HL Deb 13 February 1991 vol 526 cc115-83

3.3 p.m.

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 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 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 —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 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 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 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 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.

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 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 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 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 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, 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 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 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.

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 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 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 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 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 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 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 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 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 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 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 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 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.

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 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 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.

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 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 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, 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, 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 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 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 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 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. 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 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 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.

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 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 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.

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 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 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 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 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". 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 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 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 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.

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.

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 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 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 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 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 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.