NHS Medical Bodies and Health Department: Working Relationship

HL Deb 20 January 1992 vol 534 cc568-98

3.3 p.m.

Lord Molloy

rose to call attention to the case for a closer working relationship between the Department of Health and the medical organisations of the National Health Service; and to move for Papers.

The noble Lord said: My Lords, I begin by congratulating the Government on the creation of the UK Central Council for Nursing. It has been accepted by nurses as an interesting step forward and they are grateful. We understand that nurses will now be accountable to the nursing profession and that the nursing profession will perhaps have a lot more say than hitherto.

Another point in which the nurses are interested is that nurses elected to the UKCC will be allowed to examine all finances. With that measure, therefore, the Government have got off to a good start. I hope that they will improve on it by following the line of my recommendations this afternoon and consult more with the nursing organisations.

I know full well that the Minister understands the link between all NHS staff and professional organisations, and that must be appreciated also by the department in which she is an able and hard working Minister. I sometimes think that somebody in the department is attempting to put a brake on her attempts to have more discussions with the organisations and associations.

I should like to make clear that all the organisations and associations in the NHS knew full well that various changes had to be made. Many of them did not join in the cries when certain proposals were introduced. All the responsible organisations in the NHS knew that changes were necessary. They criticised some of the changes but fundamentally they criticised the fact that, having acknowledged that changes were necessary, greater dialogue with the Minister did not take place. They complain that the dialogue is much too limited.

I shall make reference also to what has become known as the "Selsdon Manifesto". It is causing some anxiety. I cannot say that the Government will approve of it; I hope that they will not. However, doctors, nurses and other specialists—I am sure that the noble Lord, Lord Colwyn, will agree even some of the great surgeons—are anxious that general practitioners may become self-employed professionals employing their own staff and that all hospitals will become self-governing either through sale, management buy-outs or as independent trusts. It is felt that all patients will have to choose which hospital and which GP they want. Of course there will not be a great amount of choosing. People know the doctors and hospitals in their areas. I believe that the so-called "Selsdon Manifesto" is unnecessarily causing perturbation and anxiety among people in the professions and ordinary folk.

I wish to refer also to the Dyson proposals which tend to make, inter alias the NHS a hire and fire employer by casualising the workforce. I am not totally sure what that means. Are we to have casual Lord McCoils doing a little now and again? Will there be casual doctors and nurses, and only casuals? It is causing great anxiety. All doctors, nurses and surgeons who have examined the Dyson paper, irrespective of their political outlook, find it a source of serious anxiety.

Perhaps I may briefly mention—it is not mentioned enough—an argument for dentist's charges. We discussed some aspects of the issue last week. According to my researches dentists are of the opinion that they need more money. The British Dental Association says quite categorically that underfunding can mean that patients will suffer. I feel sure that the department does not want that to happen and will be prepared to look at the situation.

I should like to talk briefly of the work done by some of the associations; first, the British Medical Association. It is a powerful association. I regretted some of the extreme views it took when opposing the Government some time ago and was glad that more sane voices prevailed. It did as it ought and will continue to be as co-operative as possible.

The BMA produced a thoughtful document which is a great credit to a great organisation. I refer to the BMA Agenda for Health. It is concerned with educational advice and it makes the point that education and advice are no substitute for fiscal measures and defective legislation. The BMA believes that NHS trusts are needed for certain types of hospital but not all. It also believes that those hospitals that are being formed into trusts should in the initial period be carefully monitored. Every specialist, surgeon, nurse and doctor does not look at the matter with a political eye. It is new. It may be right or wrong. In any case it will be correct for the department on behalf of the nation to ensure proper examination and monitoring. The BMA makes the point also that free eyesight tests for all should be reintroduced.

I mention those matters so that people can understand that it is not a question of a continual argument concerning the medical associations and organisations against the Government. All do a remarkable amount of civil and decent work. For example, the BMA is campaigning for a closer examination of the diets of our people, the amount of alcohol they drink and their smoking habits. The BMA believes that with its voice and specialist knowledge, its views should be heard.

I read an article by a very old colleague of many noble Lords. He was at one time leader of the Liberal Party. He was very witty, able and capable. He has suffered enormously of late. I refer to Mr. Jeremy Thorpe. We all know what he is suffering from and we realise how terrible it must be. In the article he refers to how upset he was that non-medical people were making vital decisions about how he should be treated although they knew nothing about what was happening to him. The priorities of the actual sickness or ailment must be a matter for the medical profession itself. The Parliamentary Office of Science and Technology has made a similar point—that is to say, concerning the discussion of the conduct of research both by and within the NHS, particularly as a result of the inquiry of the Science and Technology Committee of this House into the priorities in medical research. That is is of great value to the country as well as to the NHS.

I shall also speak briefly about other organisations. I refer first to the Confederation of Health Service Employees. It is a remarkable organisation. It covers a very broad area of National Health Service staff including nurses, nursing sisters and other ward staff, ambulance crews, kitchen staff and nearly all other auxiliaries. The officers of the confederation have great knowledge of the workings of the NHS and how they can be improved. The officers have a wealth of experience. They wish to make certain that that experience is put at the disposal of the department.

The confederation acknowledges that occasionally there are meetings with the Secretary of State but only through the TUC health service committee. The confederation believes that its detailed knowledge should be made available. Its representatives should be able to submit a case to the Secretary of State on the basis that he would be prepared to discuss it immediately and give the representatives of CoHSE every facility. It is not enough to have an occasional meeting on a certain date once a year. The confederation believes that if it comes across something which can increase the efficiency of the health service and which can help to reduce pain and suffering, then a meeting should be arranged with the Secretary of State. The confederation gains this knowledge from the experience of its members. I am sure that the noble Lord, Lord McColl, will acknowledge that nurses, ambulance drivers and such people sometimes gain knowledge which even great surgeons such as the noble Lord would not be aware of.

The current chair of the general Whitley Council is a representative of the confederation. That is a useful organisation. The confederation believes that discussions with civil servants are not enough. I can understand that. I was chairman of a Foreign Office organisation many years ago. We found life very difficult. I had to see the then Foreign Secretary, Ernest Bevin. As the noble Lord, Lord Carrington, said, he was probably our greatest ever Foreign Secretary. I cannot repeat the language which Ernest Bevin used to me about ex-civil servants, but they poke their noses in where they are not wanted. He said to me, "Whenever you have anything important, Molloy, you come to me, not to them." It is that kind of attitude that we want in the National Health Service. CoHSE believes that discussions with civil servants are very important but not enough. There is need for more realistic meetings with top flight civil servants and ultimately with Ministers.

It hurts me to have to tell the House about a little incident some time ago which affected Mr. Hector MacKenzie, the general secretary of the Confederation of Health Service Employees. As noble Lords will gather, he is a dour Scot: he does not take any insult lying down. He was insulted by the Secretary of State for Health. Mr. Waldegrave had referred to a speech in which Mr. MacKenzie said: COHSE is acting now to protect its members. Success depends on the willingness of members to stand by their unions … to push for a Health Service that acts in the interest of its staff". The Secretary of State went no further. He did not add Mr. MacKenzie's final words, and the people who rely on it". Those words were deliberately omitted, and the omission completely altered the context of the statement. It was a very important part of the statement. Hector MacKenzie had said that if one had a satisfied staff and a comfortable one which was happy at its work, it must mean that patients would be much better looked after. The Secretary of State did not bother to mention that.

I want to speak briefly about the NHS support federation. It is a growing organisation garnering support from those who want to see complaints eliminated and improvements examined. It wishes to become a worthwhile watchdog. The federation asks that a certain group of people should be able to examine all that is taking place in the health service. I am not too sure whether I agree with that, but I shall not reject anything that comes from such an organisation.

There is another great organisation which is acknowledged by doctors, specialists and nurses throughout Great Britain. It may well be the favourite organisation and its work the most valuable work of all. I refer to the Health Visitors' Association. I am proud to be its trustee. The organisation is intimate with poverty—a word that the Secretary of State has abolished. That is arrogance for you! The Secretary of State may have abolished the word; the association believes that he should be more interested in abolishing poverty. I agree with that.

