is a serious issue, affecting the future standards of personnel within the NHS as a whole. The Select Committee looked into that important problem but could not find where the responsibility lay for tackling it. It is an issue which is part of manpower policy as a whole, especially the training and education of research workers. We believe that a solution to the
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problem is of vital importance to the maintenance of the high standards of research which have existed in the NHS. Can the Minister tell the House where the responsibility lies for such manpower planning and for appropriate action to be taken arising from that? That information would add to the answers that the Select Committee received and the proposals put forward in its report.
4.29 p.m.
Lord Molloy: My Lords, I too appreciated the speech of the right reverend Prelate the Bishop of Exeter. I found it somewhat touching because I remember days in the valleys of Wales when steelworkers and coal-miners depended on the local Baptist minister. Usually he, too, was a coal-miner in a cloth cap but he did wonderful work similar to that described by the right reverend Prelate.
The House was lucky to hear the excellent speeches of my noble friend Lord Ennals and the noble Lord, Lord McColl of Dulwich. They set the tone of the debate. Of course, they were opposed to each other but in a manner that one could enjoy and understand. I was a little saddened that the noble Lord, Lord McColl, found humour in people on the waiting lists. Those of us who previously served as Members in another place still receive letters from former constituents concerning their family problems in regard to the NHS. Perhaps their mum, dad or brother is on the waiting list and that worries them.
Some of my colleagues have had letters from men in the Gulf who are worried, for example, about a mother who has been on a waiting list for so long. I am sure that they do not find any remarks about waiting lists humorous. It is that kind of thing that we have to try to understand. There are some matters that are not brought to our attention. As Aneurin Bevan, who introduced this magnificent measure, said, the problem with us is that we never recognise that silent pain evokes no response. Therefore, somebody has to stand up and attack governments, local authorities, and health authorities.
There are some of us who have always been prepared to defend the health service and to attack those who we think are running it down irrespective of what government are in power at the time. Many hospitals have been closed; on the one hand waiting lists are lengthening; and on the other hand wards are being closed. Families and indeed National Health Service staff share anxiety and grief at operations that are cancelled and at waiting lists that are being ignored, and sometimes just erased. It is not in any way funny to the family that has someone on a waiting list, or to someone who is waiting for an operation and being denied it. That is what we have to try to understand.
The present Government are in the worst possible situation. They are actually spending much more on the National Health Service than ever before, but we have a worse NHS than ever before. We are getting the worst of both worlds. Knowledgeable people within the medical profession say that this situation is without precedent in the 40 years of the National

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Health Service. Let us just take as an example Westminster Hospital down the road, which has now closed its doors to patients on waiting lists. It is amazing that a hospital that is usually recognised as your Lordships' hospital and for Members of the other place will not now take in anybody. I do not understand why it is doing it, but I believe that it is a serious issue. No government should be complacent about it. I do not believe that any Member of this House should be complacent about it. The condition of our ailing National Health Service is causing pain and anxiety.
Another aspect is the financial cuts affecting not only London's teaching hospitals but also many more hospitals right across the country. When the injured and sick cannot be attended to I believe that the situation is desperate. It should be regarded as desperate by every one of us, and not merely the children or relatives of those who cannot be attended when they are injured or sick. Heaven forbid, but if Gulf casualties have to come here for treatment will we be able to respond efficiently? I hope that the Minister, as I am sure she will, will respond to this, by saying that we shall be able to respond efficiently.
The previous Secretary of State gave a guarantee last year —and I beg your Lordships to listen to it —that the National Health Service would cope with all casualties, military and civilian. How do we reconcile that with the closing of Westminster Hospital; with waiting lists being abandoned; with people who are genuinely ill having to wait for an operation? It is a serious situation. I hope that we shall be prepared to meet the casualties that we may have, and that we shall also be prepared to see that civilian casualties will be properly dealt with and looked after as well.
Despite the promises of the reform of the National Health Service, I believe that it has not been a great success. I am sorry about that. I am sorry for the Government, and I hope that the Government are sorry that they have not been able to do better. What I find annoying too is that the privatised industries left the public sector with millions of pounds written off. British Steel had £4,500 million; the water industry had £5,000 million, yet health authorities need financial help, are begging for it, and are getting nothing. There is something wrong there. There is also this terrible myopia of the school eye service being cut. Can your Lordships imagine that eye testing is being attacked and the school eye service is being cut? All we have to do, all the Minister has to do, all that the noble Baroness, Lady Hooper, has to do is to just shut our eyes and say, "This is for ever", and we will restore those cuts in a wink.
I also believe, as the noble Lord, Lord McColl, rightly said, that preventive medicine is a vital part of the National Health Service, but it is under attack. What we believed under Bevan—and something which we endeavoured to achieve but which we never really achieved—was that care would extend from the cradle to the grave. Of course the National Health Service must be kept under review. That is vital. We
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must make sure that everything being done in the National Health Service is worth doing. That is fundamental.
Unless all industries and professions within our National Health Service march together in reciprocal activity, we shall be in danger of limping on one foot. I should like your Lordships to note that the Confederation of Health Service Employees, all the health visitors' associations, the British Medical Association, surgeons, dentists, and all the royal colleges agree that a regular review is a good thing. I hope that we shall do that kind of thing fairly regularly.
They also agree that the great moral imperative of our National Health Service is that wealth will not be advantaged and poverty and poorness will not be a disability, but rather that everybody, all of us, will be entitled to the best. The National Health Service was created after the most terrible war in history. It later enjoyed the support of all medical practitioners. It was thought by ordinary people that, in a typical British phrase, Bevan's National Health Service was a blessing, and I think it still is.
There now exist disturbing apprehensions that the fundamentals of the National Health Service might be at risk. I ask for the sake of our nation—not for a particular party but for all parties—and for the sake of our children that such risks must be remedied. We in this country created a great piece of human endeavour when the National Health Service was created. It has been maintained ever since as best we could. I believe that the present Government are slipping back. They have got the worst of both worlds; they are spending more for an inferior service.
I hope that the Government will have a look at what I have had to say and at what other noble Lords have had to say, because our National Health Service is a boon to the nation. No longer, as in 1939, are 30 per cent. of our young men unfit for national service. The National Health Service has seen to it that that will never happen again. It is a great service that is the envy of the world. Our nation created it. It is well worth looking after not only for the people of our land but also as a model for other nations too.
4.38 p.m.
Lord Smith: My Lords, I shall be brief because I have one thing to say, and one only, about the long-term objectives of the National Health Service. First, I very much hope that your Lordships will forgive me for leaving the House before the end of the debate, for today is the anniversary of John Hunter's birth and I have to be at the Royal College of Surgeons later this evening.
I was a consultant surgeon to John Hunter's hospital, St. George's Hospital, at Hyde Park Corner for more than 30 years. I was enthusiastic at the beginning of the National Health Service, but I did not foresee—nobody foresaw—that in a few decades the phenomenal increase in the cost of health care must drive a wedge between independent medicine and national health medicine, and that the inevitable result

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would be a waiting list for routine cases in the national health hospitals and not in the independent sector of medicine.
As the cost of medicine continues to increase the paths of those two medical philosophies diverge more and more. Any doctor who embarked upon a medical career from a sense of vocation would be aghast at the thought that he had to vary the treatment of patients who sought his care according to the patient's means. But that is the direction in which medicine is moving in this sad era of financial restraint.
The obvious cure, however difficult, is a move to draw together independent and national health medicine in a true partnership. I feel certain that independent medicine could do more to help national health medicine; and in return national health medicine could do more to help independent medicine. For instance, it could encourage consultants who wish to do private work to do so in national health hospitals. They would be near national health patients and not a mile or two away in a private hospital or in a traffic jam between the two. That could help both sectors of medicine.
I have spoken on this subject before. But those who speak for the Department of Health pretend that all is light in the grey area between the two philosophies; as though there were no complaints in regard to private practice pinching facilities meant to serve national health patients, and protestations that patients are better treated in private rather than national health hospitals. Many consultants are resentful at frictions of that kind. They are anxious to retain the vocational spirit in medicine and draw independent and national health medicines closer together.
In a short speech I shall not go into detail. Among the thoughts that immediately occur to me are the following. When a national health hospital has to shut an entire ward to save money, can the independent sector of medicine help? Should not the plentiful clinical material in private hospitals be of use in teaching medical students and post-graduate students? Should not the expensive technological equipment in private hospitals and the consultants in charge be available for national health patients on financially advantageous terms? Should not there be private consulting rooms in national health hospitals? That would keep consultants near their national health patients. In London, consulting rooms in the Harley Street area are villainously expensive and many consultants would rather pay the equivalent sum to the National Health Service.
In November I wrote to the Secretary of State for Health and humbly expressed the opinion that perhaps he should consider setting up a small informal working party to give him advice upon drawing together independent and national health medicine. The Department of Health does not like the idea. However, I am an optimist and hope that the Secretary of State may think again.
4.45 p.m.
The Earl of Clanwilliam: My Lords, I thank the noble Earl, Lord Ennals, for introducing this important debate and for hosting an interesting meeting earlier today on the subject of general practitioners who are interested in complementary medicine. I also congratulate the right reverend Prelate the Bishop of Exeter upon introducing a non-controversial subject into the debate, which is a feat in itself. Perhaps I may remind him that within his diocese there is, in the Exeter University, a centre for complementary health studies. I hope that it will receive his support in the future.
The long-term objective of the National Health Service concerns costs. The National Health Service is a great institution of which we can be justly proud. It has become part of the national fabric and its preservation and continuity is vital to the country. The costs of achieving that will be exorbitant in the near future. I suggest that two areas might be addressed in that regard. The first is research and development, and the other is in regard to relieving the pressure that old age pensioners place on the National Health Service.
As we heard from the noble Lord, Lord Nugent, the number of day cases has almost doubled in the past decade. There has been no enormous increase in the population to account for that, nor can the British race be described as total hypochondriacs. The reason lies entirely with the advances of medical and pharmaceutical researchers, who continue to believe that a human being is a mass of biological cells which can be controlled. They have produced products which, as was mentioned by the noble Lord, Lord Winstanley, will be impossible to finance in the future. They have produced ever more complicated and expensive panaceas to prolong life, and this in the face of the demographic certainty that an ever increasing proportion of the population will be old age pensioners. At the present rate of progress the time will come when the NHS costs will be beyond the ability of the community to bear.
The Government have already faced up to that subject in regard to the matter of state earnings related pensions. In the course of promoting that project they demonstrated demographically that in 2015—when I shall not be here to see it—the working population will have been so reduced that it will need to spend 30 per cent. of its income keeping the old age pension at its present level.
If there are to be that number of old age pensioners it will create an enormous problem for the National Health Service. One way to relieve the pressure lies in helping the elderly. Where family care exists it is more important to an OAP than anything else. Where a home environment exists or can be encouraged to exist there follows a lesser degree of dependence on the NHS. That is obvious.
In the 1960s and 1970s it was fashionable to decry the family unit. That has changed in modern thinking. The Government are introducing incentives into the sphere of supporting the old age pensioner in the home. I suggest that those could be increased to provide a positive advantage to the family which looks after the old age pensioner. They could more

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accurately reflect the savings of the social services as opposed to the Treasury's view of what is appropriate so that no advantage can be taken. Those savings are on a scale to provide genuine opulence in any family world, which indicates that opportunities must exist for additional help.
The object must be to dissuade people from flocking to hospital. The constant reiteration of everyone's right to instant total care regardless of expense has created a whole class of people who are dedicated to exercising that right. Indeed, as we know, the number of day cases has nearly doubled in the past 10 years. I believe that the problem can be relieved to some extent by Government intervention. I hope that my noble friend the Minister will be able to address that point.
We now come to the question of drugs. If only the scientists would spend more time making their discoveries economically possible rather than competing with each other to be the first in the field, the cost in terms of both money and successful results would be beneficial both to the NHS and the patient. There would be fewer costs to recover from the development and sale of drugs over some of which it might be more tactful to draw a discreet veil. I must immediately agree that the great majority of recent developments have been of enormous benefit to mankind, but the costs range between the exorbitant and the expensive.
Every effort is made by the authorities to ensure that drugs are safe and to test for safety. That again is an additional cost which has to be borne. If that had been properly projected in the first place that cost would not be necessary. Another but hidden cost of drugs to the NHS is their iatrogenic effect. Large numbers of patients either have to return to hospital or have their stay prolonged because of the side effects of the drugs administered.
That leads me to the subject of complementary medicine. I refer again to previous conversations that I had with my noble friend the Minister on the matter. I emphasise that there has been no reported instance of death in the administration of herbal remedies prescribed by qualified practitioners. What an outcry there would have been in the press if any had ever been discovered! Herbal medicines, like any other medicines, other than a placebo, have a toxicity value, but in qualified hands they are safer than artificial drugs. Much work is being done in bringing complementary medicine into the NHS and that is most welcome. I urge my noble friend the Minister to apply pressure where it is most needed—that is to say, within the higher echelons of the medical profession —to ensure that the present demand for such services is met by the NHS. One thing is sure: they will be a great deal cheaper than the drugs which are supplied.
The NHS is part of the fabric of this country. Any review of it must encompass the broad range of the nation's needs and its capacity to pay the bill. I believe that is the prime matter to address.
4.53 p.m.
Lord Rea: My Lords, it is possibly the privilege, even the duty, of a party in opposition, even though it will not be in opposition for long, to take the broader view which my noble friend's title for this debate
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suggests that we do. We should look not only at the health service but at health in the wider sense which is not the same thing as the health service. I believe that the document A Fresh Start for Health which has been mentioned by my noble friend, does just that. But it looks at the problem in a very practical sense as well. Noble Lords may remember that 12 years ago my noble friend Lord Ennals set up a small but high-powered working group to look at the question of inequalities in health under the chairmanship of Sir Douglas Black who was then president of the Royal College of Physicians.
The reason that topic was chosen was not doctrinaire; and it was not chosen because Labour is or was the party of the underdog. It was chosen for the very serious reason that the disparity in standard measures of health between the better off and the less well off sections of the population were dragging the whole of our health performance down as a nation. As an example the infant mortality rate now for those in social classes I and II—that is, the best off and best educated people—now stands at six per 1,000 births. That is the equivalent of the total national rate for countries such as Sweden, Japan or Iceland. However, if we look at the rate for those in social class IV or V, which are the less privileged, it remains at around 12 or more, bringing the whole rate in the United Kingdom up to about nine. That is a level which is now bettered by 15 or more other countries in the world whereas at one point we were among the leaders.
The same contrast by social class can be found in practically every cause of illness and death throughout the age range. That was alluded to by the noble Lord, Lord Butterfield. There is only one exception to that which is skin cancer. That occurs more often in better off people because of their greater exposure to the sun's rays in pleasant parts of the world. Overall, in the 10 years since Sir Douglas Black's report, it is true that health has improved in all social classes because of the technical advances which the noble Lord, Lord Butterfield, mentioned.
But the contrast between the social classes remains and in some cases it has even widened as my noble friend Lord Ennals mentioned. Social discrepancies in health persist and put us some way down the international league table for health. That is due to the persistence of a backlog of poor environmental conditions, housing and working conditions, sub-optimal nutrition, the persistence of smoking and other adverse life style-factors, nearly all of which have social class trends. The Black Report made a number of recommendations which went to the root of these problems. Not one of them has been tackled by the present Government even though they would not have cost very much.
It is little use exhorting people to change their life style when social and economic pressures pull them in other directions. That is what the policies of the current Government have been doing for the past 10 years. That is why I am delighted with the approach of the programme in A Fresh Start for Health. It takes up many of the suggestions of the Black Report though it

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is updated for the 1990s rather than the 1980s. For instance, it tackles child poverty, which is a basic cause of ill health, by suggesting that the true value of child benefit should be restored and that a nursery place should be offered to every child aged three to four years whose parents want it. That is one of the first ways in which the spiral of under-privilege can be negated and reversed.
It is suggested that municipal housing programmes should be restarted in order to abolish the squalid, unjust, uneconomic and altogether scandalous bed and breakfast accommodation which many homeless families have to suffer at the moment and which leads to a very bad indices of morbidity in the families who are in those conditions. It suggests that a minimum wage should be brought in which would reduce poverty among working families. A ministry of food and farming would change the emphasis from helping the producer towards helping the consumer. That would be assisted by an independent food standards agency and clearer nutritional labelling of food. These are measures which I, as vice-chairman of the National Forum for the Prevention of Coronary Heart Disease, have been trying to plug for the past eight years.
An integrated approach to sports and exercise is also suggested with more school time for physical education, and more help for local authorities and education authorities to provide sports facilities, reversing the pressure to sell off and privatise which has characterised the present Government.
The menace of cigarette smoking will be tackled by banning tobacco advertising except at the point of sale and tightening up the sale of tobacco to minors. We hope that the Private Member's Bill which is now going through another place will succeed, but if it does not the next Labour Government will see that it does. This will be combined with a policy steadily to increase excise duty on tobacco. I could list other useful suggestions in the report which will really assist people to change to more healthy lifestyles. However, the social causes of ill health are recognised and action is proposed to remedy them. At present too much is expected of the Health Education Authority and of primary healthcare teams to promote health without tackling the root causes at national and local authority level.
I see that I am approaching the end of my nine minutes. However, as an addendum, I should like to ask the noble Baroness about a completely different matter. First, I ask her to congratulate her right honourable friend, Mrs. Bottomley, on making some progress in reducing the contracted hours of duty of junior hospital doctors. How is further progress towards reaching that 72-hour goal to be monitored? What mechanisms are available to ensure that that laudable aim is arrived at? Will the department look at hard pressed health authorities to see that they make progress in that direction?
Finally, I should like to echo what was said by the noble Lord, Lord Butterfield. I am delighted that national terms and conditions of service for junior
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hospital doctors will apply throughout the National Health Service, including independent hospital trusts. Can the Minister say whether the same will apply to other grades of medical staff, such as consultants who are working for independent hospital trusts? Will they also enjoy nationally agreed terms of service so that standards throughout the National Health Service can be kept high?
5.2 p.m.
Lord Pearson of Rannoch: My Lords, I too should like to join in thanking the noble Lord, Lord Ennals, for the opportunity of this debate. I should also like to apologise to the House for arriving late but I was detained by unexpectedly difficult business elsewhere.
I wish to speak briefly and entirely from personal experience, as the father of a 10 year-old Down's syndrome girl. There are, I submit, few more shocking moments in life than when one is told that one's newborn child is irreparably handicapped. My wife and I were reasonably mature when this happened to us and so we were able to stand back from the substantial quantity of well-meaning attention which came towards us from many sides, some of which we did not find very helpful. We may just have been unlucky, but I must say I found the attitude of some of the social workers —most of whom were a good deal younger than us—unhelpful and even at times irritating. It took me some time to work out why this should have been—and perhaps I got it wrong—but it seemed to me that they felt we should have been sharing more in the pleasure they took in trying to help us; that their attitude was a little bit the triumph of well-meaning theory over reality, a reality which was much more difficult for us than they could possibly have imagined, never having been through our problems themselves.
The same problem arose when the question of our daughter's schooling came along. The special education needs experts were clearly surprised, and one of them was even openly disapproving, that we did not think our daughter would be happy in an ordinary school, or even in a special day school, but that we were convinced that she would have been most happy in a special residential school. As we therefore visited a number of these—and this is now some six years ago—we met many fine and dedicated people. Nearly all of them were very nervous of the growing trend to try to educate mentally handicapped children in ordinary schools.
In the wider context, as time went on, I became more and more worried about the extent to which it was intended to move the adult mentally handicapped and mentally severely ill out of our institutions and into the community. I felt the same good intentions were at work which I had faced in the social workers and special education needs officers, but now they were on a massive national scale. Good intentions, my Lords, but was the balance right?
I am afraid I still wonder whether we have got that balance right. I fear we may be veering too far towards care in the community, which may not be as fully enthusiastic or as competent about providing it as

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well-meaning theory suggests it should be. So from my own experience I would put in a plea for greater flexibility of provision between community and residential care.
Again, I can but draw on my personal experience to say that I am sure my wife and I were right in our decision to send our daughter, when aged only five, to a special residential school. We were extremely lucky to find her a place in a Camphill Community Rudolf Steiner school where she has made tremendous progress and is extremely happy. She has four terms and four holidays in a year. I very much hope that she may one day earn a place in a Camphill village or sheltered community.
Of course I know that residential care may not be right for many children and adults and that community care will be right for many people, especially if they really can be adequately cared for in the community. In that sense I would put in a plea that they should be under health care more than under social work care, and perhaps more so than is at present intended. I understand that many of our institutions may not have been all that good but I should have thought there must be some sound sense in a suggestion put forward by the National Society for Mentally Handicapped People in Residential Care, or Rescare, as it is known. I quote:
"Rescare believes that the evolution of suitable hospitals into village communities, each with a co-ordinating Principal and with increased autonomy for the individual living units, is one practical and economical way of improving services for all mentally handicapped people including those living at home who could be given daily access to on-site services. The NHS could provide specialist health related services, other bodies (local authorities, charities, private sponsors and voluntary groups) could manage (and provide) some of the residential units. Such community provision would be readily available to all wishing to use it".
I am sure that is a sound suggestion and worth looking at.
I am also sure that the mentally handicapped, and at least mentally handicapped children, are more different to us so-called normal people than we would often like them to be. When my daughter was seven I reminded her that the next day she was going back to her Camphill residential school. Her reply was revealing: "Oh no, Daddy, I'm going home". That is not the reply one would get from a normal seven year-old who is very fond of her family and whose family is very fond of her.
I only hope that there will be enough "homes" for the other children and adults who need them in the future.
5.8 p.m.
Baroness McFarlane of Llandaff: My Lords, I rise with some trepidation after the many exhortations to the importance of diet, exercise and lifestyle. I take a small comfort from the recently published evidence about the value of milk—what is more, whole milk —and I look to the future with hope.
Many of your Lordships have made reference to the spiralling costs of the health service and the whole problem of resource management in the health service. This is occasioned by both increased consumer
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demand for the goods of the health service and also the tremendously sophisticated advances that have been made and the tremendous improvements in health that have taken place under the aegis of the health service. This afternoon we have been told many times about the increased resources that have been given to the health service in each year of its being.
However, despite the increased resources, despite the increase in the number of staff employed, despite the increased productivity measured in numbers of operations and by other indices, there can still be to the consumer of the health service, the patient, the frustrating experience of delays and inadequacies and even the squalor of some of the buildings in which we care for patients.
Alongside the undoubted gratitude of so many patients for the care they receive and the undoubted dedication of many staff to the health service there is an increasing feeling of stress on the part of the health service. It seems to me that in future there must be not only an increase in resources to the health service to bring us at least to the level of other countries but at the same time a rationing and a determination of the priorities. My problem at the moment is that the basis of rationing is not made explicit. The system of rationing is there implicitly and covertly. We have heard about it this afternoon. We see it in areas such as waiting lists, bed closures and ward closures, in the inability to prescribe expensive drugs and in the reduction of minor operations. We have to make explicit the basis on which rationing of services in the health service will take place.
I am most concerned that the ethical basis of those decisions should be laid bare. Rationing of health services is not just a matter of medical decision-making, economic decision-making or managerial decision-making. It has a profound ethical content. That we must lay bare to the public. We need to establish guidelines for the rationing of our services and to establish them in the public domain. Honesty with the public, equity in the provision of services and many other ethical principles underlie the rationing of services.
I wish briefly to headline three concerns allied to nursing. I am sure that we are all delighted with the policy guidance on community care, but within the community many of the agencies will have to work very closely together. It seems to me that within the plans and discussions that we have had so far the pivotal role of community nurses has not been sufficiently addressed. I think in particular of the skills of health visitors not only in health education and their contribution through that to the prevention of disease but also in the assessment of the needs of the population and in the ability to target certain client groups. Health visitors are the epidemiologists of the primary health care team and can do much to direct our services in that field.
Likewise, I look at the role of district nurses and their ability to manage care in the community. The services of health visitors and district nurses are essential in the assessment of community health needs and in the assessment of individual patient care needs.

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Another issue affecting nurses is that of nurse prescribing. Although we are delighted that the Government have reaffirmed their support for this in principle, there is now a delay while a cost benefit analysis is carried out. Can the Minister give an indication of the time schedule in mind before the necessary legislative changes are brought in?
A third small item to do with nursing is the implementation of Project 2000. Again we are delighted that this has been accepted and that much of the recurrent moneys are being made available. However, there are capital implications in some of the schemes to amalgamate smaller schools of nursing into more efficient and cost-effective colleges. It would be useful to know from the Minister what plans are being made for the capital costs involved.
Lastly, I should like to congratulate the right reverend Prelate the Bishop of Exeter on his maiden speech and to align myself with much of what he said. I look forward to working with him from April onwards as a member of the Hospital Chaplaincies Council. I am sure we have no doubt about the very necessary contribution of chaplains to the health service. The health service is concerned not only with physical care but with psychological, social and spiritual care and with the less tangible aspects of care. There are certain fears within the health service that the chaplains may become a victim of cost-cutting exercises. I quote from the Hospital Chaplaincies Council report to the General Synod a fortnight ago:
"There is a serious concern that the Government's principle of devolving every possible decision with regard both to staffing and the terms and conditions of service of Health Service Staff from the Department of Health to the individual Health Authorities and Units, and the emphasis upon financial efficiency poses the possibility of a threat to those groups within the service whose contribution to Health Care cannot be measured in specifically financial terms. Hospital Chaplains themselves constitute one such group".
I should like an assurance that the circular PM 86/15, which sets out so adequately the role of the hospital chaplain, will be reissued to the new health authorities.
5.18 p.m.
Lord Auckland: My Lords, it is a privilege to speak after the noble Baroness, Lady McFarlane of Llandaff, who has given a lifetime of experience and dedication to the nursing services. I should also like to thank the noble Lord, Lord Ennals, for initiating what has been a vigorous debate and to congratulate the right reverend Prelate the Bishop of Exeter on a very fine maiden speech. In 1942, when I was at school in Devon, I was confirmed by the then Bishop of Exeter. I was particularly interested in his remarks on hospital chaplains.
Two organisations do a great deal for the health service outside therapeutic care. One is the Hospital Chaplaincies Council. It does a great deal in the long-stay mental hospitals. Where my wife and I live in Surrey we have seven such hospitals. Another organisation is the League of Friends, which raises a great deal of money for the patients and staff of hospitals. I declare an interest of a particularly non-financial nature. I am president of the friends of
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the district hospital in the town where I live. The relationship between the friends and the patients and staff of the hospital is a very good one.
There have been two endemic, main problems associated with health, both pre-health service and post-health service, for many years; namely, nurses' pay and hospital waiting lists. Members of my family served in the voluntary services in the hospital field many years before the establishment of the health service. Waiting lists are a major problem. Obviously they are worse in some areas than in others. The reasons for them have been rehearsed both in this House and in another place on many occasions. However, in this country we treat 40 million or perhaps 50 million people per year under the National Health Service, as well as treating visitors from abroad. It is worth drawing attention to that fact.
I have mentioned this before, but I think that it is worth repeating. Whenever I go abroad I try to visit at least one hospital. There are two countries with which I have a particular affinity: one is New Zealand and the other is Finland. Finland has one of the finest hospital services in the world. I visited one of its hospitals north of the Arctic Circle with a parliamentary delegation. On that occasion I asked the general manager, "You don't have waiting lists here, do you?". He replied, "We have a waiting list of 18 months for hernia operations". That was because they had a paper mill half a mile away. Therefore, I believe that it is worth mentioning that waiting lists are not confined to this country, where we treat about 50 million people a year. Even in the Scandinavian countries, with populations of only 3 million to 4 million people, and in New Zealand and Australia, with populations of about 3 million and 15 million respectively, the problem of waiting lists exists. Moreover, there is also a shortage of nurses in those countries. That is partly due to pay and partly due to the unsocial hours which nurses have to work.
I turn now to consider the second part of the Motion tabled in the name of the noble Lord, Lord Ennals. It is the part upon which I believe we should concentrate. It is easy to be critical of any government, but the question is how the Government will solve such problems. The simple fact is that in any health service, whether private or public, one needs nurses and doctors. Moreover, in many cases patients need treatment for 24 hours of every day. If someone is knocked down by a car at three o'clock on Christmas day he cannot be left in the road. Such a person would need treatment. These are simple facts, but I believe that they should be examined in debating the Motion.
I turn now to consider management. My noble friend Lord McColl made a speech drawing from his considerable experience in the health service as a distinguished surgeon. He emphasised the fact that nurses make good managers. That is true, but there is a grave tendency to compel nurses to undertake too many managerial duties. I am sure that many of your Lordships and Members of the other place who visit hospitals and talk to nurses and doctors and those in the ancillary professions often hear about such problems. They invariably say that they spend far too

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much time on courses and on management instead of being able to treat patients. I can give the example of a friend of the family who is a therapist. She is now retired, but we knew her both professionally and socially. Her cri de coeur 12 to 15 years ago was, "If only I could get on with my job of treating patients and not have to go to committee meetings".
I am not for one moment saying that managers are unnecessary. They are indeed necessary. However, there is a danger in our health service that we have too much management and too little therapeutic treatment in some places. In some respects, that is due to the Salmon report, but it is a problem which needs to be further considered.
In conclusion, I should like to express my faith, that of my family and of all those who have been treated by it in t the National Health Service. I believe that the plea which must come from this House and elsewhere is that more time should be given to nurses and doctors to allow them to treat patients and rather less time to management.
5.26 p.m.
Lord Richardson: My Lords, I am greatly indebted to the noble Lord, Lord Ennals, for the second part of his Motion which calls for us to consider the "long-term objectives" of the National Health Service. I wish to make only one point, but it is a point which will go right into the mists of the future and it is something which will affect the health service in its objectives and achievements so long as any medical service exists. It is concerned with the attitude of doctors to patients. My point was touched upon during the debate by the noble Lord, Lord Rea, who asked the Minister about equal pay for equal work for doctors throughout the hospital service. Of course the medical profession rejoices in the fact that it has been agreed that junior doctors should have their terms and conditions of employment negotiated centrally. I want to make the case as strongly as I am capable of doing for extending that agreement to all doctors in the health service.
With the leave of the House I should like to quote from a statement by the BMA. It is not in any way a unique statement but it expresses clearly the profession's view:
"The NHS must not undermine the morale of the team which delivers health care to the patients. The NHS is dependent upon the dedication and good will of its staff".
Quite frankly, the most important quality of its staff must be the dedication of those who are leading and those who are making the ultimate decisions. The morale of the team depends upon those people. They are the people who deliver the health care to the patients. Therefore, it is upon morale and delivery, the team and the patients that I wish to concentrate.
Why do I consider myself justified to take on this task which is really very fundamental? It is my antiquity. With the exception of the noble Lord, Lord Porritt, I am the only doctor in the House who can claim to have practised medicine before the war, not only in a great London teaching hospital across the river but also in an LCC hospital—a hospital with different attitudes and different privileges.
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I can also claim to be one of those who, after the war, had to compete to obtain a consultant's post in one of our hospitals. Consultants' posts were rightly frozen throughout the war. I know the disappoint-ments and anxieties felt by people about the type of hospital in which they would obtain a job. There was a sense of, "Yes, it's a nice place, but it is not quite the same". I know from working for 40 years plus -doctors are bandying that figure about this afternoon —in both kinds of hospitals the feeling that, "It's all very well for you up there".
I have watched with the greatest possible pleasure the up-and-coming members of staff of the non-teaching, non-privileged, non-specialist hospitals. They have become members of committees and inquiries both nationally and at the level of the royal colleges. As that has occurred, I have noticed a great diminution in the sense of being only second best. That was graphically illustrated in a Committee Room upstairs in the House by the secretary of the BMA when discussions on the NHS Bill were being undertaken last year. The man looked at the noble Lord, Lord Walton of Detchant, and myself with a wicked grin. He said, "I should like the Committee to understand that the difference between teaching hospital consultants and those at the periphery are diminishing very rapidly indeed". His look may have been wicked—he was laughing at us—but we were both delighted that that was so.
I feel strongly about the matter, as your Lordships may have guessed. If the Government would agree to establish equality of pay for equality of work, they would be in no way damaging the ideas underlying the trusts—the market economy and so on. They would receive a much better service from the consultants and the hospital staff if there were no sense of there being two types of hospital and two types of pay. It is pay upon which I concentrate. If the Government would agree to that idea they would acquire the continuation of an extremely valuable contribution to the management of patients. It is only human of us, if we belong to an elite corps, to feel a satisfaction in it and to give that extra bit of drive, service, consideration and perhaps good manners that make all the difference to patients when they are being dealt with in their times of stress.
In talking about those important, if somewhat subtle, ways of helping patients by keeping a balance of privilege, I am following the thinking of the right reverend Prelate the Bishop of Exeter who talked about the importance of excellence and service.
5.35 p.m.
The Earl of Longford: My Lords, if I were taken suddenly ill, something which could happen to the youngest of us—among whom I am not included—I would have a wide range of options open to me. My noble friends will forgive me if I plump for the senior and supremely qualified physician, the noble Lord, Lord Richardson. Should we need nursing attention it could be provided by the noble Baroness, Lady Cox. An operation might even be called for, and I feel sure

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that the noble Lord, Lord McColl, would put aside party preconceptions and handle me dispassionately. This is the right place to be taken ill.
Lord Ennals: I was once an ambulance driver.
The Earl of Longford: That is also helpful. There may be greater co-operation between my noble friend Lord Ennals and the noble Lord, Lord McColl, than was evident earlier.
I am sure that no one will disagree if I say there is a close connection between the efficiency of the NHS and what is called community care. In my eyes, the phrase "community care" has been a disaster. I do not know who thought it up, but in the end he has done more harm than good. It is full of ambiguities. The phrase is of course a noble aspiration, but it has misled many people and produced poor results.
I shall take the local situation in East Sussex where Hellingly Hospital is being closed. It once had 1,400 patients. There are now 100. There soon will be no one there. What will happen to the patients when the hospital closes? A patient might be transferred to a small unit, which may be the best answer. Day care might be provided. The local authority might take over responsibility for the patient, or it might not. The patient might be left in his home in a village. In many villages he might be well looked after by his family and friends. All those meanings are attached to the phrase, and a phrase that has a great many meanings is usually misleading.
I shall not dwell upon the deficiencies of community care. They have often been discussed. Whatever has been written down on paper, most of us know that the result has been disappointing. I shall talk for a few minutes about what should be done for those who have been in mental hospitals. Several years ago I was chairman of a strong committee which included several Members of the House. It produced a report on mental aftercare which was financed by the Richmond Fellowship. As your Lordships may know, the Richmond Fellowship was inspired by that wonderful woman, Elly Jansen, who, with my friend Peter Thomson, has done more than any lay person for mental health in this country. Now, 7½ years later I turn for professional guidance to the great Professor Wing of Maudsley Hospital who wrote that report and who is well known to all the doctors present.
I shall use most of my time putting one idea before the House. It is a matter of which I have given some notice—not much—to the Minister. Professor Wing had a great many things to say and many valuable suggestions to make. He considers that we should not draw a sharp line between care in the hospitals and community care. He feels that we go wrong if we do so. Part of his message, which he would have to expand for it to be appreciated, is that many of the sites of the hospitals which are being closed should be used for sheltered communities. That is just one aspect of what he has to say, but it is all part of the doctrine of not bringing about a sharp separation between hospitals and so-called community care. It is best if I say no more because I wish to lay that point of supreme importance to me before the Minister.
5.40 p.m.
Baroness Cox: My Lords, I also thank the noble Lord, Lord Ennals, for providing us with another opportunity to discuss this important subject. I shall focus on two areas: first, the so-called Cinderella areas, where especially vulnerable people tend to suffer neglect or to fall through the interstices of care; and, secondly, issues concerning my own profession of nursing.
I begin by congratulating my right honourable friend the Secretary of State on three specific initiatives since he assumed office. First, as a member of the council of management of St. Christopher's Hospice, I warmly welcome the announcement of extra funding of £17 million for hospices. Secondly, as a nurse I welcome the positive signal my right honourable friend sent to the nursing profession when he invited the chief nursing officer to join the NHS policy board. This recognition of the contribution of nursing expertise to policy making has been greatly appreciated. Thirdly, I naturally welcome the recent announcement of salary increases, although I also regret that they are to be phased, significantly reducing their value.
My first area of concern is the relationship between health care and social care, with particular reference to people with mental handicap and/or mental illness. Here I echo themes which have already been raised by the noble Earl, Lord Longford, and also my noble friend Lord Pearson.
I am a patron of Rescare, the National Society for Mentally Handicapped People in Residential Care. This excellent organisation has expressed grave fears over the confusion in current policy about the sometimes spurious distinction between social care and health care. It has expressed alarm over the statement in the publication Caring for People, paragraph 2.14:
"it has become increasingly recognised that the needs of the most [mentally] handicapped people … are largely for social, rather than health, care".
Rescare points out that for many people with mental handicap, social and health needs are linked and both must be satisfied by every agency providing care. Mentally handicapped people often suffer from some psychiatric disorder or neurological dysfunction such as epilepsy. Rescare is worried that some mentally handicapped people in community residential care establishments have been denied access to specialised practitioners through a misplaced adherence at official level to inappropriate assumptions about so-called normalisation.
I have always feared that people in community care, where the emphasis is to be on social care rather than health care, might suffer through inadequate recognition of their clinical needs. These fears are echoed by Rescare which is alarmed by health authority strategic plans to reduce residential provision for people with mental handicap in the NHS by something like 80 per cent. of the present level. It will be with management-led hospital rundown and without satisfactory alternative residential or day services. For example, the MRC's study of the effects of the closure of Darenth Park Hospital found that