The Health Visitors' Association provides school nurses. Its very first nurse, Amy Hughes, was appointed by the London School Board to investigate the health of school children. At the time of the Boer War, poor physical fitness among the working class meant that many young men were unfit to join the forces. Indeed, just after the last war Aneurin Bevan said that one of the most disgraceful things that our nation had to realise was that between 1938 and 1939 between 30 per cent. and 40 per cent. of our young men between the ages of 18 and 21 were unfit for military service. I agree with Mr. Bevan that we have to keep a strong army, navy and air force. We also need a strong NHS so all the young men serving in those great services can be fit and give of their best. I do not know whether any noble Lords would disagree with that.

The Health Visitors' Association provides probably the most poignant story of all. Its general secretary, Catherine Burns, and the members, deservedly enjoy the praise and support of all NHS organisations. The association deals with school nursing and deprived families and is active wherever poverty strikes. It works for the stricken and crippled. I am sure that the noble Lord, Lord McColl, will acknowledge that some people, with the best will in the world, are sometimes confined to bed for the rest of their lives. Some servicemen of the 1939–45 war will never get out of bed again. They depend greatly on the remarkable people of the HVA.

The association is also concerned with one-parent families and broken families, including the homeless. As the organisation provides midwives, it has to deal with the awkward situation of the unmarried girl who is pregnant and who does not know what to do. The members of the association are remarkable people. They deal with the blind and all aspects of community nursing. They are veritably the angels of mercy. The association has run a cot death campaign to which the Government are now giving support and it welcomes that. The services of health visitors, in connection with doctors, specialists, nurses and ambulances, are appreciated throughout the NHS.

Does my noble friend on the Front Bench wish to intervene? He should have listened to what was said by the Leader of the House. I did, that is why I am continuing for a few more minutes.

It would appear from Mr. Waldegrave's attitude that these NHS organisations need not exist, particularly with regard to their views on some aspects of trusts and the creation of NHS reforms. I believe that our NHS is the envy of the world. It was created within a few years of the end of the most costly war in our history. It is one of the most wonderful things we ever did; after a most terrible war when London, Scotland and parts of England were bombed, and tens of thousands of soldiers were injured overseas and had to be brought home. We built more houses in those two years of our history and at the same time created the National Health Service. It is those things that make us a great nation and an example to all mankind.

I conclude with these words. We quite rightly spend many millions of pounds on defence and assisting other nations with arms so that they can give us support. That is right and proper. However, we must work not only for massive military organisations like NATO—which is vital—but start thinking about creating the equivalent of a nursing medical NATO for the benefit of all mankind. That may well be hundreds of years away, but I believe that if there is one country which can start the medical equivalent of the North Atlantic Treaty Organisation—that is, an organisation leading to a worldwide free health service—it is this nation of ours. I beg to move for Papers.

3.23 p.m.

Lord McColl of Dulwich

My Lords, I should like to thank the noble Lord, Lord Molloy, for bringing this debate to us. I agree with him entirely that all 1 million employees in the National Health Service have a great deal to learn from one another. I pay personal tribute to many of the people who have kept Guy's Hospital and Lewisham Hospital running for many years—the faithful people of Bermondsey and Southwark who have done such great work in keeping the hospitals clean and who carry out all those jobs behind the scenes for which they do not often get a great deal of credit. They are, I believe, the salt of the earth. The noble Lord, Lord Molloy, is absolutely right to draw attention to them. Nowadays when I am operating in theatre you can see everything I am doing because it is on a sort of television screen. Everyone present in the theatre can see my every movement. Therefore, if I have had too much coffee and there is a slight tremor it is visible on the screen, so they can all make comments. They can contribute. I am very happy to listen to advice from anyone. Sometimes the porter may be in the theatre and see something he does not quite like and say, "steady there". I am very happy to have any help.

I am reminded of the relatives of a child who was very ill. The parents asked the consultant paediatrician if he would mind very much if they took the child to Lourdes. I shall always remember what that paediatrician said. He said, "Of course, we shall be delighted if the child is taken. We are going to need all the help we can get". That is the right attitude to have in the health service.

Perhaps I may go back to some of the points which have been raised on the maintenance of hospitals. It was mentioned earlier that the fabric of our buildings is, in many cases, in very bad repair. That is a serious matter. But we should not lose sight of the reason why that has occurred. I am afraid that in the past 20 years or so we have not been blessed with the best managers and finance people. It is not their fault, they simply were not trained for that kind of work.

When some managers received a bill and did not know what to do with it they put it into the "suspense" account, known as the "dustbin". Some of them left the bills there unattended for a year so there would be bills amounting to a million pounds. That very often was the basis of a financial crisis. It is unbelievable how crude the financial control was. Therefore, towards the end of the financial year there is sudden panic and a great deal of money has to be saved quickly, so they stop maintaining the buildings. Some of the buildings have not been properly maintained for over 10 years.

That is a very short-sighted policy because the total bill at the end of the day will be much more. It would have been much cheaper if they had kept up regular maintenance. That is now being done. I am sure your Lordships will be glad to hear that.

I turn now to the question of beds. I am sorry if I shocked the House with my figures. There is nothing new about them. TB is no longer a scourge. We no longer need those thousands of long-term beds. People who had suffered heart attacks used to be kept on complete bed rest for six weeks, and that was only 30 years ago. They were not allowed even to leave their beds to go to the toilet. They had to put up with that dreadful torture called the bedpan. I do not know whether any noble Lord has ever balanced on one of these things on a Dunlopillow mattress, but it is a form of torture and great effort is required to keep one's balance. Heaven knows what it did to the heart. However, patients were kept in bed for six weeks. Nowadays they are in for hardly more than a few days. That is nothing to with saving money. It is simply the best way of treating patients.

As far as concerns children it is better that they do not stay a single night in hospital. They can stay in hospital, with their parents, throughout the day and go home in the evening. That is the best way of doing things. Elderly patients feel much the same. Sometimes they refuse to come into hospital altogether, so we have to go to their homes and operate in their bed at home. I am talking about the very elderly who would be disoriented by coming into hospital, even for a few hours. In such cases we go out to their homes. That does not present any great problem except that their beds are usually rather low and to do the operation one has to kneel, which is probably the right attitude to adopt in more senses than one.

I was delighted to hear the noble Lord, Lord Molloy, say that perhaps self-governing hospitals may be right and perhaps they may be wrong. I think that is a real breath of fresh air from the Labour Party, which I welcome very much indeed. There is not a great deal of difference between self-governing hospitals today and the teaching hospitals of old with their boards of governors. And who set them up? Aneurin Bevan. He was no fool. So I am very glad that there is this attitude that perhaps self-governing hospitals are right after all. I think that they will turn out to be right because they are orientated to giving the best deal possible to the local population. That has to be right.

Lord Molloy

My Lords, the noble Lord, Lord McColl, is absolutely right in what he said. That is precisely what Bevan said. It is not possible to say that all hospitals are this, that or the other. He gave the example of what hospitals have to do mainly in South Wales. They will always have to deal with miners who have had accidents, miners who have what we call "the dust", or steel people. About 60 per cent. or 70 per cent. of all patients in those hospitals are either steel workers or miners. So what the noble Lord, Lord McColl, has said is correct.

Lord McColl of Dulwich

My Lords, I thank the noble Lord, Lord Molloy, for that intervention. I also take up the point that he made that these self-governing hospitals should be carefully monitored. That is absolutely right; but it applies to all hospitals, not only self-governing hospitals. That is a crucial part of the Government's reforms of medical audit. Again, like all the reforms in the Government legislation on the NHS, they were not plucked out of the air. They were not new. They had been tried in many places. Medical audit has been tried for something like 20 years. The Royal College of Surgeons, the Royal College of Physicians and the Royal College of Obstetricians and Gynaecologists are very much in favour of this. The Government are absolutely right to push that movement.

I am also pleased to acknowledge our debt to the British Medical Association. I have always been a member and have remained so through thick and thin. I pay tribute to the present chairman, Dr. Jeremy Lee-Potter, who is first rate. Like the noble Lord, Lord Molloy, he is a man with a completely open mind, and we are grateful for that.

The noble Lord asked whether surgeons will become casual surgeons. There is no such thing as a casual surgeon. We have to operate most days in order to maintain our skills. If we do not operate most days many of us get withdrawal symptoms. It is important to continue to be expert. When we realise that our expertise is diminishing, then is the time to retire. It is sometimes difficult to have the necessary insight to know when to retire, but the students usually give one a pretty good indication. One of our Home Office pathologists was once lecturing the students. He was talking about gunshot wounds and he was saying how worried he was in case he started to become senile before he was due to retire. He said that he had arranged with his wife—also a forensic expert—that if she saw any sign of him going off she would arrange a shotgun accident. A student at the back of the lecture theatre—the students are very sharp these days; they are better than ever—shouted out "Left it a bit late, hasn't she?" There is nothing wrong with medical students.