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one-third of the residents who had moved out enjoyed a better quality of life, but two-thirds did not. Indeed, one-third were worse off.
The research indicated that living units in a campus with large grounds or sheltered villages could offer more freedom and a more interesting life for some mentally handicapped people than could houses in ordinary streets. This is consistent with Professor Segal's book The Place of Special Villages which makes a cogent case for village-like communities, perhaps on upgraded hospital sites, as the most appropriate milieu for many people with mental handicap.
I had the privilege recently of speaking to a Rescare lobby. I was deeply moved by the difficulties experienced by many carers who give so unstintingly in looking after relatives with mental handicaps. Many of these carers are under great stress, they are getting older and need help with respite. Can my noble friend reassure these dedicated people that their experience will be taken into account in future policy making?
Similar concerns have been expressed by people involved with the mentally ill. For example, the National Schizophrenia Fellowship is alarmed at the catastrophic reduction in English mental hospital beds by over 25,000 since 1988–89, compared with an increase of only 6,000 places in day centres and registered homes for the mentally ill over the previous 10 years. Recent figures suggest that the situation is deteriorating even further. The National Schizophrenia Fellowship's advisory service has experienced a fivefold increase in serious cases. Between 7th and 31st January this year it received 49 inquiries from relatives of people whose behaviour was causing grave alarm. They were no longer able to manage effectively in the community. The cases had not been resolved by GPs, social services or any of the community care providers. Desperate relatives were left without any help. The National Schizophrenia Fellowship suggests that this is just the tip of the iceberg of need.
Thus, it is not surprising that there are reports of increasing numbers of patients suffering from schizophrenia who are swelling the ranks of the homeless. About one-third of homeless people suffer from the problem of mental illness.
My noble friend the Minister reminded us on 17th January that the Government had introduced the care programme approach for mentally ill people underpinned by the mental illness specific grant, to operate from 1st April. I heartily welcome this. However, the Government's circular indicates that hospital care should be provided for patients whose needs cannot be met in the community. Will this be possible with the closure of 25,650 hospital beds? Can my noble friend give the reassurance that they will be re-opened or replaced as necessary?
I also hope that the delay in implementing the law relating to community care may be used constructive-ly, perhaps for some radical reassessments. For example, can safeguards be built into NHS and community care policy to ensure that people with clinical needs receive adequate health assessment,
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health monitoring and health care from health professionals? Otherwise, many of the mentally handicapped and mentally ill, as well as the frail elderly, who are least able to articulate their needs or to assert themselves, will suffer.
I turn briefly to two issues concerning nursing. First, current proposals to give nurses specified prescribing rights have already been mentioned by the noble Baroness, Lady McFarlane. The primary concern here is the wellbeing of patients such as the elderly and chronically disabled; those with a mental illness; terminally ill patients and people with conditions such as diabetes. All would benefit from the quick, flexible response to their condition which the nurse, with regular and intimate contact, can provide. Others who would benefit include homeless people in bed and breakfast accommodation who frequently change addresses. Often health visitors are their only contact with the primary health care team. I therefore warmly welcome recent ministerial statements of support for the principle of nurse prescribing. I hope that legislation will soon be forthcoming.
Finally, I briefly refer to the preparation of nursing staff for care of casualties from the Gulf. We all pray that these will be few. However, it is crucial to be prepared for a scenario of unknown numbers of casualties. Meeting colleagues in different parts of the country, I find variations in perceptions of the extent to which nursing staff are being prepared to care for conditions with which they may be unfamiliar and which could occur in large numbers.
Can my noble friend reassure your Lordships that every part of the country has made comprehensive preparation for adequate numbers of nursing staff to work in highly specialised areas such as intensive care, burns units and facio-maxillary surgery? Can she say whether there are adequate numbers of well prepared reserve nurses who can care for NHS patients, if regular NHS nurses are seconded to care for war casualties? This must be of particular anxiety, given the current shortages of specialist nurses in some of these areas. I know that staff in colleges of nursing are keen to update and enhance the clinical skills of specialist nurses in practice and also potential nurse returners. They are anxious to do this before the casualties arrive, if they are given the green light to do so.
That is a specific anxiety, but one which illustrates the general point that health needs will continue to increase as we move further into the 1990s. The NHS must expand its provisions to meet these needs with the compassion and effectiveness that have earned it the respect and affection of people throughout the country. I hope that we shall finish this debate reassured by my noble friend that the NHS is indeed safe in this Government's hands.
5.50 p.m
Earl Baldwin of Bewdley: My Lords, I want to say a few words about complementary medicine. The leader writer of The Times wrote on 1st November last year,

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"The extension of complementary medicine…to NHS patients is a wholly desirable aim".
In common with three-quarters of the population I share that opinion. I speak as the chairman of the recently formed British Acupuncture Accreditation Board, and as a patron of the Research Council for Complementary Medicine. But, most importantly, I speak as a patient who has experienced a wide spectrum of complementary therapies and, I must add, has been lucky enough to be able to afford them. Many cannot afford those therapies.
Times have changed. It is no longer necessary to make a detailed case every time one speaks of the benefits of complementary medicine, and for this one must be thankful. The debate in your Lordships' House on 9th May last year, and to an even greater extent the amendment at the Report stage of the National Health Service and Community Care Bill on 12th June which so nearly succeeded in getting some complementary therapies on the NHS, showed the extent of the support that now exists for osteopathy, chiropractic, homoeopathy, acupuncture and the rest. I need only summarise the reasons why these therapies should be generally available.
In reverse order of importance these are, first, cheapness. All the surveys that I am aware of, including the Medical Research Council-funded study last year on the benefits of chiropractic, show that there are great savings to be made. The second reason for making the therapies more generally available is safety. Modern Western medical treatment hospitalises upwards of 10 per cent. of the total in-patient population. Natural medicine is not in that league. The third and most important reason is effectiveness. This is where in the past there have been most differences of opinion.
Research is crucial here. It is most encouraging to see the Labour Party commit itself to this, among other measures, in promoting complementary medi-cine in its document A Fresh Start for Health. This document was referred to by the noble Lord, Lord Ennals, when he introduced this debate, for which we must all thank him.
But I think one has to beware of falling into what I might call a medico-scientific trap over research. Good research does not come cheaply or quickly. At present there is little money in the complementary medical world and not a lot of research expertise. Furthermore there is a need for new methodologies to take account of an often very different approach and philosophy. Meanwhile, out there, there are suffering patients. So, what do you do? It seems to me there is a choice of two approaches. Either you sit on your hands and say, "There is no evidence to show that this treatment works"; in this way you maintain your academic respectability, and the patient, to take the case of chiropractic which I referred to a moment ago, waits 95 years until the case is made to everyone's satisfaction; or —and this is how we take most of the important decisions in our lives—you accept that the definitive evidence may be unobtainable at present and decide on other criteria.
Recently a medical researcher conducted a survey at a national GP trainee conference to discover what
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kind of evidence doctors considered important before accepting an alternative technique as one that was useful for their patients. The least important criteria were rated as laboratory evidence and a theoretical scientific rationale: both of these came lower than the views of colleagues or even patients. Most important was rated the organised audit of clinical experience. This casts an interesting light on the types of research that may be appropriate for complementary therapies, and on doctors' willingness to make use of them in everyday practice. It is already becoming clear that probably a majority of GPs are willing to work with other therapists within the National Health Service.
I see two ways forward for complementary medicine under the NHS. The first is the gradual approach exemplified by the current high-level discussions being conducted with the osteopathic profession which may lead to state regulation and eventual incorporation into the National Health Service. The problem here is the slowness of the process. While chiropractic may be poised to follow this route, almost all the other therapies, for historical and organisational reasons, are some years away from this kind of recognition.
This is why, from a consumer's point of view, I favour a parallel approach which would allow doctors now to refer to a local acupuncturist, say, if this was felt appropriate, or to incorporate a reflexologist in a group practice. Patients could then get the treatment they need when they need it, under the continuing care of the GP who is the best judge of the local situation. The Labour Party document talks of supporting pilot projects of this nature, and I believe this is an initiative which should be welcomed all round. There should be no legislative difficulties about it.
The noble Baroness the Minister has appeared to argue in past debates that patients are not too badly off because doctors are themselves entitled to give complementary treatments. In fact this is something of a worry, as can be seen from surveys showing doctors giving hypnotherapy and acupuncture with no training whatever. But even where they are properly qualified, their numbers are much too small to make any real impact. We need, as I have argued before, all the expert help we can get in making health for all a realistic goal.
I might add that it is time that some of the remaining misconceptions about complementary medicine were laid to rest. I think we are probably past the stage where a former government minister could cause astonishment by declaring that he knew that complementary medicine was fine for conditions above the waist (I think it was that way round) but was no good below. But I still find people who believe that complementary approaches are good for prevention, and for psychosomatic complaints, but not much else. I would go so far as to say that they offer the most exciting prospects in the fields of cancer and AIDS, as the noble Lord, Lord Colwyn, pointed out on Tuesday 5th February at col. 1130 of Hansard. The noble Lord is not yet in his place. These approaches are really not that difficult to find out about and follow up, if there is a real will to do so. The

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trouble in the past has been a failure truly to engage with alternative methods, to the real detriment of patient care. You do not learn the full picture by sitting in a medical library and searching the literature.
Other governments take a more positive stance. I could refer to many examples, but I am particularly struck by the moves that are afoot in Holland to sweep away the monopoly on the practice of medicine and promote a plurality of health care so that in principle all can practise, but under certain government restrictions and guarantees. I shall quote from a document that I have recently seen, which states:
"the patient of 1990 should be deemed mature enough to be able to choose his own treatment".
I think this motto would serve us well also. I welcome the Labour Party's stand on complementary medicine. I look forward to the progressive accreditation and eventual registration of the various therapies, but would press at the same time for a way to be found to make use of some of them in appropriate cases now, along the lines I have indicated. I believe this to be a valuable and acceptable objective for the health service for only in this way will patients get the service they need and are asking for.
5.58 p.m.
Baroness Faithfull: My Lords, I join with other noble Lords in thanking the noble Lord, Lord Ennals, for initiating this debate. The debate gives me the opportunity to speak on the need for a comprehensive, integrated child health service within the provisions of the National Health Service and Community Care Act. I pay tribute to the Secretary of State for Health and to his helpful and co-operative civil servants—I am particularly grateful to one civil servant who shall be nameless—for their help as regards providing such a service for children.
The Court Report was published way back in 1975. That report recommended an integrated service for children. Little was done from 1975 until the latest legislation was passed. However, during the passage of the then National Health Service and Community Care Bill in 1990 there was considerable worry among child health and social work organisations that the recommended reforms might hinder progress towards establishing a comprehensive, integrated child health service.
Since then, however, the Department of Health has held wide-ranging consultations and has exchanged views with interested organisations, all of which considered that they had received a sympathetic hearing and a positive response from the department and from the civil servants involved.
The exchange of views and the consultations between the ministry and the relevant organisations have made for better understanding and led to a good relationship between those within the ministry and those outside it. The document The Welfare of Children in Hospitals has been widely welcomed by the health organisations consulted.
We now await the publication of guidance covering community child health services. Here again the
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department has sought to consult with and seek the views of the relevant organisations. Can my noble friend the Minister say when we can expect publication of the document on community child health services?
During the consideration of the welfare of children in the community the department sought the views of child health organisations. In order to show their appreciation and to assist with the long-term objectives and the implementation of the comprehend-sive integrated child health service the National Children's Bureau and the National Association of Health Authorities and Trusts will shortly hold a day conference entitled "Acting Together". The effects of the National Health Service and Community Care Act will be considered in conjunction with the Children Act 1989. The sympathetic partnership between the Department of Health and those in the child health and social services concerned has resulted in policies which are acceptable to all those who desire to help children within the health service.
I join the noble Lord, Lord Ennals, in congratulating my right honourable friend Mr. William Waldegrave on his appointment as Secretary of State for Health. I also congratulate the right reverend Prelate the Bishop of Exeter who, as the noble Lord, Lord Richardson, said, has enjoined us to call for excellence of service in our National Health Service.
6.2 p.m.
Lord Pitt of Hampstead: My Lords, I too should like to thank my noble friend Lord Ennals for giving us this opportunity to discuss the National Health Service. I was disappointed in the noble, Lord, Lord McColl. I found his complacency disturbing. The National Health Service is presently in anything but a healthy state.
I am very glad that the noble Lord, Lord Winstanley, brought the question of waiting times to the attention of your Lordships. Waiting times, particularly for outpatient appointments, is of much greater importance than the length of waiting lists. I received a letter from a colleague at St. Thomas' Hospital which illustrates the present situation. It states:
"Dear Doctor,
Owing to the cuts imposed upon us by Administration to keep within budget we are obliged to reduce our out patient workload by 10%. Regrettably this means reducing the number of new patient appointments. As a consequence the wait for an appointment will now increase beyond three months. After discussion with my colleagues we thought the most efficient process would be to return the referral letter and ask you to re-refer the patient if necessary. In doing so further delay will be avoided if you can include the results of all relevant blood tests and X-rays and where the films have been performed in other hospitals arrange for them to be sent to us in advance of the appointment. Medically urgent problems will need a telephone call to the Registrar on call.
I am very sorry indeed to have to enact this policy and hope that it will not lead to any lasting breakdown in what has been a very good working relationship".
The state of the health service is the result of chronic underfunding. That has been exacerbated by the need for hospitals to clear deficits in order to enable the new arrangements to start on 1st April. The underfunding is the consequence of insufficient

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allocation for demographic changes and technological advance and the use of an allowance for inflation which is lower than the actual rate of inflation. It is also due to paying only a portion of pay awards, leaving the rest to be met by health authorities out of savings. Over the years those factors have accumulat-ed, leading to considerable underfunding. The consequences are there for all to see.
In looking at the state of the National Health Service one must also look at some of the underlying causes of disease. I am very pleased that my noble friend Lord Ennals raised the question of deprivation because deprivation is an important cause of ill health. The correlation between deprivation and health has been found in many studies to be very strong. There are physical, physiological and psychological mechanisms by which deprivation can affect health. Foremost among the areas of deprivation that affect health are damp and overcrowded housing and homelessness. Both are prominent in present society. So is low income. They require urgent action.
The Government have decided to deal with the problems of the health service by introducing a form of internal market, with health authorities purchasing services from hospitals and general practitioners being both providers of services and purchasers of services from hospitals. The market throws up losers as well as winners. There is the possibility that among the losers will be some of the centres of excellence, the London teaching hospitals. That could be a consequence of their location and capital charges.
Moreover, the insistence on separate pay awards for hospital trusts could result in the best consultants being confined to certain hospitals instead of there being an even spread of consultants throughout the country, which is one of the successes of the present National Health Service. I am glad that both the noble Lord, Lord Butterfield, and the noble Lord, Lord Richardson, dealt with that point. The Government have agreed that national pay awards should be retained for junior doctors. They should also be retained for consultants.
The National Health Service should continue to be free at the time of use and should be adequately funded. Pay awards should be met in full and full allowance should be made for inflation. Adequate allowance should be made for demographic changes and technological advances and innovation. I agree that one cannot always be sure of what percentage should be added but some allowance must be made every year. There should be a full range of services within reasonable geographical reach of all patients. While it is obvious that treatment should be cost-effective, financial considerations should not be used to override responsible clinical decisions. Adequate resources should be provided for community services.
The proposals in the Labour Party document A Fresh Start for Health meets those requirements. I join the noble Lord, Lord Ennals, in inviting your Lordships to read and study that document. I hope that the time is not far off when we shall be able to put those proposals into effect.
6.10 p.m.
Baroness Cumberlege: My Lords, I should like to start by thanking the noble Lord, Lord Ennals, for introducing the debate and to say that, although I cannot always agree with everything he says, I recognise and respect a lifelong commitment to the National Health Service.
This evening I want to concentrate my remarks on that part of the Motion which refers to the long-term objectives of the NHS. My job as a regional chairman is primarily to understand and implement the objectives, and I am happy that the nub of the reforms coincides with my philosophy; that is, the NHS has to move away from the ethic of "do as we say", which is authoritarian and paternalistic, to the ethic of fulfilling people's needs. That is a subtle shift of power from those who at the moment provide the service and work in the NHS to those who use it. All the reforms come back to that objective.
Seven million people in this country buy private health care. I think that is a measure of the NHS's failure to be user-friendly. I want to be part of a successful organisation, and I welcome the changes and the challenges to make it more successful. I want to cherish the ethic of the NHS, which I think is the best in the world, but remove the smug assumption that the services we provide are the best in the world. There is some room for improvement.
In the last month a report has been published by Jane Griffin which gives a good illustration of the need for change. She points out that 70 per cent. of terminally ill cancer patients who die in hospital had expressed the desire to die at home. We failed them. That is not just sad, but nearly 10 per cent. of NHS beds are filled by people who do not want to be there. We fail the user and fill the beds that others need. I believe we have to be holistic in our attitude to people when they are ill, as was so ably presented this evening by the right reverend Prelate the Bishop of Exeter in his approach.
As we jealously guard clinical freedom—or "the doctor knows best" approach—there is a danger that we may do what is medically right for the patient but lose sight of the person and what he or she wants. As far as clinical freedom is concerned, I share the view of the noble Lord, Lord Ennals, that we do not want managers making clinical decisions and deciding who on waiting lists will be treated. I am sure that he will be pleased to know that on the 29th January the chief executive of the NHS sent a letter to all regional managers saying:
"The principle must be that admission to a waiting list is a matter of clinical judgment".
He went on to applaud the work being done by the Royal College of Surgeons in drawing up protocols to help clinicians decide who goes on to waiting lists and who does not.
The noble Lord, Lord Winstanley, gave a superb description of the role of GPs and the strength of primary care. I think it absolutely right that the reforms start with the GP. In future, people can choose and change their GPs with much greater ease and can do so based upon information which practices give about themselves. I think that is user-friendly.

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Only the most perverse of us want to be ill, so it is right that there should be incentives for GPs to keep people fit by regular check-ups. People want a health service, not just an illness service. That is a key part of the reforms which is wholly commendable. When health promotion fails and we are ill we want our treatment to be successful.
Another key to the reforms is the concept of medical audit whereby consultants review their performance. That is not just right for users but is an efficient use of the health service, because readmissions and ineffective treatments tie up beds and waste resources. Surely, none of us wants that.
It is, clearly demonstrable that some hospitals can provide treatment at lower cost than others, and there is no correlation between costs and successful treatment. No other organisation has such a dearth of financial information. When we try to improve that sometimes it is portrayed as an increase in bureaucracy, but if we have poor management it prevents the NHS from accommodating people's changing needs, because we do not know the costs and cannot work them out.
I agree with the noble Baroness, Lady McFarlane of Llandaff, who said that choices of resources must be explicit. There is also a fear that if the NHS gets proper financial control it will radically alter the service, and in an organisation which embraces technological advance but eschews changes in provision people are deeply suspicious of change.
In my experience, fudge and muddle lower morale; waste and inefficiency are the enemies of a quality service; and poor use of resources means fewer people are treated and cared for. The NHS needs good quality management. However, I do not believe that governments are naturally good managers; rather they should be shrewd purchasers of services. The concept of trust status for hospitals is absolutely right and makes that possible, allowing the Government through district health authorities to buy the best services for people. Trusts run by local people can develop highly efficient and effective hospital services.
We have been through many of these exercises with other state-run organisations, and we know how to do it. We also know that the state is an inefficient provider of services and the NHS, which employs 1 million people, is almost bound to be extraordinarily difficult to manage other than locally. I think the act of breaking it down into smaller units having a great deal of autonomy is entirely in the interests of users.
With the deepest respect to the noble Lord, Lord Pitt, I do not share his concerns, because I believe that centres of excellence will not diminish; if they are excellent they will prosper. That is how an internal market works, because money follows patients.
The reforms provide greater flexibility, which is important, given that modern technology can provide treatment to many people on a day case basis, or even as out-patients. As I go round hospitals I know that is a very popular thing to do. The question most frequently asked in hospital is: "When can I go
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home?" People instinctively know they recover quicker at home, and there is plenty of research to back up that instinct.
Finally, everyone of worth is galvanised by challenge. When going around my region I see those hospitals which are going for trust status or GP practices which are anxious to become budget-holders. They have a new air of exhilaration and self-confidence; they want to throw away the crutches of bureaucracy and do the job their way. The empire that I chair is tremendously efficient, but for me the satisfaction will come when all the hospital and community units I cherish are strong and confident enough to govern themselves, and that will be when their ethic is to listen to the people and give them the health service they want. The reforms will enable that to happen.
6.20 p.m.
Baroness Masham of Ilton: My Lords, I should like to add my thanks to the noble Lord, Lord Ennals, for introducing the debate. I must first declare an interest, as I serve as a member on the North Yorkshire Family Health Service Authority (FHSA). I also live in London and see the stress and pressure on the inner London teaching hospitals. There is a tremendous diversity of needs. In the two places where I live I see at first hand how different the requirements are and I shall try to illustrate some of them to your Lordships.
From the inside I see many people who are now trying to make the reorganisation of the National Health Service work. There has been a monumental upheaval. New committee members have to get to know each other and non-executive members have to get to know executive members. I see some suspicion by GPs of the Family Health Service Authority members. There is no doubt that people have to learn to know and trust each other. To make the National Health Service work, people need people. They need to work in co-operation and not to be in conflict.
I should like to bring to the fore a few problems that women encounter. Recently a patient who had been in a gynaecological ward in a Stevenage hospital told me that the patients were not given any information and were very unhappy. She said that it had been a wholly unpleasant experience. People who come into hospital are often keyed up. They need assurance and a little TLC. That does not cost money. In fact, it can be very cost-effective as patients relax and co-operate.
In January I had a few days in the Westminster Hospital in just such a situation. The junior members of the staff were quite excellent but the ward sister did not bother to speak to any of the patients. This was commented upon by many of the patients in the ward, two of whom had been nurses. I asked a student nurse about the sister's attitude and was told, "She does not bother to speak to patients. She is only interested in administration. And, anyway, she comes from the Charing Cross Hospital". That appeared to explain a lot. But it seemed a pity that a ward sister did not set a better example to her students. I hope that one of the

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long-term objectives of the reorganisation will be to show helpful and kind attitudes towards all patients. That needs to be incorporated in nurses' training.
On Thursday 31st January I read in the Independent the headline:
"National Health Service cuts threaten breast screening scheme".
It was reported that breast cancer screening for women over 50 is threatened by financial cuts despite a government report which says that it will prevent one in four deaths from the disease. Will the Minister please give a progress report on that situation?
Also, as president of the North East Kidney Association, I ask the Minister, what is the future hope that EPO (erythropoietin) will be available when needed? I am told that EPO represents an important advance in the treatment of anaemia, which is a common side effect of chronic kidney failure. It also vastly improves the quality of life. A young doctor who is a user of EPO considers that it is of vital importance to many patients.
I should like to ask the Minister how different health authorities throughout the country are tackling the problem of hospital security now and in the future. Hospitals used to be places held in high esteem by the public at large. Recently there have been some horrifying incidents of rape and even murder within what should be a protected environment. Tunstall Telecom has produced a very interesting call system, and when a woman was raped at St. James's University Hospital in Leeds I asked myself whether the culprit might have been caught if the nurse who was the first person on the spot had been able to press a button in order to summon help. I am sure that the Minister would be interested to see that system. Members of staff could have in their pocket or on their person a button which, activating a call unit, immediately sounds an alarm at the central control panel and shows the zone in which the incident is taking place. Each at-risk area needs a good system for the protection of staff and patients. Well trained security staff will have to be available. It is at patient level that one needs motivated, well trained staff.
In Britain there are many general practices in rural areas. As we sit in this splendid Chamber in the heart of London it must not be forgotten that the National Health Service covers all corners of the country. I live on the edge of the Yorkshire Dales. There are many other rural areas in England, Scotland and Wales, such as Northumberland, North Wales, Lincolnshire and so on. Many rural GPs feel that they are losing out on the new contract. Many of them already have the entire local population on their practice list. They have no chance to attract any more patients. In isolated communities patients have no choice of doctor. A GP working single-handed has to carry the whole burden of overheads. The same kind of staff must be employed and the cost of a locum is very high. The additional problems of a doctor who serves a small isolated population need to be understood. The large mileage covered in rural areas by staff and patients is time-consuming and expensive. It needs to be taken into consideration.
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It is important that rural communities have good primary health care, as the nearest district general hospital may be 25 miles away. I feel that FHSAs can be of help in advising doctors and assisting with the problems of rural isolation. The difficulties encountered in travelling to clinics and outpatient appointments give rise to a need for a variety of transport schemes. Public transport is almost non-existent in certain areas.
I recently paid an interesting visit to Brent and Harrow FHSA. It was very different from North Yorkshire. Our group visited a GP practice which had been told that it would close if it did not make much-needed improvements. I could see what had been done, including the installation of a lavatory for disabled people. We were made very welcome by the staff. I believe that, if there is firmness by FHSAs about good standards and help and advice are given, patients will see improvements, though there is a great deal to do.
Nothing is more important than a healthy health service. When there is too much stress on staff and pressure for beds, the system breaks down. There are many excellent consultants who are always present and available when needed; but there are others who could help their National Health Service patients and junior staff more than they do at present. Patients will never respond well if they are treated like groceries being checked off through a conveyor belt system. The personal dignity of the individual will always be important.
6.28 p.m.
Lord Colwyn: My Lords, I must apologise to the noble Lord, Lord Ennals, for my late arrival in the Chamber this evening. I look forward to reading in Hansard tomorrow his speech and others that I missed, in particular the speech of the noble Lord, Lord Winstanley, who has perhaps been converted to complementary medicine, and that of the noble Earl, Lord Baldwin, who will have made many of the points that I would wish to be noted by the House.
With the noble Lord, Lord Ennals, I am joint president of the Parliamentary Group on Alternative and Complementary Medicine, but my noble friend the Minister will be glad to hear that it is not my intention to make yet another speech on that subject this evening. She is well aware of my views and concern that successive governments continue to pour more and more finance into a health service that will never be sufficiently funded and could be considerably helped by recognition and use of the therapies.
Those of us who support the integration of the complementary therapies with the health service will continue to remind the Minister that in June last year an amendment to the National Health Service and Community Care Bill, which would have permitted fund-holding practices to make use of complementary practitioners, received support from all sides of the House and was defeated on Division by only four votes. I am sure that my noble friend will have had

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brought to her attention this afternoon the section on complementary medicine in the Labour Party document A fresh start for health.
I support all that it states on increasing choice for patients and on initiatives to enable the eventual integration of the complementary therapies. I hope that I shall eventually be able to persuade my own party that that is the way forward.
The debate gives me the opportunity to discuss one of the least glamorous professions in the NHS, but one very close to my heart. Dentists are not always popular with the public! People do not die from dental disease. They often attend the dentist only when they are in pain. Consequently the public associate the dentist with pain, and not the relief from it or the prevention of its causes.
Nevertheless, dentistry is vitally important to the health of the nation. Anyone who has suffered from problems with their oral health can testify to the deleterious effect of such problems on their quality of life. Indeed, the maintenance of one's teeth and gums in healthy condition is essential to overall health. Dentists within the NHS have contributed significantly to the improved dental health of the nation. For example, in 1968 the proportion of adults with no natural teeth was 37 per cent. Today it is 20 per cent. Since the early 1960s, dental caries in children has been reduced by 80 per cent.
Following changes in patterns of dental disease, dentists have oriented their practices towards giving more preventive care. However, for general dental practitioners this change in emphasis was not rewarded under their contract with the NHS. As a consequence, the British Dental Association renegotiated that contract with the Government during 1989 and 1990 to provide a better service for patients and to reward dentists for preventive care. The new contract has been accepted by the Consumers' Association among others as a good deal for patients. Many dentists accept the principles of the new contract but they are worried.
General dental practitioners occupy a unique position within the NHS. They are "independent contractors"—self-employed dentists who own, finance and manage their practices as well as providing clinical services. They are paid a range of fees for different types of service out of which they cover practice costs, premises costs, staff wages, and "prescribing" costs. On average about 60 per cent. of a dentist's gross fee turnover from the NHS is needed to cover practice costs and the balance is what the dentist is paid for his/her own contribution to the practice and the care of patients. Dentists are suffering from e same pressures faced by any other small business in this difficult economic climate.
At the same time the need to contain public spending has resulted in a severe pay decline for dentists relative to other professions. They have less money with which to manage and develop their practices. It has not been surprising that some have questioned the wisdom of remaining within the NHS when fees obtained from private patients have been
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shown from a BDA survey to be much higher in the North West and the London area. Nevertheless, dentists have shown a high degree of commitment to the NHS in implementing a new contract which has resulted in increased administrative and management burdens.
Another survey carried out by the BDA last October found that over 90 per cent. of dentists were working with the new contracts. The recognition recently by the Doctors' and Dentists' Review Body (DDRB) of an increased workload has given the profession some encouragement in a year which for many will be "make or break" as to whether they stay in the NHS. But the nation needs excellent dental health which can continue to be provided under the NHS. Dentists wish to continue to provide the most cost effective dental service in the world under the NHS. They can do so only if there is government commitment to maintain their clinical standards by providing adequate resources.
The new contract and the recommendations of the DDRB acknowledging the serious situation that GDPs face are a small but significant step in the right direction.
6.34 p.m.
Lord Broadbridge: My Lords, I congratulate the noble Lord, Lord Ennals, on the timing of his NHS debate today for it was in the Radcliffe Infirmary, Oxford, 50 years ago today that the first-ever patient was treated with penicillin.
If this debate on the objectives of the NHS has turned also into something of a debate on complementary medicine the Government have in some measure only themselves to blame. Her Majesty's Government have consistently turned a rather deaf ear to the case for including some complementary therapies in the services available free on the NHS. Indeed, they have somewhat resembled the heckler who during a public meeting shouted at Disraeli, "Speak up, I can't hear you", to which Disraeli responded, "Truth travels slowly but it will reach you in time". In the brief remarks that I now wish to make I can only subscribe to the spirit of Disraeli's pious hope—but perhaps with less confidence.
To state the position simply, it might be stated that in the matter of complementary medicine within the NHS there is a triangle of involved parties: first, the patients; secondly, the doctors; and, thirdly, the Government. I should like briefly to examine their relative positions.
Demand for complementary medicine and complementary therapies is growing consistently and rapidly in numbers of practitioners, statistically recorded consultations and surveys in opinion polls. Early last year a MORI poll recorded that an average of one in three would consider using acupuncture, homeopathy and osteopathy, and that the vast majority who used complementary therapists—up to 93 per cent. of chiropractic patients—were "very satisfied" or "fairly satisfied". On a national representative basis, one in three is about 15 million people.

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A slightly earlier attitude study by the City Health Centre concluded that the majority across age, sex, income and occupation, wanted complementary medicine to be available on the National Health Service and on private insurance schemes. Back pain is a classic example. According to the Office of Health Economics, the cost of lost production through back pain alone amounts to over £1,000 million a year.
The European view is still more emphatically in favour of complementary medicine both in practitioner numbers and in funding. Complementary therapies are proving ever more popular through Europe and beyond. France has 10,000 doctors who also practise homeopathy. We have 500. Validity of homeopathy and acupuncture is accepted by the French Academy of Science and the prescriptions and consultations to which they give rise are reimbursed by social security payments.
In Germany naturopathy and nature cure are the dominant therapies. The German Government are spending 800,000 deutschmarks on complementary medical research rising to 3 million deutschmarks after three years. In the Eastern bloc herbalism is very popular. In Switzerland, acupuncture and homeopathy are widely practised. In Britain osteopathy, chiropractic and homeopathy are widely practised, the latter by six generations of our Royal Family.
The second point of my triangle is the doctors. In the BMJ of 7th June 1986, in a study on complementary medicine and the general practitioner, two doctors—one a general practitioner—reported on the responses of 145 randomly selected GPs in the Avon area. Their findings were that overall GPs knew little about the techniques of complementary medicine. However, despite that, over the past year 110 GPs—that is, 76 per cent.—had referred patients to medically qualified colleagues for such treatment and 72 per cent. had referred patients to non-medically qualified practitioners.
We must remember that it is only about 12 years since the General Medical Council rescinded a total ban on referral of patients to non-medical practitioners. Indeed, this interest by general practitioners to become more involved with complementary medicine is one of the most marked recent developments in the relationship of complementary medicine to conventional treatment. Interestingly, a study in the Lancet of 17th October 1986, showed that the highest levels of complementary consultations were found in Oxford, Cambridge and Exeter, all cities which are well served medically. Other reports have also established that complementary medicine does not thrive in regions where conventional medicine is poorly represented. It would surely be reasonable to deduce from that that complementary therapies do not exist to prey on populations which are poorly represented conventionally but truly on a "two-plus-two-makes-five" basis, to complement established orthodox practice.
Furthermore, the disorders for which patients see complementary medical practitioners do not exactly overlap those for which they see conventional practitioners. They focus on chronic and mild muscular-skeletal and stress-related dispositions
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rather than on infections. About one third of complementary medical patients are known to be seeking help from conventional doctors. Thus, again, the role of complementary medicine is truly complementary to, rather than conflicting with, conventional medicine, with each system finding its separate region of competence.
Finally on the subject of doctors, a survey conducted as long ago as 1983 and reported in the BMJ showed that 76 per cent. of general practitioner trainees wished to learn one or more complementary medical skill.
The third and final point in my triangle of involvement with complementary medicine is the Government. The latter have consistently taken the view expressed concisely in May 1988 by Sir Richard Bayliss of the Royal College of Physicians when he said:
"the same standards of assessments should be used to determine the efficacy of complementary as of orthodox medicine and drugs".
It was for that reason that nine years ago the Research Council for Complementary Medicine (RCCM) was established. During that period some 109 projects have been presented to the council for a call on its very limited funds. But in March last year the Department of Health grant of £70,000 towards the administrative costs of the council came to an end. Although much appreciated, it pales into insignificance beside the sum of £500 million of government funding and charitable donations for conventional medical research. The RCCM has struggled to support some 20 per cent. to 25 per cent. of the proposals put to it on the basis that they would be of primary value in discerning the proper use or mechanism of some of the complementary therapies. In addition, they would contribute towards answering Sir Richard Bayliss's stricture that the same standards of assessment should be used to determine the efficacy of complementary as of orthodox medicine and treatment. But it is difficult to compete with £500 million on a budget of £70,000 plus donations.
I mix my metaphors somewhat in saying that the complementary medical horse wishes to drink, but the Government have turned off the water supply. I ask the Minister who is to reply whether the Government will give more help because, in conclusion, I believe that additional Government funding for the RCCM in Britain will guarantee that adequate research is done, will protect patients from exploitation and will encourage authentic therapeutic practitioners. In addition, it will lead to greater co-operation between orthodox and complementary practitioners and, importantly, to considerable economies for the NHS in the annual drugs bill, as mentioned by several noble Lords.
The doubters and the unsympathetic would do well to remember that in a Gallup poll carried out five years ago 50 per cent. agreed with the statement that:
"Human nature is such that we are frequently prevented from seeing that that which is taken for today's unorthodoxy is probably going to be tomorrow's convention".
6.43 p.m.
Baroness Robson of Kiddington: My Lords, I too thank the noble Lord, Lord Ennals, who is no longer in his place, for introducing the debate. Any debate in this House on the National Health Service is always attended by a large number of Peers and contributions come from an enormous number of informed speakers. The reason is that on all sides of the House there is a deep anxiety about the future of the NHS.
The one issue upon which we all agree is that the NHS constitutes a unique and precious asset which provides basic services of a high standard at a low cost proportionate to GDP and compared with other countries. The noble Baroness, Lady Cumberlege, my successor as Chairman of the South West Thames Regional Health Authority, said that the NHS was galvanised by change. To my knowledge it has been four times galvanised. I was part of the first galvanisation in 1974. It was later galvanised by Griffiths. It was galvanised again by the abolition of the area health authorities, with which I totally agreed. Now it has once again been galvanised. Members of this House should pay tribute to the people who work in the NHS and who have put up with the four-yearly changes that have occurred. They have done so with no lowering in the standard of care for their patients. They deserve our praise.
In introducing the debate, the noble Lord, Lord Ennals, referred to our debates on the National Health Service and Community Care Bill. He believed that the community care part of the Bill should have been introduced first and that the rationalisation of the NHS should have been the second priority. I agree with his view because there was hardly any controversy over the community care provisions. They were universally welcomed and would have enabled the setting up of pilot schemes on the alterations in the management and functioning of the NHS. Like the noble Lord I regret that the Government did not see fit to take that order of priorities.
But they did not and, as a result, 66 hospitals have applied for trust status. I do not disapprove of that. I understand that 56 hospitals have been accepted and have been given the go-ahead from 1st April 1991. I also understand that 123 units are working on trust status for 1992. I do not remember hearing during our debates on the National Health Service and Community Care Bill that external financing limits would be put on the trusts, although I may be wrong. I am certain that some of the hospitals which have applied for trust status believed that they had the right to go to the commercial market and to develop in the way they wished. They also believed that they had the right completely freely to pay their staff and set standards of salaries and wages within their hospitals. I wonder whether now, in hindsight, they believe that they were sold an idea on a slightly false prospectus. That is how I should feel. I may be wrong about that. If the provision was contained in the original prospectus I shall be corrected by the Minister.
I welcome the fact that the junior doctors will be paid the same throughout the National Health
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Service, whether in trust hospitals or not. I agree with the noble Lord, Lord Richardson, that that condition should apply to members of staff at all levels. I welcome too the fact that the Government have gone a long way towards solving another problem; they have reduced to a maximum of 72 per week the number of hours worked by junior doctors. However, even that is a great number of hours. In order to make the necessary arrangements it is essential to change the working practices of the consultants. I understand that the Government have accepted that fact and that, as a result, a greater number of consultants must be appointed.
When I was chairman of South West Thames, I occasionally got permission to appoint one or two extra consultants. But I never got the cash to do it, so even when I got the permission I found it very difficult. I got the cash for the consultant's salary, but if you appoint a consultant the cost of establishing him will be at least double that. Therefore, I am a bit wary about believing that we can appoint enough consultants to enable junior doctors to work only—I emphasise "only"—72 hours a week.
One of the strengths of the National Health Service is the general practitioner service. My noble friend Lord Winstanley mentioned the uniqueness in our National Health Service of general practitioners. I am a bit concerned about reports that I have seen in the press that general practitioners who are going to be fund-holding are having pressure put on them to use the contract that the district health authority has negotiated, because I always thought that the strength of the GP service was that they could refer their patients to any hospital they thought fit.
There have been many questions about how we can afford a health service of the type we want. My noble friend Lord Winstanley referred to priorities; the noble Baroness, Lady McFarlane, spoke of rationing. I think we should be quite dishonest if we went to the nation and said that we could afford everything that was needed for everybody. It is not true. Therefore, we must develop a better system for measuring outcomes. We have to make certain not only of the duration of survival but the quality of that survival. We must be able to measure that real outcome.
As long ago as 1863, Florence Nightingale wanted to assess the standard of hospitals, and she wanted to set targets to measure those hospitals. She said, "You have to measure how many dead, how many relieved, and how many unrelieved". In a way, that is what we must set about doing. This is going to be one of the most difficult problems which will face us in the future. Unless we can measure the real outcome of what we do in the NHS, we shall not be able to afford the future.
6.53 p.m.
Lord Carter: My Lords, we have had a wide-ranging debate on the one area of social policy that affects every member of the community. All of us will, at some time in our lives, have to use the National Health Service. I should like to deal immediately with one important aspect of health care that was touched