I should like to deal with the question of finance. It has been said that this Government are not putting enough money into the National Health Service. I should like to analyse that claim in a little more detail. The British Government put into the health service 5 per cent. of gross national product. America puts in 5 per cent.; Switzerland puts in 5 per cent.; many European countries put in 5 per cent. But the difference is that all the European countries, the United States and Japan put a great deal more into the private sector. In this country 1 per cent. goes into the private sector and 5 per cent. goes into the health services through the Government. In the United States 5 per cent. comes from the government and 7 per cent. goes into the private sector. We must bear that in mind when we hear constant attacks about finance.

The position is not quite as it seems. If one goes to Germany to have one's hernia repaired one is given two week's holiday, with physiotherapy, in Lindau am Bodensee. Is that really necessary? Is it not the height of extravagance? The patient should be back at work in two weeks. Running repairs is the name of the game. It is safer to get back to work as soon as possible. It is safer to spend as little time in bed as possible.

Finally, there was reference to the noble Lord, Lord Mellish, and myself being powerful advocates on behalf of Guy's Hospital. I am sorry that that was said. The noble Lord, Lord Mellish, has given marvellous service to Bermondsey and Southwark and he has been of tremendous help to the hospitals. He is an astute man with tremendous insight. I can assure the House that he has been around our hospitals and has been very critical; critical in order to improve them. He has made many extremely helpful suggestions. Neither of us would ever use our positions to further our hospitals—when I say "further our hospitals" I mean further in an undesirable way—but we use our positions to try to improve the service given by our hospitals because we believe that that is the right thing to do.

3.34 p.m.

Lord Rea

My Lords, by his choice of wording for the Motion my noble friend Lord Molloy has given us an opportunity to range fully around the National Health Service. We have just heard a very entertaining description of the journey of the noble Lord, Lord McColl. I have chosen the narrow interpretation of my noble friend's Motion. By "medical" I shall refer to the medical profession as such, of which I am a member, though I fully agree that a closer working relationship between all health workers and the Department of Health is vital.

There is a continuous dialogue between the Department of Health and the medical profession. The BMA has at least six standing committees and other ad hoc bodies which have frequent meetings, sometimes regular fixed meetings, with Department of Health officials. Ministers attend at critical junctures. There are regular meetings with the Chief Medical Officer. The Royal Colleges have frequent meetings with the relevant officials to discuss legislation and other matters affecting their special interests. I am not saying that all is sweetness and light at those meetings. There are a number of issues of a political nature where the Government's position appears fixed. To describe a meeting over such an issue as a consultation, as has happened in the past, is a euphemism.

In this respect I am thinking in particular of the imposition of the limited list and the general practitioner contract, the latter when M r. Kenneth Clarke was Secretary of State. However, when, as with the current reforms, Parliament endorses changes, the British Medical Association and the Royal Colleges, opposed to them in principle, discuss with the department the practicalities of operating the changes in a constructive manner. The current discussion on general practitioner fund holding is an example. One result of that dialogue is that the Government appear implicitly to have recognised the potential damage that a high proportion of unrestricted GP fund holders could have on the planning and operation of a health district's budget. I am delighted that collaborative projects between district health authorities and GP fund holders are now to be set up in a number of districts. Had the Government listened to advice from this House two and a half years ago they would have instituted such projects right from the start.

Another issue on which the profession differs from the Government is the abolition of free eye tests, a point to which my noble friend alluded. Since they were abolished in 1989–90 the number of tests has gone down from 16.2 million to an estimated 10 million only. There is a great need for closer monitoring of the effects of this reduction in eye tests. Ophthalmologists are very worried, especially in regard to glaucoma.

Altogether, the effects of the National Health Service reforms have not been as beneficial as the Government would like us to believe. Only last week a Department of Health report on increased activity revealed no such thing. In fact the increase in the number of in—patients treated—I accept that there was an increase—was slightly less than the increase in the preceding year. What is needed is a more objective and rigorous monitoring exercise that is not designed mainly to reflect credit on a Government running up to an election. Perhaps that is too much to ask at this time of the year in this particular year.

Lastly, I wish to mention a running sore. I refer to the pay of clinical academic staff, a subject with which my noble friend Lord Butterfield will deal in more detail. Since the late 1960s clinical academic staff have been paid on identical salary scales to those of NHS hospital doctors. Parity of salary between clinical academic staff and their NHS counterparts was introduced to resolve a long-standing problem of recruitment and retention of the best doctors into academic medicine.

Sadly, I can remember that issue causing problems as far back as 1967–68, when I was a full-time academic at St. Thomas's Hospital. It seems incredible to me that a formula has still not been devised which avoids that embarrassing hassle. That is possibly because the profession has to deal with the Department of Education and Science and not the Department of Health. That should not happen; universities should automatically be given the top-up required for clinical academic staff from the Department of Health through to the DES every time clinical salaries are reviewed.

From time to time joint meetings of the Department of Health with representatives of all the branches of the professions may be required. Very strong representations suggesting beneficial changes to the NHS Bill were made to the Government in 1989 by an impressive and unanimous array of Royal colleges and other organisations. Sadly, the Government did not listen. But, on the other hand, the ongoing dialogue at relatively mundane working level which goes on day by day and week by week achieves a great deal. The relationship between the Department of Health and the professions is probably closer and better than in nearly every other country. Such discussions sometimes even result in modifications of rigid government positions which cannot be achieved by political means.

3.42 p.m.

Lord Colwyn

My Lords, I too should like to thank the noble Lord, Lord Molloy, for introducing the debate this afternoon and to say what a pleasure it is to take part in such a good tempered debate on the health service. I was going to apologise to the noble Lord for widening the range of the subject, but he has shown me that that will not be necessary. I have kept my eye on the speakers' list and, in view of the fact that there are not too many names on it, I believe that the noble Lord will not object if I say something about the dental profession. I feel confident that it can be described as a medical organisation of the National Health Service. However, I should first declare an interest as I am a dental surgeon. I should also point out that I have notified my noble friend the Minister of some of the points that I intend to cover this afternoon.

In September of last year a sample survey of dentists in the general dental service was conducted to present an overall picture at national, at regional and at individual family health service level to establish whether, following the introduction of the new contract, dentists were still treating patients under the health service and, if so, whether they were being selective in the type of patient whom they were treating. Nationally, it was found that 76 per cent. of dentists routinely accepted all National Health Service patients; that 22 per cent. of dentists were selective in their acceptance; and that only 2 per cent. did not accept any NHS patients.

That finding, and the British Dental Association's press release on Friday 10th January, which showed that, in the South East, fewer than 70 per cent. of dentists accepted all patients, caused quite a stir in the national press. On 11 th January The Times ran the headline, "Dentists turn away NHS work". A headline in the Telegraph stated, "Dentists refusing to treat NHS patients". In the Independent the headline was, "NHS dental work disappearing in South-East" and the Guardian quoted, "Dentists turn away NHS patients".

In a letter to The Times on 13th January my noble friend the Minister repeated the department's denial of any problem. The last paragraph of her letter read: The vast majority of dentists still work within the NHS. In most parts of the country there is not the slightest difficulty in obtaining NHS dental treatment, and if anyone has a problem, steps will be taken where necessary to improve the problem". My noble friend repeated that in her Answer to a Question on the same subject tabled last Thursday by the noble Lord, Lord Dean of Beswick.

The new contract means more work and that has been endorsed by a workload survey which is due to be published at the end of the month. The Government are keen to have some sort of performance-related pay and I am aware that the Secretary of State has summoned the chairman of the GDSC to bring forward proposals for this by the end of the month. The dental profession would welcome a scheme which rewards commitment to the NHS by dentists. I know that there are general principle proposals with the department on this, but it must be paid for with new money—not by shuffling round the existing money in the GDS pool.

The existing system penalises the profession for its success. The more patients that are signed up, the more of the population will be covered. But, if dentists exceed the income recommended by the review body, then it will be clawed back in three years' time. Over the lifetime of this Government, the sum of £4,509 per dentist has been recovered because more work than was anticipated had been done. The Secretary of State has recently written off £1,529 of that "overpayment", which will help; but it should not be regarded as an overpayment. The work has been done and, in effect, the Government are applying an incomes policy, as happened in the late 1970s under another administration.