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on by my noble friend Lord Longford and by other speakers in the debate, and that is community care. The House will remember well the many hours that we spent on the community care section of the National Health Service and Community Care Bill, and indeed the amendments that the House accepted —which were later overturned by the Government—to secure the ring-fencing of community care funds.
We now know, of course, that our efforts on the Bill have been somewhat reduced in value by the Goverment's decision, as a direct result of their panic over the poll tax, to postpone until 1993 the full implementation of community care. An idea has been floated recently that, as a part of the Heseltine review of the poll tax and in order to secure a reduction in local authority spending, consideration is being given to removing responsibility for community care from local authorities, and handing it over to health authorities. There have been similar proposals for the education budget.
I should like to ask the Minister—and before the debate I told her that I should be asking this question —whether in fact such a proposal is being considered by the Government. If it is to happen, am I right in thinking that this would require a new Act of Parliament? Indeed, have the Government any plans at all to amend the timetable for the introduction and implementation of community care? I am sure that the Minister will know that some recent reports have suggested that the implementation should be brought forward from 1993 to 1992. I am sure it would be extremely helpful, and would help to allay anxieties outside the House, if she could answer those questions.
My noble friend Lord Ennals, in his powerful opening speech, drew attention to the problems in the health service and in April's impending reforms. He set out the proposals that we have formulated as the Labour Party policy that we shall wish to put into effect in government. The central problem is of course the source and the quantum of the funding of the health service, and those would be problems for any government. Various calculations have been made. They tend to suggest that, taking into account specific health care inflation rather than the general RPI, overall funding since 1985 has been only about one-quarter of the amount required to maintain and improve the service.
We are all aware of the problems—particularly for the National Health Service—arising from what was described some years ago as the revolution of rising expectations. That is a phrase which I believe was first coined by Mr. Enoch Powell. The argument goes that no society can afford the level of health care required to give everybody the treatment they need when they need it. Or, per contra, no government can impose the level of taxation required to produce all the necessary resources in the public sector.
I believe that both these arguments are false. No one in his right mind expects the waiting lists for hips or hernias to be reduced from 18 months to 18 days. To reduce them to 12 months and then
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eventually to six months would be a great boon to a great many people. When the Government refer, entirely correctly, to their increased expenditure on the health service, and they link this with what the taxpayer will stand, what they are really saying is that they cannot spend even more on the health service and at the same time reduce higher rate taxes by about £26 billion, spend hundreds of millions of pounds on the fees and advertising of privatisation, pour some £10 billion down the drain on the poll tax, and give £40 million tax relief for private health care and so on. I am describing and not criticising. Every government has the right to choose its own priorities. But it is a fact that a Labour Government will have some very different priorities, and, as a result, more resources will be available for the health service.
We all know that debates like today's produce a great deal of helpful briefing from outside organisations, but it occurred to me that it would be also useful to also hear from the people actually operating the service. I therefore wrote to a number of doctors, both consultants and GPs, and I told them about our debate and I asked them for their views. I do not know, nor do I wish to know, their politics. I just know them all as very good, caring doctors.
Their letters illustrate much better than anything I can say the state of the National Health Service today. A general practitioner says:
"As a general point there is little doubt that in this area at least the service is getting worse; that wards are closing routinely, so far as I can make out, for financial reasons; and that this has an inevitable knock-on effect on waiting lists. The main problem certainly seems to be on the surgical side, but there is also the matter of consultants who are trying to keep within their budgetary limits and are asking the general practitioners to prescribe the often very expensive drugs that they recommend".
I quote from the chairman of an orthopaedic department in a substantial hospital in the West Country, who says:
"Due to a combination of factors, not least of which is the general trend towards a reduction of junior doctors' working hours, we have been unable to fill 50 per cent. of our Senior House Officer posts in Orthopaedics and Accident and Emergency … It is therefore with deep regret that we have had to take the step of cancelling all cold Orthopaedic surgery (except for those cases with an urgent medical priority) as from Monday 4th February 1991 … The same embargo will apply to out-patient clinics, where new patient referrals will have to be deferred, (again with the exception of urgent cases).
"We are very aware of the terrible consequences that such a reduction in service is bound to have on the local community but are not prepared to struggle on with a second rate, potentially dangerous service."
A general practitioner in the Midlands states:
"Several hospital managers are already on record that they will not agree to pay for patients referred to hospitals with whom they have no prior contract and most others say they will insist on written agreement being obtained before such referrals are made".
Later he adds:
"Community Health Services have been hit not only by health authority cuts; transfer of responsibility for the elderly, or handicapped, to Social Services has meant a further series of cuts due to 'rate-capping'. Examples are chiropody services, the supply of commodes, incontinence appliances, etc., 'Home Help' services, 'Meals-on-Wheels', hospital transport".

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A consultant anaesthetist said:
"Emergency surgery, however, gets a very raw deal, and, with our ageing population, our orthopaedic service suffers most. For 15 years we have been trying to get a dedicated orthopaedic trauma theatre funded—we are still waiting!"
He also refers to a recent operating list and says,
"Beside the name of each patient … is the time these patients had been waiting [four days to two weeks] with their fractures for surgery. Disgraceful treatment, I am sure you will agree".
Continuing, he says:
"We shall be cancelling all surgery for one afternoon a month as regular Audit meetings will become a necessity, and doctors are not prepared to give up any more of their free time for yet more meetings".
Later in the letter he says:
"Morale amongst consultants is reasonably good because of the opportunities in private practice. Without the latter, my NHS salary would probably be the same as that of a young doctor just starting in general practice".
I received a letter from a consultant anaesthetist in a general hospital, in which he writes:
"I am genuinely distressed to have to admit that despite my personal effort—I spent 25 hours in theatre on Saturday and Sunday—we were unable to provide either a proper emergency service or a proper trauma service … The trauma service is in a state of crisis and, if it is not possible to rectify this situation from within the resources of the Acute Unit, the District Health Authority should be formally apprised of our difficulties. We must demand that resources for an appropriate service are made available or else we should cease to provide a trauma service".
I received a long and helpful letter from a consultant in the Midlands, in which he states:
"You will know that, whilst Health Authorities are being forced into increasingly unpalatable cuts in service in order to stay within budget, virtually unlimited Central Government funds are available for anything related to 'White Paper implementation'. This includes hardware, software and any category of staff as long as they are not connected with patient care, i.e. business managers, accountants, statisticians, advisers, training officers".
He adds a postscript, which reads:
"I have just learnt that the facilities for long term and respite care for elderly disabled people at this hospital are to be closed to meet the April 1st deadline after an interim period during which the existing patients will be put under the care of psychiatrists. Responsibility for this appalling decision is being fudged between the Health Authority and the hospital management".
I ask noble Lords to compare those reports with the panegyric that was given to the House by the noble Lord, Lord McColl. One should also contrast that with the experience of a young lady of whom I was told only yesterday. She has been waiting for a non-urgent operation for over a year. She was offered by her consultant a weekend package deal in a private hospital for £1,500 as soon as she wanted it.
Only last week on the "London Programme" on television there was information that health authorities in the South of England are investigating the setting-up of contracts with hospitals in France. A hospital spokesman in Boulogne was interviewed. I ask the Minister whether the Government are aware of that, and if so whether they approve of it. What would happen if anything went wrong? Who would the patient or health authority pursue in the case of medical negligence? Would they have to go through the French legal system?
Almost all the problems related in those letters that I have quoted are due to the requirement to balance the books of the health authorities by April. Why are
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the Government prepared to write off billions of pounds of debts to prepare nationalised industries for privatisation while they refuse to write off around £100 million of health authority debts? I quote from the general manager of a substantial hospital in West London which had to close wards. He writes:
"I don't like doing this and it is very unfortunate that patients will have to wait longer for treatment but I have a responsibility to balance the hospital's books at the end of the year and this was the least damaging option".
Time does not allow me to deal with the many other problems faced by the National Health Service. I conclude by saying that there is a genuine and sincerely held difference of view between the Government and the Labour Party regarding health policy. In the Labour Party we believe fundamentally that the provision of health and community care is peculiarly unsuitable for the imposition of a market mechanism. The Government, although entirely sincere, believe the opposite.
Rejecting the market mechanism does not mean that cost efficiency audits are not required or necessary as a means of providing information to increase efficiency. But they should not be used to allocate medical care. That must be done on the basis of medical need.
Let us consider the health service in the light of the Government's own theory of the free market. If the supply of any product is restricted—in this case through under-funding—and demand increases as a result of an ageing population, increases in technology and demand for higher standards, there are only two ways of allocating resources to clear the market. That can be done only through rationing or through price.
We know that rationing is already taking place, either behind closed doors or out in the open, as in the example given by my noble friend Lord Ennals. The North East Thames Regional Health Authority has laid down the medical conditions which it will not allow on to the operating list. It is true that we have an inefficient system of rationing health care. A valid point in that regard was made by the noble Baroness, Lady McFarlane.
The Government intend to solve the Problem by a gradual introduction of the price mechanism; first, through the proposed contract system—the so-called purchaser/provider relationship. When that fails, as it undoubtedly will, those customers who can afford to will exercise their consumer choice and migrate to the private sector, no doubt encouraged on their way by generous tax reliefs. Or, to put it more graphically, the patient will have to wait longer, to travel further or to cough up.
I am reminded by my noble friend Lord Molloy that all the Royal Colleges, the BMA, the Junior Doctors' Association, the Confederation of Health Service Employees and the Health Visitors' Association have condemned the Government's proposals for the health service.
We should contrast the approach of the Government—we are entitled to do that—and their use of the price mechanism with the Labour Party policy set out in our policy document, A Fresh Start for Health. That places the emphasis on the prevention of ill health; providing the treatment that patients need in a hospital of their choice; the ring-fencing of

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funds for community care; the establishment of a quality commission for community care; the abolition of the market mechanism in public health care; the full funding of health service pay awards; the establishment of a charter for patients; and the establishment of a quality commission for the health service as a whole.
However, the most fundamental difference is that a Labour Government will truly believe in a properly funded health service providing high quality health and community care allocated according to need and not according to the ability to pay. We reject the market mechanism as a method of allocation. When the time comes we have no doubt which policy the electorate will choose.
7.9 p.m.
Baroness Hooper: My Lords, at the outset of the debate we were enjoined by the noble Lord, Lord Winstanley, to concentrate on an informed discussion. We have had that. We have had the benefit of people's personal experience and expertise. We were also privileged to hear the right reverend Prelate speaking for the first time in your Lordships' House. He referred to the important role of hospital chaplains. His contribution was extremely timely as the department is currently considering the need for an overall review of hospital chaplaincy services.
The noble Lord, Lord Ennals, has given everyone the opportunity to air their views on the current state of the National Health Service. He has given me the opportunity to assure the House about the current healthy state of the National Health Service, and to outline some of the important developments we plan for the future. I am grateful for that. As my noble friend Lord McColl said, there is much good news to tell.
The Motion asks us to consider the long-term objectives of the health service. Throughout history different meanings have been given to the concept of health. The one, central to the development of modern medicine, is freedom from clinical disease. The fundamental goal of the health service is to sustain this by providing the means to restore health to everyone in need regardless of income, and with resources financed mainly out of general taxation. We have no intention of changing that. I probably had no need to repeat that, but I felt it worth it.
We set out our objectives for the NHS in our White Paper Working for Patients. They are as follows: to extend patient choice; to delegate responsibility to those best placed to respond to patients' needs and wishes; and to secure the best value for money. We said that the result would be a better deal for the public, both as patients and taxpayers, and that we would build further on the strengths of the NHS while tackling the weaknesses. All this we are doing.
The founding fathers of the health service expected demand for health care to fall as people reaped benefits of its high quality clinical care. As we all know, the opposite actually occurred and demand for services has risen dramatically. The ability of the NHS
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to respond depends not only on funding but also on management. We have met this challenge with structural reforms designed to make the service even more patient centred, with clear targets to work towards and more accountability.
It is now less than two months before the main elements of these reforms come into effect. The massive programme of change to ensure that better patient services are delivered locally is on target. The service must be congratulated for that. My noble friend Lady Cumberlege was able to confirm that from her standpoint as a regional health authority chairman. For example, the newly constituted district health authorities are taking on their new responsibilities in purchasing services for the people they serve. NHS contracts that include challenging quality measures—we are all agreed on the importance of quality in patient care—are being finalised. Hospitals and other units providing services are developing independence, and 57 will be operating as trusts and are already running in shadow form. I say to the noble Baroness, Lady Robson, that as regards National Health Service Trusts, I believe that I was always clear in confirming that they would remain within the National Health Service. It therefore goes without saying that public sector borrowing requirements apply. With all these changes there has been a major shift in attitudes. The changes include the substantial number of GP fund holders. These changes mean putting quality and responsiveness to the patient at the top of the agenda and it is exactly what the reforms are about.
I say to the noble Lord, Lord Carter, that using the tools of business does not mean that we are trying to turn the National Health Service into a business. We are just trying to make it more businesslike. The noble Lord, Lord Ennals, suggested that the cost of implementing the reforms would be at the expense of patient services. The extra £1.9 billion provided by the Exchequer for hospital and community health service revenue and capital spending in 1991–92 takes full account of the cost to health authorities of implementing the reforms. Apart from the substantial increase in health authorities' main allocations, they will receive funding for specific review-related projects such as medical audit. There is no question of funding for patient services being diverted to fund the introduction of the reforms.
We have been reminded that the total National Health Service spending in the United Kingdom is at record levels. Our plans for the next financial year will bring it up to £32.6 billion. That is 50 per cent. higher than in 1978–79. At 14.2 per cent. of total government spending, health is the second biggest publicly funded programme after social security. Financial growth has been sustained throughout our period of office and demonstrates to anyone in doubt our commitment to the National Health Service.
I say to the noble Lord, Lord Pitt, that activity growth has more than kept pace with demographic change because of extra government finance and National Health Service efficiency.

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We have also carried out the largest-ever hospital building programme. Gross capital expenditure by health authorities increased by 45 per cent. in real terms. Over 475 schemes, each costing over £1 million, have been completed. For example, I refer to the new control centre for the Surrey ambulance service in Banstead. It is the first of its kind in the country and uses the most advanced computer-based control and display techniques to enable location and availability details of its 50 front-line ambulances to be accurately pinpointed. This time last year the ambulance service was high on the health agenda. It is very interesting to note that not a single speaker in the course of today's debate has mentioned the successes that we have had in the ambulance service.
We shall continue our work to improve the infrastructure of the health service. Throughout England over 470 similar capital schemes are at various stages of planning, design and construction. A capital loans fund providing £50 million over three years which was launched in January last year will help with the rationalisation and modernisation of the NHS estate. An additional £8 million is being made available for 1991–92.
It has been said many times that more people are employed in the National Health Service than in any other organisation in Western Europe. The numbers of doctors, dentists and nurses have increased significantly during the lifetime of this Government. I shall not go over all the figures on this subject because they have been quoted in the course of the debate. What is most important is the fact that as a proportion of the total National Health Service workforce, direct care staff grew to 67 per cent. in 1989. In the family health service the number of GPs increased by 22 per cent. in the 10 years to 1989, enabling list sizes to be reduced.
The Government are conscious of their responsibilities as an employer. Not only are there more doctors and nurses now, but they are better paid. For example, basic nurses' pay has risen by over 41 per cent. in real terms since 1979. It has been recognised by a number of your Lordships that we are also working with doctors to bring down unacceptable duty rotas. The agreement signed on 17th December about junior doctors' hours was a major breakthrough. We shall be funding 200 new consultants and 50 new grade posts in England alone. I reassure the noble Lord, Lord Rea, that we shall most certainly be monitoring the effects of this agreement.
As employers we also take most seriously matters concerning education and training, both in terms of initial qualifications and in-service training, to keep up with the pace of technical developments. That includes training, in management techniques. I note the point made by my noble friend Lord Nugent on the resource management initiative. It also includes arrangements for doctors who wish to obtain qualifications in homoeopathy, for example. We appreciate in this context the role of the royal colleges and other professional bodies because manpower issues are very much within their domain. We believe that we are working very much in partnership on this.
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Since a number of your Lordships referred to the national terms and conditions for medical staff—although I recollect that we discussed this on a number of occasions during the passage last year of the National Health Service and Community Care Act —I must point out that my right honourable friend felt that it was necessary to make a special case for junior doctors in view of their training needs. But for senior medical staff we still intend that existing contracts will transfer from regions to trusts which will then be free to negotiate with consultants to make mutually acceptable changes to the terms of the contract. I reiterate that we see this as an opportunity to secure increased motivation through a shared vision of the corporate objectives, greater involvement in the running of the organisation, greater flexibility in working patterns and the provision of opportunities for more training.
Continued growth in government funding, however, has to be linked with a drive to improve efficiency. This is what has enabled activity rates to increase to levels that do more than meet increased demand. Over the 10 years to 1990 the numbers of acute in-patients treated rose by nearly 25 per cent. to 5.8 million; the number of day cases treated doubled to 1.1 million and the number of geriatric in-patients treated rose by almost 90 per cent. I realise that it is easy to quote numbers and I am well aware that at the end of the day statistics represent individuals. We have to recognise that some on waiting lists are more ill than others but that all deserve to be treated as quickly and as considerately as possible.
Because we are treating more people than ever before, waiting lists have fallen. Half of all our patients are now admitted immediately, and another 25 per cent. have to wait for around five weeks for admittance. The number of people waiting for more than a year fell by 7 per cent. in the 12 months to March 1990. Our waiting list initiative, costing £119 million so far, will we hope improve matters further. The noble Lord, Lord Ennals, referred to the North-East Thames Regional Health Authority. We commend the determination of the authority to make an impact on its long waiting times. Its plans have been greatly misinterpreted. In considering cases the region proposed that clinicians should establish whether treatment was still practical or possible in some cases and that it should be a matter for clinical judgment. That is precisely what the noble Lord, Lord Ennals, was calling for.
In terms of the impact of Gulf casualties on the National Health Service workload, I can assure my noble friend Lady Cox that, although some non-emergency admissions may need to be deferred, the extra money for casualties announced by the Secretary of State on 16th January will enable health authorities to continue to use all the money in their normal allocations for their normal workload. We are confident that the health authorities can deal adequately with this increased emergency workload.
My noble friend Lady Cox and the noble Baroness, Lady McFarlane, referred to nurse prescribing and welcomed the recent comments of my honourable friend the Minister of State supporting nurse

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prescribing. We recognise that this could have benefits for some categories of patients; but we believe that more work needs to be done before legislation can be introduced. However, I can reaffirm that this remains our objective.
Our reforms to put patients first extend beyond the hospital service and into primary health care where we are concerned not only to treat illness but to promote better health. Many of your Lordships have raised this issue. The new GP contract introduced last April creates strong incentives for GPs everywhere to increase their accessibility, provide better information about services, improve services to the elderly, give regular check-ups and step up immunisation and vaccination and disease screening. The noble Lord, Lord Butterfield, expressed his particular anxieties and hopes in this area. Again, it is good news. Only this morning I was able to visit the Health Education Authority and discuss with it its programme and very responsible role. The latest figures show clear evidence that GPs have got up to speed on childhood immunisations and cervical screening. For example, the trend in immunisation against diphtheria, tetanus and polio is up to 90 per cent.; whooping cough 83 per cent.; measles 88 per cent. A Pulse survey shows that an extensive range of health promotion clinics has been set up by 75 per cent. of the GPs surveyed, covering a wide range of activities including anti-smoking, diabetes, well-person, alcohol control, diet and exercise clinics. Fifty-three per cent. of GPs are being remunerated for providing additional services in the area of child health surveillance and minor surgery. The new capitation system for children's dental care is very important in the preventive field.
Far from falling behind on breast cancer schemes, as the noble Lord, Lord Ennals, alleged, the United Kingdom is the first country in the European Community to introduce nationwide breast and cervical cancer screening programmes based on inviting women by computerised call and recall. I can say to the noble Baroness, Lady Masham, that the response has been excellent. In this area we are setting the pace in preventive health care for women.
Baroness Masham of Ilton: My Lords, perhaps I may ask the Minister whether the press release was false. It said that there were cutbacks in this area and that some surgeons were very worried.
Baroness Hooper: My Lords, the figures do not in any way agree with the information in that press release. There has been an enormous increase.
I move on now to the important subject of research. I am grateful for the welcome of my noble friend Lord Nelson for our new director of research and development. Having been barely a month in post, he is currently developing plans for an improved scientific basis for health care development. An important objective will be to provide reliable, relevant and readily accessible data on costs and benefits to the providers and purchasers of health care and to introduce more effective ways of assessing new
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and existing health practice methods and technologies. The plans will seek to ensure that appropriate methods are employed to measure the outcome and quality of treatment and to identify obsolete and ineffective methods of investigation and treatment that should no longer be employed. I should also point out in regard to National Health Service trust applications that special provision has been made to ensure that research should be specified among the statutory functions of individual trusts where this is a major activity. My right honourable friend the Secretary of State holds reserve powers to ensure that research is carried out by National Health Service trusts. Therefore, the present statutory duty for the National Health Service to provide facilities for clinical research by university, medical and dental schools will continue.
The noble Lord, Lord Ennals, and others referred to health inequalities. These can exist for a number of different reasons. They can be caused by geographical, medical and social factors and not merely by economic ones. This has to be taken against a background of steady improvement in overall health and wealth of the nation. It is important to remember that perinatal mortality in England and Wales has almost halved since 1978. Infant mortality is down from 13.2 to 8.4 per thousand live births and life expectancy is now 72 years for men and 78 years for women. That is an overall improvement.
I was also asked about winter deaths. In this regard there has been a steady decrease in excess winter mortality over the past 35 years, from 68 per cent. in 1951–55 to 24 per cent. in the period 1986–89. Hypothermia was the principal cause in less than 1 per cent. of those excess winter deaths. Because we recognise that medically the causes of mortality and morbidity are extremely complex, we have asked the Medical Research Council to undertake a project to look into this area.
The noble Lord, Lord Smith, advanced the case for an enhanced independent health sector and closer links with the National Health Service. The Government welcome the contribution the private health sector makes with more than 26,000 National Health Service patients treated annually. Health authorities continue to explore ways of improving current arrangements. We are very happy for that to be the case.
My noble friend Lady Faithfull endorsed the plans to publish a guide on the welfare of children in hospital. We were aware of the many good practices in this area, usually initiated locally and often with the support of voluntary organisations. We seek to disseminate this good practice more widely by bringing together the main points in a single document. We intend that the guide should be used by both the new district health authorities, as they prepare and refine contracts for children's services, and by provider hospitals as they seek to develop the services to meet the standards required by the districts. We plan to publish the guide in April. I can confirm that we are planning a similar document on the child

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health services delivered in the community by GPs, child health clinics, health visitors and the school health service.
Alternative and complementary therapies were referred to by a number of noble Lords. Indeed, we held a comprehensive debate on the subject last year. Our view remains that although we encourage a wider availability of National Health Service treatments from which patients can benefit, we still believe that it is not for the department to influence doctors on how they should treat their patients: that is entirely a matter for the clinical judgment of the practitioner concerned. I am glad too that my noble friend Lord Colwyn drew our attention to dentists and to the fact that the new contract encourages continuing care and the practice of modern preventive dentistry.
The noble Lord, Lord Carter, referred to the subject of community care and asked whether any changes were envisaged. I can assure him that there are no plans to change the phasing in of our community care policies which remain on target, as planned, for full implementation by April 1993. I hope that that reassures the noble Lord.
Perhaps I may say to the noble Baroness, Lady McFarlane, that we recognise the role of district nurses and health visitors in community care. That is integral to the provision of high quality primary care. Implementation of our proposals will enhance these roles.
Lord Carter: My Lords, did the noble Baroness say that responsibility for community care is to stay with local authorities? That was not entirely clear from her answer.
Baroness Hooper: My Lords, in saying that we were continuing on target as planned, we intend it still to be transferred to the local authorities.
On the subject of mental illness and mental handicap, both very important subjects, the noble Earl, Lord Longford, was concerned about the closure of hospitals. I must say again that contrary to popular belief the aim of current policy is not to close all mental hospitals; it is to develop a wide range of local hospital and community services which will render many of the traditional large and often remote hospitals unnecessary. No hospital closures will be approved unless it can be demonstrated that adequate alternatives have been developed.
The Earl of Longford: My Lords, if that is a new policy, it sounds better than the existing one. Until now a good many hospitals have been closed without alternatives being available.
Baroness Hooper: My Lords, that is not intended to be the case. There are still a number of institutions as well as arrangements for community care provision. The proposal of Professor Wing, to which the noble Earl referred, for sheltered communities is still one of the possible arrangements within the range of provision. There is certainly a need for asylum care as part of that range. A sheltered community of the kind proposed by Professor Wing would be perfectly acceptable. My noble friend Lord Pearson drew our attention most movingly to some of the problems of
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mental handicap and in a sense made a similar point about the provision of a range of facilities. That is certainly our intention.
We are all agreed that health care has developed dramatically over the past 11 years. Treatments previously unknown or barely available are now a matter of routine. With our reforms on course, it is now time to look beyond organisational matters. The next step is to build on the reforms to bring about genuine improvements in health for which so many have called. We have set in hand the development of a national strategy for health in England. The strategy will be about identifying, setting and achieving a number of priority objectives. Its starting point will be the identification of the most important areas to concentrate on. Achievable national targets will be set to give a sense of direction and purpose and to provide a realistic goal at which all those with a part to play can aim. The strategy will develop over time.
We shall not seek to be comprehensive from the outset. To avoid over-reaching ourselves we shall be very selective in what we deal with at each stage in the process. Nor will national initiatives ride roughshod over local circumstances. National strategies should be capable of blending local needs to form local strategies which serve the needs of differing patients. The National Health Service is being involved in the preparation of this strategy right from the outset. We intend that a consultative document will be published this spring.
The one true indicator of the state of the National Health Service is the health of the people. We have seen steady improvements in this regard, whatever anyone may say about particular areas. We are proud of our record but we are not complacent.
7.37 p.m.
Lord Ennals: My Lords, my first task is to thank all those who have taken part in the debate—noble Lords, noble Baronesses, right reverend Prelates and all. One of the great features of your Lordships' House is that for debates of this kind we can assemble people with an enormous range of experience in research, in the administration of regional health authorities and in social services. We have GPs and dentists. We have an extraordinary range. I am most grateful to all those who have taken part in the debate.
We have a problem of statistics. We always disagree on statistics. I think we might ask the department to set up a small working party to see whether the noble Lord, Lord McColl, is right in his recollections or whether I am right in mine. It all depends on where one starts, where one finishes, over what period of time one makes one's assessment, whether one takes into consideration an industrial dispute which suddenly threw the figures out for a month, whether one takes average figures and so on.
I was accused of being slightly partisan in my opening speech. I do not apologise for that. I happen to be the Opposition spokesman on health. If I did not oppose, I should not be doing my job, for which, as noble Lords will know, I am very fully paid. It would be foolish to pretend that there were not some quite sound differences both of principle and in priorities

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between the Opposition Benches and the Government Benches. A debate such as this gives an opportunity for those priorities to be assessed and for the experts to bring in their views. I am grateful to all those who have done so.
I am convinced that we need to have a full day's debate on community care. Community care was referred to on a number of occasions. Both the noble Baroness, Lady Faithfull, and my noble friend Lord Carter referred to it. In a sense, community care is part of the continuum of care of which the health service is a very important part. However, we have concentrated today on the health service. I hope, therefore, that we shall find the opportunity very soon, whether it be provided by government time, by us or whoever, to have a major debate on community care. There are colossal problems in that area with which we ought to deal. Having said that, I should like to thank once again all those who have taken part in the debate and at the same time I beg leave to withdraw the Motion.
Motion for Papers, by leave, withdrawn.

Musical Instruments and Theatre in Schools
7.40 p.m.
Lord Donaldson of Kingsbridge Lord Donaldson of Kingsbridge rose to ask Her Majesty's Government what steps are being taken to safeguard the teaching of musical instruments and theatre in education programmes in schools, and whether at least one cultural subject will be made mandatory in the national curriculum after the age of 14.
The noble Lord said: My Lords, while the Chamber is emptying I should just like to express my pleasure at the fact that I am starting the debate at least 20 minutes before anyone expected would be the case. Having been a Member of your Lordships' House for a long time, this is the first time that I have ever opened a debate in such circumstances. I hope, therefore, that the debate will end as satisfactorily as it began.
From time to time it is wise in very bad circumstances to turn and look at other things. In the presence of a major war, a ferocious cold snap and an infinitely dispiriting depression, I shall concentrate upon the very detailed edges of the education system which are capable of having a profound effect on the future of the nation. I propose to inquire into one or two aspects of our education policy. If, as I suspect, I can convince the Government that they are being dangerously neglected, I hope that we shall receive some kind of indication from them that they will do something about the matter. I was urged to do so by the National Campaign for the Arts. Its director, Simon Mundy, has given me and other speakers in the debate some very useful briefing.
As I said, I do not propose to enter into a general discussion on education. I have always been sceptical about educational thinking. It seems to me that it usually contains too many vague theories which are supported by too few hard facts. In my opinion, there
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are only two hard facts in education: the first is that good education depends upon good teachers and the second is that good teachers are born and no one knows how to make them. I shall not, therefore, pursue that rather negative beginning but turn instead to the more fruitful question not of how to teach but of what to teach. Even here I shall avoid the main problems and concentrate upon one small point of what should be taught. I refer to the necessary function of the nation to present some aspect of the arts to all children as a regular part of their curriculum.
One of the objects of education—not, I admit, the only one—is to teach children to enjoy life. One of the most direct roads to enjoyment is through the arts. However, not all the arts can reach everyone. But I believe that there are very few children, given the chance at an early age, who would not find something to please them for the rest of their lives in the sounds and rhythms of music, in the beauties or difficulties of drawing and painting and in the magic of words in poetry, literature and drama. I shall pick out just two details from that list; namely, the teaching and understanding of musical instruments and what is known as the "theatre" in education. Both of them have grown up through pressure being put on local authorities to provide such facilities. Over a period of about 30 years, both have worked extremely well. Of course standards have varied from authority to authority, but in general all children leaving school have regularly seen good theatrical performances in real theatres and have also had the opportunity to learn how to play an instrument. Moreover, if they have shown talent in the latter, they have been able to have individual lessons, instruments have been lent to them and their parents have been given advice about buying instruments if they wanted to take the matter further.
However, both those widespread and, on the whole, very successful undertakings seem to be in serious decline. If anyone doubts that fact, there is an article in The Times today which deals with it. It says,
"the provision of peripatetic instrumental teaching in the state sector has sunk to a level that threatens, in many areas, to undo the advances made by borough and county orchestras in the 1980s".
It goes on to suggest that there is some endorsement of the idea that state education is opting out of all responsibility for training the musicians of tomorrow. That is the kind of thing we want to avoid.
Perhaps I may first look for a moment at "Theatre in Education". That is a general term for a movement which has been building up for about 25 years. It was initiated by a combination of local and touring theatre companies in collaboration with the local education authorities and helped by discretionary grants from the Government. Plays are performed free, or at greatly reduced prices, at matinees for children drawn from schools in the local authority's area. It has been extremely successful. The actors enjoy the performances and feel that they are building up an audience for the future. Moreover, the children love the afternoon out, enjoy the plays and ask for more.
The finances for the movement have always been provided by the local education authorities, helped very much by the local theatres who provide the performances without profit, and sometimes with actual loss. That applies all along the line from the puppet theatre in Birmingham to the Royal Opera House at Covent Garden. However, I have evidence of serious reductions in performances, and attendances in about 16 local authority areas and other areas will be equally affected. I shall quote one or two of the most evident examples. At Greenwich the Young People's Theatre faces cuts of £120,000; in Hackney, the Half Moon Theatre has been closed; in Newcastle, the Skin & Bone Theatre has lost its entire £32,000 grant "to avoid poll capping"; and in York, the Young People's Theatre has collapsed after 23 years. I shall not continue because other speakers know more about the theatre than I do. I shall, therefore, leave it to them to enlarge upon the signs of real decline in the theatre.
I shall now concentrate upon a subject about which I know a little more. I refer to the teaching of musical instruments. Perhaps I may begin by saying that it is the best and most direct way of creating future audiences. All, or nearly all, children when presented with a trumpet, a violin or a clarinet will at once want to try to play it and will be anxious to be shown how. Of course, only one in a hundred will emerge after school days as a worthwhile performer; but many of the high percentage who drop by the wayside will retain a permanent interest in music and in its performance. I speak from experience in that respect. When I was five years old I was given a drum. I spent many happy hours trying to do a roll. When I was seven I was given a violin and I continued to have lessons until I finally gave up at the age of 22. That was because a professional string quartet stayed at my house and, on hearing them practise, it became clear to me that it was a case of Wimbledon as opposed to country-house tennis. Therefore, I gave up playing —but not listening. That has remained the greatest source of innocent pleasure in my long life.
The arrangements which were working so well and which now seem to be in decline were known as the peripatetic instrument service. That has been built up over the past 30 years by local authorities which have employed visiting instrument teachers (peripatetic teachers) who go around the local authority schools working alongside classroom teachers teaching smaller groups and providing specific individual support for the specially gifted.
Noble Lords will be surprised to hear that up till now Britain has led Europe both in the number of children learning instruments and in the high standards achieved. Local music centres have evolved to provide a superb resource for children from different schools to play and sing together. Many local authorities provide not only instrumental teaching but also a vast range of musical experience within orchestras, bands and chamber groups as well as specialist teaching services. Once again, I can speak from experience. I have two grandchildren who took musical scholarships to Pimlico. Both achieved decent
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amateur status on the violin and cello. A third, without the special advantages of Pimlico, managed to play second desk viola in the excellent London Schools Symphony Orchestra. They were the product of the brilliant teaching of Sheila Nelson, and all of that came free.
There are three dividends to be gained from that system of instrumental teaching. First, there is the discovery and fostering of the really talented. A recent straw poll of 400 players from British orchestras indicated that 285 (71 per cent.) had had the benefit of free instrumental tuition during their school years. In the case of the Bournemouth Sinfonietta, 19 out of 30 said that they would not now be professionals had it not been for the free start they had received. Secondly, those who fail to reach such standards form that large group of happy amateurs who love to nuke music for themselves and to whom it can sometimes be a pleasure to listen. Thirdly, most of the majority who drop out early keep enough interest to listen to some music at concerts, on the radio and so on and enjoy it.
It cannot be right to let such a fruitful series of combined efforts run down and slowly wither away. It looks very much as if that is what is being allowed to happen. I find it impossible to believe that the Government meant or wanted it to happen. However, I fear that it is happening.
We have now been told that there will be no provision of time for the arts in the 14–16 curriculum. Secondly, the local management of schools, combined with the enforced devolution of funding from the LEAs, added to the pains of the poll tax and charge capping, have already produced severe cuts in that broadly based instrumental service and more are expected. At present, I have evidence of drastic cuts in no fewer than 34 local authorities. I shall give one or two examples of the worst. Barnsley has axed 23 posts in the peripatetic service; Bedford and Coventry have sacked their musical adviser; Hillingdon has 12 peripatetic jobs at risk; Manchester has 22 teacher redundancies; St. Helens has sacked 17 peripatetic teachers and closed its music centre, and so on and so on.
However, to be fair, some local authorities are struggling on manfully. My county council (East Sussex) is doing well. Three years ago it provided instrument teaching for just over half its schools. To bring in the other half it has persuaded the parents of existing pupils to put up £20 each so that the teaching can be extended to the other schools It has thus doubled the number of children receiving instrumental teaching, but of course that is not a poor area.
There may be a ray of hope in the fact that in the Prime Minister's constituency of Huntingdon his daughter is learning the clarinet. At least they will not be able to conceal the facts from him. As I have said, my noble friends will paint a no less depressing picture of the state of the theatre in education. We are contemplating, not by any means for the first time under this Government, a major change in organisation and finance, based upon strictly ideological grounds, which has been carried out without serious attention being paid to its secondary and less immediate effects. I do not for a moment

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believe that the planners responsible for local government reorganisation said to the Minister, "At least you will get rid of all that nonsense about Theatre in Education and peripatetic teaching". I do not believe that they have even heard of them. Those two admirable, inexpensive and socially valuable developments will be left by the wayside unless something positive is done.
I can now ask my Unstarred Question of the Minister. Does she agree that those successful and detailed approaches to arts in education are declining and are at risk of disappearing? Does she agree that they are obviously and urgently worth saving? If so, can she give us any idea of how that can be accomplished? Can she at least persuade her right honourable friend to agree to restore one cultural subject as mandatory for the 14–16 curriculum?
7.55 p.m.
Baroness Birk: My Lords, we are all extremely grateful to my noble friend Lord Donaldson of Kingsbridge for asking this Unstarred Question tonight. It is sad that a prime subject which should have been in prime time attracts such a small audience. As the debate will be reported in Hansard and as the Minister is here to reply, we hope that it will go further and receive wider attention. About five hours was rightly spent discussing the health service this afternoon, but a balance must be reached. We were talking about the physical and mental health of a community but its cultural health is equally important and that is what we are discussing.
The new national curriculum which was set out in the Education Reform Act embodied the important principle that all children are entitled to a broad and balanced education. I believe that that meant it should further their cultural as well as their academic and vocational development. The notion of entitlement received wide cross-party support during the lengthy debates we had on the Education Reform Bill in 1988. For the first time, the arts were to form an essential part of every child's education from five to 16. Since the inception of the Act, forward-looking schools have been preparing new courses in arts, design and the performing arts to meet new requirements. Those initiatives were taken in good faith. They are suddenly under threat. The whole future of arts in education is in jeopardy.
It is usually pleasing to find that one is right and can say, "There you are, I was right about that". This is an occasion when I feel sad to say, "Yes, I was right", because during the passage of the Bill in Committee in May and on Report in June, I moved an amendment. It had all-party support. The noble Baroness, Lady Young, put her name to the admendment as did the noble Lords, Lord Gibson, Lord Kilmarnock and Lord Young. My name was first, and I moved the amendment. The amendment proposed to leave out the words "music, art" and insert "the arts".
Everyone believed that that was a simple amendment and one that should have been accepted. Not one voice in the Chamber argued against it except the Minister's predecessor, the noble Baroness, Lady
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Hooper. I do not blame her because she was doubtless following instructions and Government policy. On the first occasion we did not vote. It was about two o'clock in the morning. It was grouped with a great many other amendments covering many different subjects.
On Report I moved the amendment again, this time on its own. Considering it was so late at night, we had an intensive debate. Everyone except the Minister, accepted that sensible, innocent amendment. When we pressed it to a vote at a quarter to one in the morning, unfortunately it was lost by two votes. Such was the feeling at the time. We felt that it was important to widen the field and include not just art and music but the arts. There should have been a forewarning that many problems lay ahead which went even further and deeper.
During the past summer when Mr. MacGregor was Secretary of State, he indicated that there would have to be some form of adjustment in the foundation subjects. Recently the present Secretary of State, Kenneth Clarke, announced a change. It was apparently off-the-cuff, but everything he says sounds as if it is off-the-cuff even though it is not, since he has that air. Certainly his remarks were made without consultation with the arts working parties or any of the working parties on the national curriculum. He threw up the idea that in order to relieve congestion in the curriculum at what is known as "keystage 4"—that means after the age of 14—music and art would no longer be included as part of the entitlement curriculum for 14 to 16 year-olds. My noble friend Lord Donaldson of Kingsbridge pointed out the tremendously grave disadvantages of this move.
It is well known that the status of school subjects after the age of 14 radically influences how they are valued and even how they are taught lower down the school. To make art and music optional at the age of 14 will immediately have the effect of reducing their significance in the eyes of parents and children, as well as in the opinion of the Government who are doing this. It is no use the Government saying, "Yes, of course we take art seriously". All governments say that, but when it comes to it, priorities do not work out that way, there are always more serious subjects to be considered before art. That is the way the funding goes.
Dance and drama are already struggling against the handicap of being subsumed into physical education for dance, and into English, for drama. Yet these are quite different subjects. There may be a link in that PE and dance are both physical. Drama and English are both the art of speaking the English language and it is better if one knows something about drama. Nevertheless, the subjects are entirely different. Dance and drama are performing arts, quite different from English and PE.
The arts have always been undervalued in this country and this will be a further body blow. Up till now—and this will probably continue and there will be no satisfaction—many parents have deliberately tried to choose schools where they know that the arts subjects are taught well. They will be in a great