We need to encourage dentists to register NHS patients by putting in pump priming money so that we can increase the proportion of the population who have their own dentist and encourage those dentists who are committed to the NHS. Even now members of the profession are working hard to ensure that their patients are receiving a high standard of care under the NHS, but there is no doubt that their health, their bank balances and their family life are suffering—to the extent that some are finding that they are no longer being able to afford to offer NHS treatment, while others are taking early retirement or leaving the profession altogether. For the first time since I qualified in 1966, I am aware of bankruptcy involving dental practices.

I know that my noble friend will deny that there is any crisis and that she will tell me that there are now 100 or so more dentists working in the GDS than this time last year. However, she must be aware that many who opt out of the NHS still retain their FHSA number to treat family or friends, and to avoid the considerable superannuation, pension implications of leaving the NHS altogether. In some areas, particularly London and the South East, one in every five dentists has registered less than 200 patients for the first year of the new contract—meaning, in effect, that they do not taken on NHS patients. Low fees are certainly the biggest problem, but dentists are also leaving the health service in low-cost areas where overheads are relatively low. The fees are the same as in the South East, so I must ask: why is this happening?

I have spoken to many dentists, who all say that the "registration" aspects of the new contract are in complete chaos. Unless patients are registered with a dentist, he or she cannot undertake a course of NHS treatment. Registration involves compatibility of the details on the computer at the Dental Practice Board with the treatment form sent in by the dentist. If there is any fault, such as an initial or a spelling being given incorrectly, the patient's form is rejected on the ground that the registration cannot be found and the eventual process can be delayed by six months or more.

The British Dental Association tells me that it has been trying for over six months to negotiate changes in the system with the department, only to be told just before Christmas that there were insuperable legal problems which it would require primary legislation to correct. My noble friend will no doubt point to her various public statements, including a press release issued in October 1991, in which she expressed her willingness to enter into discussions with the GDSC about "fine tuning" of the contract. However, I am told that the profession has found progress in the negotiations to be extremely slow. For example, meetings have been cancelled at the last moment and there are frequent delays while officials in the department consult among themselves, with Ministers, with the Treasury and with legal advisers. Nor are such delays confined to the dental service. I hear that the Joint Negotiating Forum for the Community Dental Services has not met since last August because, apparently, it is awaiting responses from the department on various issues raised by the profession.

An administrative letter to the Dental Practice Board is not now routinely acknowledged owing to shortage of staff. Moreover, replies can take up to five months to be dealt with. When the contract was introduced in 1990, most dental practices were inundated with extra dental work, to the extent that many dentists took on extra staff to deal with the workload. At the same time, it transpired that the DPB—this is confirmed in its annual report—was laying off staff as part of a cost-cutting programme. That has made practitioners extremely angry.

It is also argued by practitioners that many hundreds of dental forms are being lost or are going missing at the DPB or en route to the DPB. That means lost registrations and lost payments. If those forms are eventually described as officially missing, the practitioner has to produce a duplicate form which is valid only if it has the patient's signature. That is often difficult to obtain. I am aware of practices where there are many hundreds of such forms, all originally sent to the DPB by recorded delivery, which are awaiting a new signature before the work, carried out many months previously, can be validated and paid for.

Children registered into capitation in October/ November/December 1990 all lapsed on 31st December last unless a roll-on form was completed to reactivate the capitation. Because of the delays, I suspect that hundreds of thousands of those forms are unprocessed and sitting at the DPB. My anxiety is that that will result in all those children being missing from the dentists' lists this month and it may be some considerable time before they are re-registered.

When the GDSC has raised those worries with the DPB it has been assured that no major problems exist. It would seem that the problems experienced by dentists are not taken sufficiently seriously by the board and that something must be done to improve communication between the board and practitioners.

The board's chairman and chief executive have been extremely helpful in conversations I have had with them. While they admit that there have been some problems with the tremendous volume of paperwork and the large number of invalid forms, they do not feel that there is much wrong with the system, and they state that cash flow to dentists is being maintained. I am aware that the board has made high levels of payments in the past few months, but some members of the profession have found that not to be the case. Perhaps I can persuade my noble friend to visit the DPB with representatives from the dental profession to obtain some firsthand information.

Capitation works well in areas where there is no dental disease, but in areas where there is a high caries rate, or expenses are particularly high, it has produced devastating problems. Due to the fact that all treatment must be completed within fixed financial limits, thousands of children are not being given the full treatment they need or are being referred on for extractions under general anaesthesia. I should be grateful if my noble friend would, yet again, give an assurance to all my dental colleagues that dentistry is not being carefully withdrawn from the NHS. Following the Government's launch of the Patient's Charter, my right honourable friend the Prime Minister said: This is the first time that a Government has put its weight behind a set of rights which all patients are entitled to under the National Health Service. It is also the first time that a Government has introduced national standards for the NHS. By implementing these fundamental rights and national standards we have signalled our commitment to preserving and improving the standards in the NHS".

The dental profession is concerned that the charter did not even contain the word "dental" and that no dentists have been involved in any of the NHS strategy meetings. I must say that that does appear a little suspicious. I hope that my noble friend can state categorically that the exclusion of dentistry from the mainstream of the NHS in the charter is not a Government admission that the idea of universal NHS dental provision has been abandoned.

Morale is low. Perhaps my noble friend can cheer us up and give an indication that the Government will accept in full the forthcoming report of the Doctors' and Dentists' Review Board and not stage the award as has happened in the past. In conclusion, will my noble friend say whether she is aware of any progress made with the Oral Health Strategy Group, which was set up under the chairmanship of the Chief Dental Officer to advise the department on the development of a consultative document to propose more detailed targets for improvement in dental health than those contained in the Health of the Nation Green Paper, and when the profession can expect an announcement of the action to be taken as a result of the Poswillow Report on dental anaesthesia and sedation?

3.55 p.m.

Lord Butterfield

My Lords, I thank the noble Lord, Lord Molloy, for giving us an opportunity to air some of the matters that are worrying us. The noble Lord, Lord Rea, has already said that an issue which is worrying me and many of my colleagues relates to the pay of academic doctors; that is to say, doctors who work in the university departments and who work with the NHS. The situation is unsatisfactory. It is sad because each year—I am sure that the noble Lord, Lord McColl, will be able to confirm this—heads of university departments have young men and women academic doctors who face difficulties because their pay rises do not come through at the same time as those of their colleagues.

I hope the Minister will not be too upset if I tell her that we should be most grateful if she could solve that problem in the near future. It is having an unfortunate effect upon the morale of people whom I regard as among the most important and valuable members of the medical profession—those who take responsibility for teaching our medical students, organising research programmes, publishing papers, setting examination papers and ensuring that candidates' standards are maintained, who go abroad and produce papers about the great achievements of British medicine, who stand up for the NHS when it is attacked in America and who are in fact some of the Government's most important shock troops in the whole medical profession. I hope that other Members of the House who may not feel so strongly about such people—I admit that I have a personal interest in them because they are my young friends and they are the young people whom I feel I must do what I can to support—will understand that they have had a wretched time.

It was pointed out by the noble Lord, Lord Rea, that year after year the Doctors' and Dentists' Review Board has worked out what would be a reasonable salary increase for the people beside whom its members work on the wards, in the operating theatre and in the outpatient department, the people with whom they may well be planning curricular developments for our students, with whom they are working in the community and with whom they work, even late at night, on the statistics that result from their experiments. They are working beside those people and they are conscious that while they were in medical school most of them were the top boys and girls—those who received the medals and whom the professors all identified as the sharp-eyed people who would maintain the cutting edge of our profession. They feel, and I am sorry to have to put this so firmly, that they cannot matter very much if they become a shuttlecock or political football—whatever one likes to call it—in the interactions between the DES, the CVCP and the UFC on one side and the Department of Health on the other.

Sometime during the year a salary rise is given to people within the NHS. When that happens we have to start negotiations within the university world to try to get a rise for the people who are doing similar work but who have many additional important responsibilities which they cannot duck to do with the teaching and research side of the profession. It should be remembered that such people cannot be promoted these days unless they have an astonishing record of research and of publishing papers and giving lectures all over the place. They will not receive their salary rise until some great chess game is played behind the scenes by the people who are responsible for getting them their salaries—but out of where?

The problem is that it is difficult for the university organisations to know by how much the review board will increase salaries. There are between 2,000 and 2,300 such people out of perhaps 30,000 academics altogether. They form only a small section of the academics. I admit that they receive good salaries and get rises, but it is hard for the bursars and university finance officers to be able to budget for those rises; so they are not budgeted for. If they are not budgeted for, when they arrive everyone scratches their heads. They say that the doctors and the surgeons will have to wait and, "They are busy. They will not notice that their salaries are not going up". They do notice. In these days when mortgages and interest rates are part of the warp and weft of a young person's life, such people go to their professors and ask, "I'm in a fix. Is there any chance that I can do better in America?". Sometimes they go there.

I very much hope that a way will be found to solve the problem. I have many friends who point out to me repeatedly that, "You will never win on this one. If these people are paid by the Department of Education and Science but are working with and helping the Department of Health, there is no way you will be able to get money out of the Department of Health budget into the Department of Education and Science conduit".

I beg the Minister to examine the situation because I believe that that argument is flawed. Having served for many years on regional health authorities, I know that those authorities grumble when they find that they have to pay the merit awards—that is the top-up, to make sure that people do not emigrate when they are at the top of the tree.

The merit awards are paid into the salary pool of these people out of the Department of Health funds. If it could be arranged to pay the superstars like the noble Lord, Lord McColl, and me in my day, why on earth can we not arrange to pay for the young chaps and young women who replace us? It seems to me that they should know, first, that this is happening with the merit award system. It has always been kept rather quiet, understandably, in the past. If they knew that, they would be cross. I do not say that they would march because they are not that kind of people, but they would be cross. Secondly, if they found out that this had been going on for many years they would wonder what on earth the likes of us professors had been up to over the years in not helping to defend their just deserts in terms of salary rises year by year.

I hope that the Minister will not mind my bringing this out. It is a serious matter for about 2,500 young men and women. To me they are a special group of young people because they not only carry on their clinical work but take on many other responsibilities, carrying out research, publishing papers, going abroad. Everyone says, "Oh, they go swanning off on a wonderful trip", but when they go abroad they have to stand up for Britain. They have to give their papers impeccably so that other nations do not think that British medicine is slipping. I can assure the House that it is not, but the morale of these people is low.

People have asked me over the years, "If they really think that we are so important, how is it that they cannot solve this apparently simple problem? Are they not supposed to be clever people in the Treasury?"

4.3 p.m.

Lord Auckland

My Lords, one point is agreed by all parties: that this House has not been short of discussions on the National Health Service either during Question Time or in general debates. We need make no apology for that at all. Good health is essential to any country. Whether we have a recession or a boom, one thing is quite certain: the health of the nation is all-important.

We are all very much in the debt of the noble Lord, Lord Molloy, for having initiated the debate, which until now has been good tempered and extremely constructive. One depressing point is that at the moment in the run-up to the general election—and I have witnessed a few general election campaigns in my time—there is constant backbiting about the National Health Service. All political parties seem to be entangled in an unholy row. Who are the losers? The losers are the nurses, the doctors and others who are employed within the health service, as well as the patients, as has quite rightly been said. In a democracy differences of opinion must be aired. In the time prior to an election it is only natural that fairly strong views should be expressed, particularly in the elected Chamber. It is, therefore, a breath of fresh air that we are able to have such a debate and I hope that it receives wide circulation. Many of the speakers taking part have extremely close experience of the National Health Service.

Turning to the Motion, I wish to thank my noble friend the Minister, who wrote me an extremely explicit introduction to a conference at which I had to speak in Copenhagen in September, the second European seminar on the registration and national care of the elderly. It is a subject in which I must confess I am not particularly expert. But it was an extremely interesting conference, and the Minister's foreword was received with enormous enthusiasm.

Knowing Scandinavia as I do, particularly Denmark and Finland, I made the point that we are treating at least 40 million people under the National Health Service every year, plus European Community nationals and many others who come over here. Whatever differences of opinion we may have on hospital trusts, the condition of hospitals or nurses' pay, the large number of patients is something which all political parties will accept.

My family has been connected with health care for six generations, although I have pointed out to your Lordships before that only our younger daughter, who is a practice nurse, is employed in therapy. The noble Lord, Lord Molloy, mentioned Mr Aneurin Bevan, who is acknowledged as one of the outstanding health Ministers, even by those who may not necessarily agree with all his views. In the early days of the health service, my uncle was secretary of the Kingston Hospital in Surrey. There was a regional board meeting going on, and Mr. Bevan came into the oak-panelled council room with all the doctors there. He said, "You so-and-so doctors, it's a very different game now, boyos". Then he gave them quite a lecture and walked out of the room. They all thought, "By jove, the next board meeting will be north of Moscow". He came back an hour later and my uncle quotes him as saying, "I am sorry, I was rather angry with you. Please forgive me. We must all work together", and they did. They may have disagreed but there was an enormous amount of working together in those days, even though the inception of the health service had certain problems.

I wish to make a somewhat provocative point here. Looking at the health service with hindsight, I believe that if some minimal charge had been imposed at its inception, if only for patients' food, despite national insurance contributions and so on, the service at that time would have been better funded. I believe that the policy would have been continued. However, that is water under the bridge and I mention it only because whenever I go overseas I always try to visit a hospital. I ask two questions: "Do you have waiting lists? Do you have a nursing shortage?". I must say that I am surprised to hear that, in the majority of countries, in almost every case the answer is in the affirmative, even in Scandinavia, where there are a relatively small number of people to treat. Hospitals there often have much better operating theatres and wards because they have the finances which are often denied to this country through the enormous number of people we have to treat. But they are faced with similar problems. We must get this matter into perspective.

In yesterday's edition of the Sunday Times there was a survey of waiting lists in hospitals throughout the country. I am always rather suspicious of surveys as they represent the state of affairs that exists at one time only. However, the survey in the Sunday Times was interesting in that it showed that hospitals situated north of Watford have shorter waiting lists. It was a little depressing to note that Westminster Hospital came bottom of the list of credits. However, I am not at all sure that one survey necessarily proves anything.

I was particularly keen to note that the Epsom hospital trust—as your Lordships may know, I am a friend of Epsom general hospital—was rated highly as regards facilities for ear, nose and throat treatment. I believe such treatment constitutes a vital part of our health service, particularly as regards children. The National Health Service has an important role to play in that area.

My father used to be the chairman of a London children's hospital in Chelsea. In those days there was a kind of one upmanship as regards removing tonsils and adenoids. Their removal constituted a status symbol. My father intervened in that matter as many children who needed such operations were denied them as a certain amount of queue jumping went on. That is one area where it is essential to ensure that everyone has equal access to treatment.

I have always believed, as a canny Scot, that one should make haste slowly in the matter of hospital trusts. I believe the idea of the trusts is a good one. It has certainly worked in the area where I live. In my area there is a superb manager and a substantial number of staff have been appointed. However, this is a matter that needs to be looked into. I have never believed—I do not think many people believe this should be the case—that all hospitals should be made into trusts at a stroke. It is equally vital that local control should be given to the trusts. Much depends on the manager, and also on the number of nurses who now become nurse managers.

This is an important debate. In two days' time we shall have another important debate on a much narrower subject. For the sake of nurses, doctors and patients I hope my noble friend the Minister will make some interesting points when she replies.

4.15 p.m.

Lord Beaumont of Whitley

My Lords, in the various public national services there is almost always a tripartite structure, either acknowledged or covert. It is that of, first, the professionals, secondly, the public, and, thirdly, the political parties, including primarily the party of the government of the day. Those three combine to make the success or failure of the services.

I take an example from the area of education where I am more at home than I am in the area of health. In education the running is almost always made by the professionals. They like to pretend that that is not the case. Perhaps I am being unfair in saying that they "pretend" since they may not always be aware of how much influence they exert and to what extent they govern the climate of opinion at any given time. I have little doubt that the professionals also have an important part to play in forming the opinions which lie behind the running of the health service.

However, it is to a certain extent for the government of the day to hold the ring. Not only are the consumers and professionals involved but there is rivalry either acknowledged or unacknowledged, between various branches of the profession. The Government's job consists not only of putting into practice and into legislation the decisions that are made by all these bodies, but also in ensuring that none of the bodies is being done down. The Government will, of course, inject their own ideology. That is right because that is what governments are for and that is why we have political parties. If that means that from time to time we have reversals of ideology, that is the price one pays in a democracy. Recently, we have not had to pay that price often enough.