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quandary if, after children reach the age of 14, in many schools the subjects are no longer demanded and are no longer mandatory. That will completely devalue them.
Further, the move will undermine precisely those principles of breadth and balance that have such importance in the education of adolescents. Their education will become predominantly technocratic and utilitarian at the very time when they look to test their new-found sense of identity against models embodied in the arts, in the great works of fiction as well as in imagination. Such models play an essential part in providing alternative bases for young people in their personal taste and values and by that I mean alternatives to some of the trash values of the commercially generated youth culture. Young people need a cultural and multi-cultural education more than ever in adolescence. I do not say that it should not be open to them to read, see or watch any of the trash they wish because I do not believe in such restrictions. But possibilities of greater value should be available to them so that they have the opportunity to judge and make up their minds. Much of this arose in a different context during the debate on broadcasting.
The arts in schools are further threatened by the LMS, local management in schools, as the noble Lord, Lord Donaldson, mentioned. Local education authorities no longer have the funds to continue to support many of the arts activities for which they were responsible in the past. The poll tax and capping play their part. When schools have to weigh their priorities and whether to spend money on the arts or a new roof or some physical improvement in the school, it is extremely difficult for them.
The noble Lord, Lord Donaldson, gave examples where the theatre and education were failing or were being underfunded and they had to give up. Unfortunately, we all have immense lists of such examples both in music and the theatre. I need only mention two since I do not wish to keep the House with a list of these wretched failures. In Birmingham, the arts and music centres, the youth orchestras, youth theatres, the peripatetic instrumental teachers are all in difficulties or at risk. The audiences at Cannon Hill Puppet Theatre were down 25 per cent. last year; and audiences at the Studio Theatre were down 39 per cent. The Birmingham Hippodrome expressed concern that there have been tremendous falls in school party visits.
In central London, the Bubble Theatre and the Unicorn Theatre for Children have seen school performances cancelled and attendances fall during the past year. These are only a couple of examples which could be multiplied all over the country.
The problem is further compounded by the Education Reform Act's charging policies because the cost of events that take place more than 50 per cent. out of school time can be passed on to parents. Children nonetheless cannot be prevented from going because their parents cannot or will not pay. Therefore if one child's parents do not pay, nobody goes. It is then up to the school. If the school can
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afford the cost, the children can go, but mostly it cannot do so, in which case the whole outing is cancelled.
During school time, events must be free, but we come up against another snag. If that is so, the schools must be able to afford the events. There is no central activity and there is so much devolution away from the LEAs that it is difficult for schools to cope financially.
I fear that we are moving inexorably towards a situation where the arts which are meant to be our common heritage—I agree that that is a hackneyed phrase but it explains exactly what we mean—could become the exclusive province of those who can afford them. That means that fewer people will have the opportunity to develop a lifelong commitment to and participation in the arts. Fewer people will seek employment in the arts because they have not been trained in them. People will not have the chance to develop their innate talents. That will affect the whole position of future patrons of the arts. Often those patrons give to the arts when they acquire some wealth as a result of some art instruction, or an introduction to the arts that they received when they were young. In many cases they wish to give something back to the arts in return for what the arts have given to them.
There will also in future be less generation of wealth through the arts. As a country we have a high reputation for theatre, opera and for our orchestras. That affects the financial wealth of the country and also our cultural heritage. We need to recognise the central role that the arts play in a civilised and civilising education for young people. Education is where a love for the arts starts. If that love is not aroused at a young age, our young people will be like the baby dwarf who did not speak. The other dwarfs said that was because he had never tried to speak. That will be the position our young people will be in because the door to the arts has not been opened for them. The effects of that situation could be more far-reaching than the Government realise. I would not like to think that the Government have acted in this matter with any sense of malice. They have introduced this provision as a cost-saving and time-saving exercise. I believe Ministers, too, have been brought up to believe that arts come at the bottom of the priority table in education.
I join forces with the noble Lord, Lord Donaldson, in asking that the Secretary of State should reconsider his decision to make music and art optional at the age of 14. The Secretary of State should ensure that dance and drama are available too. The latter two subjects are part of the performing arts. The Secretary of State should take note of the views of the working party on the visual arts—I believe that working party has already reported—and of the working party on music. I believe that latter working party is meant to report either today or tomorrow. I hope the Minister will be able to comment on that matter.
The arts must be restored to a secure place within a genuinely broad and balanced curriculum. I do not believe that is asking too much of a Government who always say they place great importance on young

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people's development. If they really mean that, they can try to achieve that objective in a small way. Nevertheless in doing so they will achieve great results.
8.13 p.m.
Lord Birkett: My Lords, I join other speakers in congratulating the noble Lord, Lord Donaldson, on introducing this matter into your Lordships' House. The noble Lord said he wished to discuss three small details in the relationship between the arts and education. Although those are only three pebbles on an immense beach, they are fairly symbolic because between them they emphasise the importance of the arts at every stage of one's life. Obviously when one talks about education, one is talking about the earliest stages of one's life.
The following point has already been made many times, but it bears repeating. I suspect that the arts are the single most civilising influence in our national life. If they are to play the part that they should in our life, a taste for the arts and the vocabulary of the arts should be introduced at the earliest stage.
I can appreciate that there are essential objectives in education which everyone must attain. Everyone must be able to read, write and add up. After those essentials, I cannot think of anything more important in the educational life of a child than a study of our cultural heritage. The nice thing about the phrase "our cultural heritage" is that in the arts it is not just a matter of Britain's cultural heritage. It is not the same thing as the history or the geography of these islands. In the arts the cultural heritage is the world's cultural heritage. The arts are free to range across the entire globe. Music is the most international of all the arts. Certainly the work in the theatre, in music, dance and in all the visual and literary arts is a common heritage for every nation. That should be available to our children too.
Happily I have just become the president of a school which will cope with this matter. It is a new school for the performing arts and technology based at Selhurst in Croydon. The school represents an entirely new endeavour. It is a free school, thanks to the generosity of the British phonographic industry and the funding of the Department of Education and Science. It will be a free state school and it will take children from the ages of 14 to 18. Children in the school will be taught—as they must—the national curriculum, but they will be taught that curriculum via the performing arts. Wherever possible the curriculum will be delivered—I use the fashionable phrase—via the performing arts.
The school will also deal not merely with the arts as performance, and the arts as a taste to be inculcated in children, but also with the background of the arts and the business and technology sides of the arts. The union and legal sides of the arts will also be taught. I speak of my hopes in this venture because the school does not open until the autumn. I hope that the people who follow that education in the arts will acquire the real vocabulary of the world of the arts. The world of
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the arts has always been highly competitive. The existence of the arts bodies has always been unreliable. They are forever threatened in various ways.

If the arts world is both unreliable and competitive and appears to be something of a jungle, I hope that the schooling we intend to give the children at the school will at least give them a map of that jungle so that they understand the world that they are going into. Their education will not be based exclusively on the performance of the arts or a taste for the arts. The school will therefore produce children who do not feel that if they do not become a famous and international performer, they must leave the business altogether. That feeling has been prevalent in the past. People have often felt in the past that either they must become a star such as Yehudi Menuhin, or they must give up the whole thing and become a bus driver.
One can take part in the arts world in many ways, not just as a performer. The arts world requires gifted and sensible administrators, financiers, lawyers and technicians of all kinds. I must not weary your Lordships by constantly referring to the wonders of the school that will open in the autumn, but I believe that that kind of education in the arts will be of real value to those intending to make a career in the arts. Even for those who do not intend to make such a career, the arts must feature as part of the basic curriculum. It is up to educationists who are far more skilled than I to determine how they feature in the basic curriculum and by what legal process that is undertaken. I believe the arts are an essential feature of the entitlement of children to education.
The new school that I have mentioned will concentrate on the technology of the arts. The arts are nowadays as complex technologically as any other business or industry of which I know. It would not surprise me if the technology of the arts were not made one of the technologies which are accepted at all levels of education as a technology in which one can specialise and obtain degrees and qualifications. At the moment that technology is regarded as a rather far out, one-off subject. I believe it should be far more central than it is. It is not only an intriguing subject in its own right, but it also leads one to the arts just as much as a conventional education in literature or music. In future, technology should be more closely linked to the arts than it has been in the past.
During the debates that concerned the abolition of ILEA, I remember very clearly the almost universal concern that was expressed in your Lordships' House that that abolition might lead to the collapse of instrumental teaching in London—that is, the very subject that the noble Lord, Lord Donaldson, has raised tonight—and to the disbandment, or to the creation of problems for, the London Schools' Symphony Orchestra and the other orchestras connected with it.
Members of this House were very helpful and the reply of the noble Baroness, Lady Hooper, was particularly helpful. It was a matter of saving those organisations. The Government and Members of this House were agreed. It would be tragic if in spite of all those good intentions and that endeavour—which

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focused upon London because that was the city that we were dealing with, but was symptomatic of the position in the rest of the country—the teaching of instruments and the very fabric of music in children's lives were to disappear so few years after those debates.
I am chairman of the Theatres' Advisory Council in succession to the noble Lord, Lord Jenkins of Putney, who is to speak later in the debate. That is an umbrella organisation which caters for all elements of the theatre—the managers, the actors, the technicians, the unions. Over the past year or two it has been concerned about what is happening to theatre in schools. It is not simply a matter of Theatre in Education, which has hitherto been highly successful. It is a question of schools regarding the theatre as something that all children can experience through visits to the theatre and visits from actors and technicians. There is overwhelming evidence that school visits to the theatre are becoming fewer and the element of theatre in school life is diminishing.
There are dozens of different causes. There is the famous problem of charge capping. There is also the question of individual responsibility which is now laid upon schools. Although it is for the schools to make their own decisions, somehow it is always the arts subjects which are cut. Those are the subjects which are easiest to cut out. They appear to be peripheral, the icing on the cake, the jam on the top. In fact they are the fabric of our nation. The arts should no longer be the subjects which are dropped in a difficult financial situation.
Is there no way of ensuring that despite charge capping and whatever may happen as a result of recession, our children's entitlement to that vision of the world which the arts can give them is not impaired? Can we not ensure that the arts are not always the scapegoat of finance?
8.23 p.m.
Lord Addington: My Lords, I am somewhat humbled by those who have spoken before me in this debate. My noble friend Lord Donaldson spoke with great authority and knowledge about the teaching of musical instruments. The noble Baroness, Lady Birk, spoke with a great deal of sense about theatre and its place within the arts. We are considering the place of the arts, and in particular the performing arts, in our school system. I shall address most of my remarks to the subject of theatre, principally because unfortunately I am one of the most unmusical of people and come from an unmusical family.
The noble Lord spoke about people being trained in the basics of music. From that pool of people with basic knowledge of a musical instrument come the professionals and the talented amateurs. We must also consider the less competent or even incompetent amateurs who simply enjoy playing a musical instrument, regardless of how annoying that may be to others. When I was at university somebody who lived two doors away had an electric guitar which he attacked with great vigour until the small hours of the morning. He enjoyed himself greatly, at least until the instrument was forcibly taken from him on some
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occasions. He had acquired the basic skill when he was at school when he had been taught how to play the guitar. Thousands of young people in this country acquire a taste for playing a musical instrument. They may not become great exponents of the instrument but at least they gain pleasure from it. They are given enough basic technical knowledge at school to allow them to enjoy it.
It is impossible to enjoy such activities if one is totally incompetent at the instrument. It is rather like playing tennis when one does not know how to play the game; one spends one's time picking up the balls and does not enjoy the game. With a musical instrument one has to be taught the basics before one can do anything with it.
Turning to theatre, there is a danger that in the educational process the drama element is dropped just when young people reach the age at which they can begin to appreciate it. Until the age of 14 young people do not experiment very much. It is a fallacy that young people are adventurous. They tend to conform with their own group and only occasionally shock their elders. I speak as someone who has until fairly recently been guilty of that himself. At the age of 14 young people begin to experiment with certain cultural ideas. From that age they begin to develop more individual tastes in music and no longer slavishly follow the pulp music which is found even at the top of the charts. Cultural education in music means that they can appreciate different types of popular music and does not simply mean classical music. At that age young people need appropriate education.
In the case of drama that is particularly important because at that age people begin to express themselves on a more individual level. It is therefore important that their experience of drama is not restricted to reading plays during English lessons. I can remember that torturous experience. Copies of a play would be handed round the classroom. If by some miracle the teacher managed to get the right person to read the right part the play could become alive. More often there would be a staccato delivery by people with no interest in the part they were playing and who probably were of the wrong sex for the part. They would read, '"Move stage right'.—Oh sorry, Miss, do I read that out?" That does not provide an education in the arts. It is merely reading out something that is not designed to be read even to oneself. One must experience standing on a stage and interrelating with people in order to get an idea of a play. That type of exposure to drama is the classic way of ensuring that young people do not like it. To force someone to do something and to do it badly is the best way of putting them off it. To do that when young people are at an impressionable age will guarantee that they do not look at drama again for years.
The question of the exclusion of cultural subjects from the core subjects of the national curriculum is vital, as the noble Baroness said. If they are not to be taught until the final years they will be regarded as peripheral subjects. There is also a danger that people will insist that children are examined in the subjects. We should merely offer young people the opportunity

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to experience the arts at that stage, with the possibility of an examination if they so desire. However, as academic pressure grows we should make sure that teachers, schools and parents do not put pressure on young people to take exams in inappropriate subjects. Education is not only about exams. We should not make children do too much so that everything suffers. There is a very fine line which has to be drawn and it will vary from school to school and from pupil to pupil.
We should encourage education about education in the arts. We should encourage people to believe that the theatre is for everyone, and not just for other people. The "them and us" syndrome, although a rather dated expression, is probably appropriate here, and is something we should try to avoid instilling in pupils.
Much of what I was going to say has become superfluous in view of earlier speeches. We must try to create a situation where sufficient funds and time are made available for these subjects to be taught alongside the more technical subjects which have been given greater weight in the national curriculum. I do not know whether it is true, as noble Lords have said before me, that the arts are a great civilising influence, but it is certainly a great part of our cultural inheritance that we understand them. We may not like them but we should all understand them. I suggest we make sure that everyone who goes through the school system at least understands them. Let us ensure that when the young people of today and tomorrow say, "I do not like the theatre", at least they know what the theatre is.
8.32 p.m.
Lord Jenkins of Putney: My Lords, we are all grateful to the noble Lord, Lord Donaldson, for introducing the debate. The noble Lord, Lord Birkett, said I was his successor as chairman of the Theatres Advisory Council. That is true. However, I have another successor—the noble Lord who opened the debate. When Jim Callaghan succeeded Harold Wilson as Prime Minister and decided to change the arts Minister, his glance fell upon the noble Lord, so I had to make way for an older man. I do not suppose that at that time either of us felt that one day we would be on slightly different Benches, but speaking in harmony on the same subject.
The noble Lord, Lord Donaldson, in opening the debate, was right when he said that the Government did not intend the consequences of their own actions, but this is par for the course. I do not suppose for an instant that they wanted to have a couple of million unemployed or a record number of bankruptcies after about 12 years of Conservative government. But the consequences of the policies they follow lead not only to major disasters but also to minor ones. Is it relatively unimportant that schools will no longer have the opportunity of entertaining large numbers of children? That is what is happening. For example, in theatre education many fewer children are now having
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the experience of going to the theatre than was the case in the past. The cause of the trouble is the heavy hand of the Government on local authorities.
Another effect of government policy—I do know that it is the cause—is their determination to keep control over all sections of expenditure. The heavy hand of central government deprives local authorities of the ability to do the things they want to do, with the consequence that the political blame sometimes falls upon them rather than upon central government. What I have just described is a typical example of what is happening.
I mention in passing that when Lord Donaldson and I were arts Ministers we had an autonomous area within the empire of education. That is no longer the case. The noble Baroness, in replying to this debate, will be replying for education rather than the arts. However, we have been talking about the arts rather than the relationship between education and the arts. Without putting it forward as a fact, I am wondering whether there has been a less happy relationship between education and the arts under the present Government than was the case at one time. I do not suppose the noble Baroness will tell us if that is the case, but I put forward as a possibility that perhaps this would not have happened if the relationship between education and the arts had been a little bit closer than it is today.
The briefing I have received on this subject has not been confined to the excellent one to which the noble Lord referred in opening the debate: there was also information from a rather unusual organisation called The Performers Alliance, consisting of British Equity, The Musicians' Union and the Writers' Guild. It is probably the employers' most popular trade union, because it exists to promote the organisations within which it exists. Of course, there are occasional quarrels, but on the whole a harmonious relationship exists between these groups of people who work in the arts and those who employ them.
In the opening sentence of their brief, which I am sure would be agreed by all, they state:
"There are few areas in education where the United Kingdom leads the world, but the development of the peripatetic instrumental teaching services run by many Local Education Authorities is one of these".
That accounts for a great deal, because it means that the growth of the theatre and the arts generally over the past few years has not been solely a case of government putting more in. The Government may not have gone as far as many of us would have wished, but we should not deny them credit for having taken on the responsibility of funding the arts. They have not tried to destroy the arts or privatise the National Theatre, and they have recognised there are areas in which government must accept responsibility. Why are they acting as they are? I believe they do not know what they are doing. If the debate serves the purpose intended and the right message is conveyed by the noble Baroness—possibly it will be read in Hansard or picked up from the papers—it may be that some of this can yet be put right. It may be a small thing, but the consequences are grave, not only for the theatre but for music as well.

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The arts generally deserve greater recognition for the part they play in education as a whole. I believe they are essential to a broad, balanced, civilised education. Just as Lord Addington was speaking from an earlier stage I speak from the other end but come to the same conclusion.
The arts activities and trips to theatres and museums are essential to the development of the perception, awareness and sensibility that, whatever our political views, we want to see in a civilised person. We want to see the development of creative, intellectual and social skills, and the arts can help in that. We want people to be able to grasp the enormous possibilities opened to them by a capacity to appreciate the arts. So many people go through life completely unaware of the great things which are open to them. For example, surprisingly, Pavarotti singing "Nessun dorma" on television during the World Cup has introduced a large number of people to the possibilities of opera. Education is necessary. We are trying to introduce this kind of thing at an earlier age and to open people's minds to the possibilities that exist. If that happens, their minds will not be engaged in more trivial and possibly less desirable occupations.
Arts education makes a major contribution to the nation's economic and cultural development, producing artists, entertainers, craftspeople and designers. If at this stage the Government take steps to force local authorities to withdraw the support that is needed, no one else will introduce it. It is not something for which one car obtain a great deal of advertising, sponsorship and so on. It must come from the local authorities. We ask the Government to reconsider this matter and see whether in some way or another the restrictions placed on local authorities and the difficulties put in their way can be removed.
8.40 p.m.
Baroness David: My Lords, I am very glad that the noble Lord, Lord Donaldson, asked this Question tonight. It is very important and pertinent at this moment. If I may say so, I greatly enjoyed his speech. I endorse almost every speech that has been made in this debate with the possible exception of that of the noble Lord, Lord Birkett. I enjoyed a great deal of what he said. His eloquence and enthusiasm for the arts are tremendous. But his advertisement for the City Technology College I cannot entirely accept from these Benches, although I thought that it was a very good advertisement. However, one has to remember that the money that goes from individual sponsors and the Government into these specialised areas is taken from state schools for the most part, just as the grant maintained schools received so much more money for capital expenditure than others. So I have that reservation to make. We shall watch with great interest how this situation develops and how other schools in the area of that college also develop. It is an important area to watch. I want to say that we shall be looking out.
I return to the topic that has been raised by the noble Lord, Lord Donaldson. A great many people in the arts world, and in the music world in particular, feel that a crisis is very near. I hope that this short
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debate will alert the Government—and Mr. Clarke in particular—to the anxieties and fears that exist. I believe that we are in danger of jettisoning an activity which we are extremely good at. As the noble Lord, Lord Donaldson, said, and I do not apologise for repeating it, Britain leads Europe both in the numbers of children learning to play musical instruments and the high standards achieved. In percentage of population Britain has more young people's orchestras, ensembles, bands, groups and choirs than any other European country and certainly rivals the United States. We do not always keep that far ahead of our European partners, so it is something of which we can be proud at the moment. Let its hope that it continues.
The music centres that have evolved through children within one region joining together and benefiting from rehearsing, playing and singing are in danger as the costs are funded by discretionary grant from the LEAs. Not only are LEAs strapped for cash and some are suffering from poll tax capping, having to cut out a great many activities which are not seen as essential, but local management of schools will make a huge difference. When decisions on where to spend and what to spend are made by governing bodies, it is the governing body which will decide what music teaching to buy in.
The overall view that the local authority had will be lost. Only centralised services can manage the provision of expensive and untransportable instruments, selection of highly specialised teachers, the maintenance of instrumental stock and centralised library provision. At the end of last month in Manchester there was a conference chaired by Professor Swanwick of the University of London's Institute of Education. It was called Music in Crisis. There was unanimous agreement among the 200 or more teachers taking part that important elements of British musical provision were being lost.
Attached to the briefings that we have been sent from the National Campaign for the Arts is a fearsome list of LEAs which have reduced their provision and cut their peripatetic teachers. At least 111 posts have already gone and 53 more are under consideration for redundancy. The Manchester forum agreed on two resolutions. The first expressed urgent concern at the threats to LEA music services. It comments on the haphazard way in which instrumental teaching has developed since the 1940s and says that that is mainly due to the lack of any coherent national policy. It says that it is essential to have a structured policy for the future. The second resolution states:
"This Forum urges the DES to ensure that action is taken to plan coherently for the future of regional structures of instrumental teaching and other forms of music-making, with benefit to both schools and the community".
Is the DES paying any attention to those resolutions that have been passed over to it? I hope that the Minister may be able to give some response, although I realise that the forum only took place at the end of last month. Perhaps she can say how soon there might be a response.