The Government's job is also to ensure that the voice of consumers is heard as loudly as possible because consumers are very much on the receiving end in every sense of that phrase. It is difficult for them to combine sufficiently to make themselves heard unless the institutions through which they do so are provided by the Government. Things are much better in the health service today than they were in the past when the voice of the customer was not often heard. The present Government have a certain amount to be proud of in that respect.

It is also the job of the Government to look after the whole area in which the great national services operate. In the field we are discussing today the Government have not always been as understanding of the professional interests as they might. If that is so, what of the future? We must all welcome the Patient's Charter. That must be a step forward in an important area where the Government can make provision for the ordinary consumer and the ordinary patient. It is by definition in this field that the patient is doubly or trebly at a disadvantage as opposed to consumers in other fields because he or she is usually feeling ill. It is important also that the Government should pay attention to those areas where it appears that trouble is brewing because where trouble brews it is usually for a good reason.

I was interested that the noble Lord, Lord Colwyn, spoke in such detail of the problems in the dental profession. That is an area where the Government must do something to heal—how impossible it is to get away from medical metaphors—a running sore in the National Health Service. Like the noble Lord, I hope very much that the Government are not sidelining the dental profession, which is a very important part of the National Health Service.

The whole question of eye tests needs to be considered again. Much more care, trouble and time needs to be taken over the establishment of NHS trusts. It is undoubtedly the case that they can be a good thing, but there appears to have been too much haste in the implementation of some of them.

A tremendously important area is the impact of poverty on the health of the nation. There is a group we have come to know as an underclass—a debatable but I think correct term—of people, who are singly, doubly or trebly handicapped in various ways. They are not able to look after themselves because they are not given the opportunity to do so. Among them—because of poverty and poor diet—illness and disease are rampant. Often, the health service they receive is not as good as it should be, not through any fault of the professions but because that is the way of society. Those who are already unfortunate and who have little find that what they already have is taken away from them.

It is important that local and professional representation should be included on all the governing bodies of the National Health Service. We should press for that. We are grateful to the noble Lord, Lord Molloy, for initiating what has proved an extremely good debate. I am particularly grateful to the noble Lord, Lord McColl, who made an excellent and illuminating speech, as did several other noble Lords.

We have a great health service still, despite all the problems. Those of us who from time to time go to the United States of America and see one of the alternatives come back to Britain thanking God for what we have here. We must keep it. All parties to this great debate are learning and doing better. The Government are learning to co-operate, even when they feel rather impatient in terms of their own ideology. I know that the medical profession is improving. When I was young it was fairly difficult to find a general practitioner who was not a little bit of a dictator. Now if one tries to find a new practice to attend under the National Health Service one will find that almost everywhere doctors have learnt the new language of co-operation with patients as opposed to dictatorship.

I go to the Bolingbroke Hospital in Wandsworth, which has won prizes for the best outpatient facilities in London and for serving the people courteously, efficiently and in very pleasant surroundings. It is extremely good that there are such competitions. All hospitals appear to be improving their service.

The main principle is co-operation. It is a matter for the Government primarily to see that the bodies concerned, including themselves, hold the right balance in co-operation and in using the resources that are available to the very best effect and to the benefit of patients in particular and the general health of the nation in general.

4.26 p.m.

Lord Carter

My Lords, like other noble Lords I thank my noble friend Lord Molloy for making the debate possible and the Government for making it necessary. We are all in favour of closer working relationships. That must mean openness and access to information. It is not just a matter for the medical organisations, which are mentioned in the Motion, and the health care professionals; the voice of patients and client groups must also be heard.

Unlike the noble Lord who has just spoken I am glad to see that the Government appear to have dropped references to "customers" of the health service. The term was heard a good deal at the beginning of the reform debate.

We all agree that lack of constructive dialogue leads to ill thought out and badly planned projects. Noble Lords will remember the very short time allowed for consultation—was it five months?—between the issue of the White Paper Working for Patients and the publication of the reform Bill, a change which we were told was the biggest in the National Health Service for 40 years. An even shorter time—was it five days?—was allowed between the White Paper on community care and the publication of the Bill on that subject. Your Lordships will also remember that many organisations and many Members of this House and the other place begged the Government to take more time, to try out proposals on a pilot scheme basis and to listen to the advice they were receiving. Sadly, that did not happen. Despite a barrage of public relations publicity—and I fear that we shall receive even more between now and the election—some of our fears have been realised.

Curiously, where those fears have been slightly alleviated it has been because the Government have acted to stop the reforms working as they were supposed to. The example of the GP fundholders was given by my noble friend Lord Rea. To prevent queue jumping the Government had to introduce a protocol almost as soon as the reforms came in, although the fears expressed on that subject had been brushed aside before the reforms were introduced. A second example is the decision to require health authorities to negotiate "solid state" contracts to ensure as little upheaval as possible to referral patterns, presumably before the election. A third example is the ducking of painful decisions about hospital provision in London. In effect, the reforms in London have been put on ice, again presumably until after the election.

To be fair, the picture is not all bad. There is the recent example of the Nurses, Midwives and Health Visitors Bill, a non-contentious Bill drafted after lengthy consultation and supported from all sides of both Houses. I understand that there is shortly to be a Private Member's Bill on nurse prescribing, again a sensible proposal which has been drafted after lengthy consultation.

Therefore, the Government can consult if they have a mind to do so. But why make the process of consultation, dialogue and local involvement more difficult by excluding local and professional representation from health authorities and packing them with property developers and company directors, the majority of whom I suspect rely largely on private health care?

I ask the Minister what proposals the Government have for monitoring the performance of the trust hospitals on an objective and credible basis? If the performance last week on activity levels is anything to go by, we shall not receive that objective monitoring from this Government. That point was well made by my noble friend Lord Rea. The same applies to waiting list statistics. Your Lordships will know that many doctors have pointed out that, to improve the statistics, patients who had been waiting for over two years with non-urgent conditions have been given preference over patients with more urgent conditions who had been waiting for less than two years.

The noble Lord, Lord Auckland, referred to an article in The Sunday Times yesterday. It quoted a device whereby, to cut long waits for inpatient treatment, authorities are deliberately allowing longer waiting times for outpatient appointments because the clock on the waiting list does not start to run until the consultant authorises the treatment. It seems that we now have waiting lists for waiting lists. To quote the Sunday Times: For example, Southmead hospital which serves the Bristol constituency of the Secretary of State, sent a letter to an orthopaedic patient that says: 'The consultant presently has a waiting list of 60 weeks to see him and therefore rather than booking an appointment too far into the future we have added your name to our pending list'". I would ask the Minister if she has any figures on the length of pending lists.

Yet another example of lack of dialogue and local involvement is the deliberate downgrading of the role of community health councils, with one third reporting that they have not been invited to comment on the general contract plans and over half being excluded from input into individual contract specifications. As so many noble Lords have said, why will the Government not listen to the BMA and to the many other organisations which want the reintroduction of free eyesight tests for everybody? Why did the Government not listen to the fears that were expressed over the new dental contract? That was a point well made by the noble Lord, Lord Colwyn. We now know that nearly one dentist in four is not offering the full NHS dental service, and in some areas the figure is much higher.

The Government were warned about the effects of the closure of geriatric beds. We now learn that there is enforced and substantial shift of geriatric care from the National Health Service to the private sector.

Another area where consultation and closer working relationships, which we all want, are being put at peril is that of patient confidentiality. One FHSA now employs a doctor to go round to GPs' surgeries and take patients' confidential medical records from the shelves to check up on the payments to that doctor. I understand that the department has turned a deaf ear to pressure on that issue from local doctors, from the data protection registrar and from the community health council. The department said that such action was required for the effective management of the service. I would ask the Minister whether, if a patient expressly stated to his or her GP that the medical records were not to be revealed to third parties without the express consent of that patient, the GP would be entitled to refuse access to the records to another employee of the health service?

An article in the British Medical Journal of 31st August last year stated: The threat to patient confidentiality is the most disturbing feature of the whole process". That is a reference to extra contract referrals. Patients who are referred extracontractually may have their name, address, diagnosis, and proposed course of treatment transmitted, often by facsimile machine, to people not directly concerned with their care without their knowledge or consent (which they would probably withhold were they to be given the choice)".

If we are to ensure closeness of working relationships, this must mean trust between staff and management. Is the Minister aware that in at least one general hospital due for trust status in April 1993 non-executive directors were appointed last October and the shadow chairman of the proposed trust now expects to chair the various appointment committees? The shadow chairman is not a member of the health authority, and the hospital will be directly managed by the health authority until April 1993. There is a statutory procedure for appointments to various committees. I would ask: what is the legal status of the shadow chairman and the appointments made under his chairmanship?

Is the Minister aware that in some cases the national agreements regarding study leave for doctors and associated expenses have been abrogated? In one district health authority in the West country, which I know well, the total costs for doctors on study leave and expenses have been slashed to a maximum of £200 per year while the limit for managers is £500. Is that the way to build up the closer relationships which we all want to see?

Time does not allow me to take up all the points made in the debate, but I must refer to one matter raised by the noble Lord, Lord McColl. He drew a not unreasonable analogy between the governance of self-governing hospitals and what used to happen under Nye Bevan. I hope that the noble Lord is not therefore arguing that the late and great Nye Bevan would have supported the internal market. If the noble Lord believes that, he will believe anything.

Lord McColl of Dulwich

My Lords, I thank the noble Lord for giving way. I should like to point out. that Aneurin Bevan had some very remarkable ideas. He introduced the system of merit awards whereby secret payments made to consultants could double their salaries. A third of all consultants had them. So he had a very open mind, possibly in many ways more open than the minds of some of the present members of the Labour Party.

Lord Carter

My Lords, if the noble Lord really believes that Nye Bevan, with all his background, would have supported the internal market, I have to say that he would believe anything.

I referred at the beginning of my speech to the fact that closer working relationships must extend beyond the medical organisations to patients and to all interested parties. It is only proper in this year and from these Benches to indicate the policy of the next Labour Government in this area.

In the general area of public access to information, we shall introduce a freedom of information Act. So far as the health service is concerned, we shall consult with community health councils and local authorities regarding the health needs in their areas and the drawing up of performance agreements. They will have the right to comment on the proposed strategies and agreements, as will the general public through the use of forums. We shall allow NHS employees to comment on the service and not attempt to gag them with confidentiality clauses in employment contracts.

We shall end the nonsense of the internal market. We shall work with local authorities, with community health councils, and with business and industry, to promote better health. Above all, we shall involve patients and consult them about the health service they want and certainly deserve.

4.37 p.m.

Baroness Hooper

My Lords, I too welcome this opportunity to discuss the very good working relations that exist between the Department of Health and the medical organisations. I agree with the noble Lord, Lord Beaumont of Whitley, that it has been a good debate. I have noted also that many contributors to the debate have taken the layman's use of the word "medical" and have not confined themselves to referring to doctors' organisations. I shall therefore follow suit in responding, but I shall try to stick to the theme of the debate.

The Department of Health has long established procedures for consulting the various parts of the medical profession. In general these work very well. Quite apart from negotiating meetings, officials attend various committees of the medical royal colleges, usually as observers. There are also numerous contracts on a day-to-day basis with individual experts and professional associations. Indeed we could not function properly without good formal and informal working relations with the medical professions.

There are two main sources of formal advice to the department on hospital medical and dental matters: the statutory Standing Medical Advisory Committee and the non-statutory Joint Consultants Committee, both having their origins in the setting up of the NHS.

The Standing Medical Advisory Committee was set up in 1949 to advise the Secretary of State on technical medical matters. Over the years it has been an invaluable source of advice for Ministers, for the Chief Medical Officer and for the department generally, offering an authoritative medical view based on a balance of experience between individual specialties and general practice, between teaching and non-teaching hospitals, and between London and the rest of the country. Membership of the committee includes the presidents of the royal colleges and faculties together with the chairman of council of the BMA.

The department consults with the Joint Consultants Committee, or JCC, on all matters of concern to hospital medical service, save those to do with terms of service and remuneration. The committee comprises representatives of the BMA and the presidents of all the royal colleges of England and Scotland, the Faculty of Dental Surgery and the central consultants and specialists committee of the BMA, the hospital junior staff committee of the BMA and the dental committee for hospital dental services of the British Dental Association.

The Chief Medical Officer, supported by representatives of the Department of Health, meets the full JCC every quarter. There are also four interim meetings during the year. The department is thereby able to give the profession an early view of new and revised policy affecting hospitals, and the doctors are able to raise matters of concern. Such regular and early consultation meetings are regarded as of the highest importance by the department. The successful implementation of government policies often depends upon them.

I can give a very good, recent example of the value of consultation with the JCC. When the new reforms were introduced concern was expressed in some quarters that patients of GP fund holders were receiving priority on waiting lists. Officials from the department met with the JCC and agreed guidance on contracts for health services between hospitals and GP fund holders—guidance which was published. This timely action ensured that fund holders' patients were not advantaged at the expense of others. The noble Lord, Lord Carter, referred to that. I am glad that he acknowledges that we have fulfilled our undertaking that we would monitor the introduction of the reforms and take action where necessary.

On general practice, the profession and the department meet regularly and with a common purpose to improve the quality of care that patients receive. The Chief Medical Officer meets jointly the leaders of the Royal College of General Practitioners and the General Medical Services Committee to discuss professional issues. Other officials meet to discuss contractual matters, and do so in a businesslike and effective way, although, as the noble Lord, Lord Rea, said, all is not always sweetness and light on those occasions.

This businesslike relationship can be illustrated by the setting-up last year of a Joint National Health Service Review Committee, consisting of Department of Health officials and GMSC negotiators. The committee provides a forum to discuss review issues, including the effects of GP fund holding. The Government have always wanted the profession to be involved in the development of GP fund holding; the committee offers such an opportunity.

Noble Lords will be well aware of the criticism levelled at the Government—many noble Lords have voiced it today—over the introduction of the new GPs' contract in 1990. However, the Government have shown their good faith in being prepared to listen to genuine concerns and acting upon them. I must emphasise to your Lordships that despite the fears expressed, the first year of the contract has been a success, with targets achieved and almost 1 million health promotion clinics held in the first year.

Having said all that, in terms of the practice of the profession, one of the most important areas in which we work with the profession is that of undergraduate and postgraduate education. I am surprised that more people did not dwell on that topic. The noble Baroness, Lady Seear, had indicated at one stage that she might join in the debate. I am sure that had she done so the ground would have been covered more fully.

In the field of undergraduate education the department's contacts with the relevant medical organisations have been further improved in recent years. Following a critical review of the mechanisms for joint policy development between the Department of Education and Science, the health departments and the University Grants Committee, a conference between the parties concerned in 1987 led to the formation of what is now the Steering Group on Undergraduate Medical and Dental Education and Research, chaired by the Permanent Secretary of the Department of Health. All the interested parties are represented.

The noble Lord, Lord Butterfield, made a plea on the subject of the pay of academic doctors. The Government believe that clinical academics should have parity of pay with their National Health Service counterparts. That has long been accepted. An undertaking was given by the Government in 1986 that if a pay settlement was agreed for clinical academics which provided increases equivalent to those in the National Health Service arising from the review body report, then the Government would provide the universities with additional funds to cover the cost of that settlement to the extent that it exceeded the pay settlement for non-clinical staff. The problem with that formula—I realise that the noble Lord knows it, but I believe that it should be on the record—is that the sum needed cannot be determined until both settlements have been reached. A new formula has therefore been proposed and is currently being considered. We trust that it will have rapid results.

Another excellent example of the way in which the department works closely with medical organisations is through the Medical Manpower Standing Advisory Committee. This was recently set up by my right honourable friend the Secretary of State to advise him on future developments in the balance of medical manpower supply and demand in the United Kingdom. Although the committee does not have representatives of medical organisations as members, it has written to over 60 bodies inviting their views on medical manpower issues. I am pleased to say that the Health Visitors' Association, of which the noble Lord, Lord Molloy, is a vice-president and trustee, is included in the list.

The department has also been actively working with the profession in improving opportunities for women in medicine. Again it was not a subject raised in the debate. However, I should like to put on record that the department has taken action with the working party on part-time training which will review and develop the present arrangements for part-time appointments for senior registrars. A second group, called the Women in Surgical Training Working Party, aims to encourage women actively pursuing a career in surgery by establishing regional advisers and providing information on career progress of women trainees.

The department's Chief Medical Officer also has many contacts with the profession. He is, for example, a member of the General Medical Council, which meets regularly. Together with the medical director of the NHS Management Executive, he frequently meets with the 14 regional directors of public health for England and the Association of Directors of Public Health to discuss matters of mutual concern. The CMO also has regular, informal meetings with representatives of the academic and research sectors of the profession which are much valued by both sides. In addition he has consultant advisers who can advise him on their particular areas of expertise.