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Instrumental teachers are prepared to meet the challenges and want parents and governors to understand the important role that they play. They are ready to work within the national curriculum and to demonstrate that they are not just skilled instrumentalists and musicians but also educators involved in the mainstream education of all children. Music is a national curriculum subject. At the North of England conference early in January Mr. Clarke said—I think my noble friend also quoted him—

"Art and music should be options at key stage 4. I do not believe that it is right for the Government to use the law to compel every single pupil to continue to do these subjects after the age of 14".
I do not know what on earth he thought that his Government were doing during the whole of the passage of the Education Reform Bill when the national curriculum was made legal. In any case, let us contrast that with what his predecessor, Mr. McGregor, said exactly one year previously in January 1990:
"I expect the full range of foundation subjects to be studied by pupils at key stage 4".
We get used to encountering retreats on the curriculum. I suppose that there is a certain pleasure, as my noble friend said, in saying, "We told you so". All the way through the long hours of debate on the Education Reform Bill we begged for greater flexibility. We said that the Government's plans were too prescriptive. The noble Lord, Lord Joseph, supported us. Now predictably the Secretary of State has realised that the number of subjects and the amount of testing and assessment involved are quite impossible to fit into the timetable and are too much to put on teachers. So we constantly hear of changing plans. It was the seven year-olds a week or so ago; now it is the 14 year-olds.
On this side of the House we certainly hope that at least one cultural subject will be mandatory after 14. Otherwise, the broadly based curriculum that is asked for in Section 1(2) of the Education Reform Act will not be met. I want to remind noble Lords of what is said there:
"The curriculum for a maintained school satisfies the requirements of this section if it is a balanced and broadly based curriculum which—
(a) promotes the spiritual, moral, cultural, mental and physical development of pupils at the school and of society".
I hope that the Government will remember that.
So far as concerns the GCSE in music, instrumental tuition and group coaching are essential. For such pupils performance is mandatory. I ask whether there will still be the opportunity to take the GCSE in music. I understand that the recommendations of the music working group are now published and come under fairly severe stricture in an article in The Times today which I believe has already been mentioned. One feels a little despondent about the future when one reads that 19 per cent. of schools have no qualified music teacher teaching music and that 68 per cent. have only one or two specialists, whereas 19.8 per cent. of independent schools have three or more.
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I have spoken chiefly of music teaching. However, Theatre in Education is as much at risk with the resultant narrowing of experience and loss of fun and enjoyment. The noble Lord, Lord Donaldson, referred to that. When considering providing audiences for the future, that is very important. One gets into the habit of going to the theatre. I well remember being extremely moved by a schools' performance at Covent Garden. The enthusiasm of the audience was terrific. It was a wonderful experience.
Many theatres have now seen school attendances diminish by as much as 25 per cent. over the past year. Three Theatre in Education companies have already closed. Others are surviving on loans. How long can one expect that to last? Local authorities are cutting their grants. Will the Government stand by and allow those closures to continue?
There is the question of charges. The charging sector of the ERA has resulted in bookings and attendances falling. Charging for teaching instrumentalists inevitably means that it will be the better off children, the middle class children, who receive the lessons. The noble Lord, Lord Donaldson, gave us the interesting fact that over 80 per cent. of the players in UK orchestras had had free instrumental tuition at school. No wonder Simon Rattle stated in a recent radio interview, "We shall see a great difference in our orchestras in 10 years' time".
I end on a personal note. My sister-in-law is my chief informer on matters musical. She taught at the Saturday courses at Pimlico for the Centre for Young Musicians. She worked for ILEA for a considerable time. She has repeatedly talked to me and written to me of her total dismay about the way matters are changing and the reduction in the service. I am aware that Westminster has taken on the funding for CYM—in case the Minister thinks that I do not know that. I do not know whether the Minister will refer to the Foundation for Young Musicians. However, my sister-in-law states that it is a much cut version from that which was run by ILEA for years. Several big boroughs have opted out. Many children unable to attend CYM Pimlico used to have financial help towards lessons. That has been abolished.
My sister-in-law wrote that London should be proud not only of the standard achieved, but the fact that a vast fraternity—it now numbers in thousands—of inner city children was established. Those children went on at least two holiday courses a year, often abroad. They spent many hours a week outside school hours working and practising rather than in what she called "inner city sin". It was a unique educational project. She concludes, "It's a crime". I agree. ILEA's music was unique.
However, we now have to deal with the situation as it exists. We want to hear from the Minister that the Government are determined that there will not be a similar devastation with reduced service in both music and theatre all over the country. I hope that the DES is aware of the need for action and of the strength of

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feeling which has been expressed tonight. It is remarkable that we have not had a single speaker from the Conservative Benches.
The Government are constantly talking about standards and quality. What about the standards and quality of music and theatre?
8.53 p.m.
The Parliamentary Under-Secretary of State, Department of the Environment (Baroness Blatch): My Lords. I too am grateful to the noble Lord, Lord Donaldson of Kingsbridge, for the opportunity to reaffirm this Government's proven commitment to safeguarding the place of the arts in our schools. I say "proven". As I listened to the debate I felt almost as though I had landed from another planet. It is this Government which after all included music and art as foundation subjects of the national curriculum and which have ensured that all pupils must study them in a coherent and progressive way between the ages of five and 14; and that those who continue with them after that age will do so on the basis of a far more secure foundation than has been available in most schools in the past.
The Government also fully share the admiration which has been expressed here today for the work of local authority instrumental teaching services. We are aware of the crucial part that they have played in enabling hundreds of thousands of children to start to learn instruments; and in bringing those with commitment and talent to the high standards which are demonstrated in so many local orchestras, bands, choirs and other ensembles. It can indeed be said without exaggeration that those standards are the envy of the world.
We have heard today of the fear that these services are now under threat from two major causes: local management of schools and community charge capping. On the evidence we have so far, I do not believe that fear to be justified. The fact is that the effects of local management of schools on these services is not yet clear. Many local authorities still retain central control of the music services, and a variety of schemes for delegated funding are being tested or developed by others.
Where a local authority decides to delegate the funds allocated to its instrumental teaching service to schools, it is by no means self evident that the service will suffer in consequence. Nor need the peripatetic workforce necessarily be disbanded. It is open to the local authority to offer these services to schools and charge the costs to the budgets of those schools who use it. Heads, parents and school governors are just as capable as the remainder of us of recognising a good thing when they see it. Indeed, there is evidence from some authorities which have reorganised their services and introduced charging for instrumental teaching, where previously it was free, that there is now increased take-up and expansion of those services.
I can see no reason why the community charge, and charge capping, should cause long term harm to these services. It is a matter for local authorities to be innovative and enterprising in the ways in which those
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services can be delivered. I was struck by the example that the noble Lord, Lord Donaldson of Kingsbridge, gave us of his young relative who did extremely well, learning music for free in our schools. I believe that he would admit that that free service was offered to all too few children. Because it was free, inevitably, no Government—this or any other—could make that service available as a right to all children. Therefore because provision was made for small numbers of children, there was concern that something needed to be done. In the 1988 Act the clarification for charging for music was made. Again in some authorities that meant an expansion of the service.
As I have said, I can see no reason why the community charge and charge capping should cause long term harm to these services. The instrumental teaching services have been developed and funded by local authorities, and their continuance is a matter for decision by those authorities, in the light of local spending priorities. But those priorities are determined by the views of local people; and we have already seen some evidence that, where the value of music services is perceived and defended by schools, governors and parents, local authorities will think very carefully about how they may be maintained even within a reduced overall budget.
We are not washing our hands of the potential problems, however. As I have said, the Government value the instrumental teaching services very highly, and wish to see them continue. We shall be watching the situation very closely, and in particular where we see examples of effective provision which both meets the needs of schools and ensures efficient central co-ordination of the music services. We shall in informal ways seek to disseminate the good practice involved. It is too soon to reach firm conclusions, since the picture we have at this stage is a confused one with adverse reports from some areas admittedly but also some good ones of business as usual or even expanding from others. My expectation is that after a period of uncertainty while new arrangements are worked out, we shall see a better organised and better publicised service emerge in many areas than has existed in the past.
The noble Lord has also suggested that Theatre in Education programmes in schools are under threat from the same causes. And of course the arguments here are very similar. Once again, we have services which we all admire, and which have gained an international reputation for their high quality. Once again, the picture we have of the effects of local management of schools on Theatre in Education programmes is confused.
What is clear is that if a local education authority gives schools the freedom and the funds to pay for the use of the Theatre in Education service, that need not pose any threat to its future. Schools will decide whether or not to support it, depending on whether they believe it offers good educational value for money. The evidence we have so far suggests that where Theatre in Education companies have made their work relevant to the national curriculum demand for their services has remained high. Where they have

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not done so bookings have fallen away. That supports our view that where the service is valued by schools and parents it should be able to look forward with confidence to the opportunities which local management of schools brings.
Lord Donaldson of Kingsbridge: My Lords, do I understand the Minister to be saying that where theatres in education have decreased in use it is because they have performed badly? The Minister appeared to say that and, if so, it is an important point which will need a great deal of proving.
Baroness Blatch: My Lords, the situation is not so clear cut and I am not saying that. The service has been highly valued. We are dealing with the way in which LMS is working out in local authorities; it is a question of who has the money and who determines whether or not theatre companies will attend schools. Where the service was provided centrally and where there was no cost to the school no consideration was given to whether what was being performed was of particular relevance to the school at the time. Where the school is the purchaser, the customer, of the theatre we believe that there will be better linkage between what is provided by the theatre companies and what the school requires. In many authorities prescription was determined by the local authority centrally or by the theatre company which came along with an offer, as opposed to the school itself having a view about what the local theatre should provide. I am now referring to the customer-provider relationship, but I do not wish to downgrade what the theatre companies were doing. If Theatre in Education was able to float free of the local authorities' control and market its services direct to schools, the linkage would be more fruitful.
We are also being asked whether at least one cultural subject—by which I take the noble Lord to mean music, art, drama or dance—will be made mandatory in the national curriculum after the age of 14. My right honourable friend the Secretary of State for Education and Science has, as the noble Lord is aware, sought and received the views of the National Curriculum Council on how to introduce greater flexibility into the curriculum for 14 to 16 year-olds; that is, those in key stage 4 of the national curriculum. In addition, we have been listening very carefully to the views of teachers who have the task of implementing the new curriculum. It was largely in response to their concerns that the decision was made to reduce the requirements of the national curriculum at this key stage and in particular to make the study of art and music optional for this age group.
I must point out to the noble Baroness, Lady Birk, that a great deal of thinking, listening and consulting took place before the decision was taken. It is not true to say that it came out of the blue. I well remember the discussions on the 1988 Act and the two powerful arguments that were then deployed. One argument was that there should be no prescription; in other words, that there should be total flexibility for the professionals to determine what should be taught in the schools. It was widely argued that prescription was
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not good in terms of telling teachers what to teach children. The noble Baroness spoke of the plea to have the arts included in the national curriculum rather than music and art. That is a debatable point about which one could continue to argue because a relevant issue still exists.
Whether arts or art and music are included as compulsory subjects we should still have the problem that some children will have gone through school without learning music, drawing, drama or theatre. The basic issue remains of whether the arts as a subject should be taught. I believe that we have the best of all worlds. We have art and music as foundation subjects in the national curriculum and we have drama as a compulsory core element of English, which is a mandatory subject to the age of 16. Therefore, three elements of the arts are being taught in the national curriculum—
Baroness Birk: My Lords, I thank the Minister for giving way. My information is that the working parties which are most closely involved in these subjects were not consulted before it was decided that the subjects should be optional. I asked the Minister why that was so. Secondly, she said that these are early days and that we should see how the Act works out. I agree with her but I wish to know why a decision to stop any arts subject being mandatory after the age of 14 has suddenly been made. I believe that it would be best to leave the situation alone and see what happens but to make sure that arts subjects are taught.
Baroness Blatch: My Lords, we asked the National Curriculum Council for advice: the working parties are a constituent part of that council. The art working group has made comments to the Government. We understand that its comment on the optional aspect of music in the national curriculum beyond the age of 14 will form part of the report that will be published tomorrow. The art working group would have liked art to be continued beyond the age of 14.
The noble Baroness asked why we took that action. We did so because of the request for flexibility from the age of 14. There is wide support for flexibility. Part of the debate in 1988 was that it should be considered at the age of 14. I make no apologies for opting for a complete change at the start. There were schools in which children were not taught art, music, science and many other subjects and therefore left school with no knowledge of them. We believe that something radical had to happen. The national curriculum was put in place and we have quickly responded to the call for flexibility and the introduction of some vocational education post 14 years.
We did so because we consider that by the age of 14 pupils are beginning to look beyond compulsory schooling to work, training or further study. Therefore, the rigidity of the 10-subject curriculum at key stage 4 would have restricted the time available for other worthwhile options which lie outside the national curriculum. Our overriding concern was to ensure enough breadth and balance in the 14 to 16 curriculum without sacrificing the variety which is so important as young people begin to mature. We believe that we have achieved this.

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There will also be continuing opportunities for pupils to pursue some aesthetic study at this key stage, and we expect that many will do so. Schools will be expected to continue to offer GCSE courses in music and in art, but such study could also include drama and dance and could be provided either through short single subject or combined subject courses.
Drama will form part of the national curriculum at key stage 4 through its inclusion in the attainment targets and programmes of study for English; but pupils wishing to undertake more specialised study of the subject could do so through a separate GCSE or a combined subjects course which included drama. In our view and in that of many teachers, it is important that pupils of this age should be studying arts subjects, and above all because they want to.
I think the point made by the noble Lord, Lord Addington, was important. Compulsion at any age is not good, but compulsion between the ages of 14 and 16 is particularly difficult, and particularly with these subjects, because compulsion is a problem post 14. I would predict that more young people, having studied arts subjects from the age of five through to 14, are much more likely in key stage 4 to choose them as subjects, because I believe the grounding will be very important. The national curriculum music working group, whose interim report is to be published tomorrow, will be having regard in its further work to the possibility of combining music with other subjects at key stage 4, as of course will the art working group in relation to art.
On the specific points raised by noble Lords and noble Baronesses in the course of the debate, the noble Baroness, Lady David, asked me specifically about the resolution from the Music in Crisis conference, and indeed from any body. We have not received the resolution as yet, neither Ministers nor in the department, but when we do we shall respond to it. I think I have dealt with the point about the Government in retreat.
First, may I welcome the comments of the noble Lord, Lord Jenkins of Putney, and his rare compliment to the Government on their contribution to the arts generally. We have a major department of arts and libraries in government. However, the noble Lord hinted that perhaps there was a problem in the relation ship between the arts department and the education department. There is absolutely no evidence for this suspicion, and I am pleased to tell him that there is a healthy, robust and enthusiastic relationship between the arts department and the education department. We certainly have raised the profile of the arts with this major department. I am entirely confident about the education department, which is the first department of any government to have made the arts a central part of the national curriculum.
The noble Baroness, Lady Birk, was worried about the loss of status of music and arts. Again I have to say that these arts subjects will be compulsory from the age of five to 14. They will be taught in a more regular and coherent way than ever before. Given that they are foundation subjects, we expect that there will be more positive choice of continuing with these subjects
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past the age of 14, given the variety of ways in which young people can either take them to examination, take them as shorter courses or indeed take them as combination courses with other subjects.
The noble Lord, Lord Donaldson of Kingsbridge, mentioned the decline in school visits. On the evidence we have so far, we do not have evidence of a general decline in visits since the law on charging anyway was clarified in the 1988 Act. The evidence we have is that the level of visits seems to depend very much on the attitude of head teachers and the value they place on such visits. We know that in some areas visits have increased in number as a result of the changes. In others they have diminished. Again, our evidence so far suggests that the fluctuation has a great deal to do with the attitude of the schools to such Visits and their value to education.
The noble Lord, Lord Birkett, queried the future of art and music as they impacted on local authority spending. Again I have to say—and it is very repetitive—that whatever happens to local authority spending, art and music will remain a foundation subject for all children from the ages of five to 14. That will continue. Therefore, it pre-empts and prescribes priorities for educational spending. They will, beyond 14, remain an option, and drama will remain a core part up to level 6 in English, which will remain a mandatory subject up to the age of 16.
The noble Lord, Lord Addington, also argued for flexibility. I have told him, and I hope assured him, that we are with him on this issue of flexibility post 14. Just one word on drama in the national curriculum, where I said it is a core element of the teaching of English. It will of course include performance skills, which have been referred to in the debate. It will mean also that all pupils will be required to participate in drama, and role playing is very much an activity that many teachers use as a method of teaching other subjects too.
All pupils will be required to experience live performance —another important point made during the course of the debate. We also say that pupils should have an adequate introduction to drama through its inclusion in the study of foundation subjects, and the opportunity to study it in non-foundation time so as to be able to make an informed choice when considering drama as a subject to be studied either for pleasure or as an option for examination.
The noble Baroness, Lady David, mentioned the foundation for young musicians. As I am sure she is aware, they are being provided with money from the Government for three years only. That is the arrangement. It is a one-off measure taken to secure the continuance of provision previously funded by the Inner London Education Authority. The Government contribution is more than matched by those of the inner London boroughs and by business sponsors.
This has been an important debate. I hope that what I have said will convince noble Lords that the Government believe this subject to be an important part of the national curriculum. It is now central and

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will be an experience for all children to enjoy. The information and advice we are receiving from both the music working group and the art working group will be taken seriously. I am sure that it will produce valuable ideas for attractive and often vocationally-orientated courses. I have every confidence that in the circumstances outlined we shall, over the next few
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years and contrary to what was said in the course of the debate see the arts flourishing in our schools for all age groups as never before.

Namibia Bill [H.L.]
Returned from the Commons agreed to.
House adjourned at sixteen minutes past nine o'clock.