So far I have concentrated more on the regular well established links with the profession which do not arrive as of right but which have been vital in developing recent policy initiatives. During the year-long review of the National Health Service which resulted in the reforms currently being introduced—an issue raised by the noble Lord, Lord Molloy—the Government gave thorough consideration to a large number of submissions from a wide range of organisations including many representing staff and other interested groups. Their opinions and suggestions were taken fully into account in drawing up proposals for reforming the health service, even though, as my noble friend Lord McColl stated so well, those ideas were not plucked out of the air but represented good practice up and down the country.

Another example of consultation and listening to advice is in the launch of the consultative document, Health of the Nation, which was published in June. We have received responses from the BMA, the royal colleges, medical schools, many health authorities, community health councils, family health service authorities, local authorities and other interested parties. Those replies will be taken into consideration in the preparation of the forthcoming White Paper.

The profession has also been fully involved in the development of medical audit, whereby doctors meet to examine critically each other's work. Both the department and the profession share the goal of improving the quality of care patients receive; the Government have provided over £60 million this year towards the implementation of a comprehensive system of medical audit in the National Health Service. Supervisory committees have been put in place to ensure that all doctors can and do participate.

I have already given examples of the readiness of the Government and the Department of Health to listen to genuine concerns. However, I remind the noble Lord, Lord Carter, that we always made it clear that we would monitor the changes and respond as and when necessary rather than delaying what have proved to be effective and necessary reforms. The establishment of the Clinical Standards Advisory Group is another example. It was in response to anxieties expressed in your Lordships' House that I introduced an amendment to the National Health Service and Community Care Bill to set up the group. The Government had carefully considered arguments made by noble Lords and the concerns expressed among doctors about the possible effects of the reforms on clinical standards, and they acted accordingly. The group, which was set up on 1st April 1991, has met and is giving an excellent example of closer working relationships between the Department of Health and medical organisations.

The first months of the reforms have already started to dispel any fears about a fall in standards. We welcome the British Medical Association's change of attitude to the reforms. But it is thanks largely to the dedicated work of doctors, nurses and all those who work in the National Health Service that the reforms are starting to deliver the benefits to patients and the National Health Service in general. More and more doctors are recognising the advantages of devolution of responsibility, allowing them to control and organise the services that they provide in the most caring and efficient way for patients. Indeed, I heard only last night from a nurse that she would never choose to go back to the old way of running the system and not knowing where the money was coming from. Patients too are more than pleased with the standards of the new trusts. A recent survey of 900 patients treated in eight trust hospitals conducted on behalf of the department by an independent organisation showed that 96 per cent. were quite satisfied with the quality of the services that they had received.

The Government have never pretended that all the problems in running the National Health Service could be solved at a stroke. As my noble friend Lord Auckland pointed out, some of the problems in the National Health Service are not just national but international problems. Yet there is ample proof that we are on the right track.

As noble Lords will know, a report entitled NHS reforms—The first six months was published only last week. It suggests that an additional 250,000 patients will have been treated in 1991–92. It points to further encouraging falls in the numbers of patients waiting over two years for treatment. So there is no doubt of the improvements that the changes have brought. In the area of primary care, GP fund holders also are demonstrating the benefits which their independence and innovation can bring to their patients and to other patients too.

In the course of the debate more than one noble Lord referred to the dental service. I disagree with the suggestion of the noble Lord, Lord Molloy, that the service is underfunded. Annual gross spending on National Health Service dental services has increased by 48 per cent. in real terms over the past 12 years. Dentists are earning more. In the first five months of the financial year payments to dentists were 11.2 per cent. up on the same period last year.

My noble friend Lord Colwyn referred to the chairman of the GDSC being summoned by my right honourable friend the Secretary of State. That seems to be entirely within the spirit of this debate. It is not as one-sided as it sounds. It was the representatives of the dental profession, whom we were consulting over the introduction of the contract, who indicated clearly that we should go ahead with the dental contract in the first place.

The family health service authority survey which we have just conducted—at the end of the first year of operation of the dental contract—pointed to areas or pockets in which there was more of a problem than in others. I recently met the chairmen of the four London family health service authorities which have the lowest registration levels. Each of them assured me that when asked to find a dentist who provided National Health Service treatment, he was able to do so. Therefore the answer must be: go to your family health service authority and it will be able to help. However, the question of the new contract meaning a much heavier workload has been taken into account in the workload survey that we conducted, the results of which are still being analysed.

There is a difficulty on the general matter of remuneration because an averaging system applies. Dentists' fees are set at a level which is intended to enable the average dentist to earn a predetermined target average net income. That can only be realised—after the fact of course—by balancing actual income against intended income. The balancing mechanism for dentists operates three years in arrears and is similar to the system that operates for doctors. So it is fair to dentists and the taxpayer. Any suggestion made to dentists that this system should be changed has always been greeted with shock and horror. I hope that my noble friend appreciates that.

In 1988–89, net payments to dentists averaged £4,874 per dentist in excess of the intended level. We decided that a special factor related to the rate of processing of the dental practice board, which was exceptional and once for all, should be excluded from the sum to be recovered. We therefore waived £1,529 per dentist. That represented a constructive and substantial response to the profession's concerns as they were expressed.

We are discussing aspects of remuneration with the General Dental Services Committee and my right honourable friend the Secretary of State will have further discussions. In reply to the allegation that dentists are leaving the NHS, there are currently 26 per cent. more dentists practising in the general dental services in Great Britain than there were in 1979. After all, dentists are independent contractors who have always been able to do as much or as little National Health Service work as they wished. Although my noble friend alleges that in some areas and particularly in London and the South-East one in every five dentists registered fewer than 200 patients during the first year of the new contract, the average number of National Health Service patients for dentists at the end of the first year of the contract was 1,426 and 26 per cent. of dentists had 2,000 or more registered patients.

I emphasise that even before the new contract there were dentists on FHSA lists in London who did very little National Health Service work. Although some dentists have withdrawn from dental lists in London, most London FHSAs still enjoy a higher ratio of dentists per head of population than most parts of the country. Another example of the Government taking into account the arguments of the profession is the introduction of an early retirement scheme for dentists which was introduced on 1st April last year. It was introduced at the request of the profession and is an example of fine tuning, as was the reimbursement of rates to which we rapidly agreed.

We have been in continuous discussion with the profession about the new contract and how it might be improved. There have been notable moves: for example, the introduction of reimbursement of business rates (to which I have already referred); improvements to the dental claims form; some changes to the fees scale; a relaxation to the requirement for issuing treatment plans; and the removal of root treatments from capitation. Progress is being made and although there may be a number of dentists who are unhappy with the capitation system, as my noble friend alleged, I suggest that there are just as many, if not more, who are content.

In answer to a specific question, the oral health strategy group has had useful meetings and will issue a consultative document. We hope to be able to make an announcement shortly on Poswillo.

I must refer to another point raised by the noble Lord, Lord Molloy, about CoHSE having regular meetings with my right honourable friend the Secretary of State. I remind the noble Lord that the TUC health services committee meets the Secretary of State once a year and ad hoc meetings are sometimes arranged. The membership is drawn from general secretaries and senior officers of health trade unions. There is no reason to believe that the interests and views of the health unions are not sufficiently represented.

I refer specifically to the question of sight tests since that matter was raised by several of your Lordships. I stress that recent surveys have indicated that the demand for sight tests is returning to normal. The optical profession has published a series of surveys in the past few months purporting to show that the demand remains low. However, many of the surveys use an artificially high baseline as their starting point, which gives a distorted picture of future trends.

In conclusion, since 1911 when the National Insurance Act first created a right to health care for employees on low wages, successive governments have seen the need for effective working relationships with the medical profession. The phrase which was then used then was "the need for an honourable partnership between the State and the Profession". For our part, we wholeheartedly support that in the interests of the people of this country. Nevertheless, there will be times when conflict arises, as Lloyd George, Bevan and, more recently, Kenneth Clarke have found out. Government must govern and no one group, however distinguished, can expect always to prevail.

Lord Molloy

My Lords, I congratulate the Minister on her reply, although it is a pity that she ruined it right at the end. She has covered many of the points raised. I am extremely grateful to her for what she said and for the undertakings she has given.

I am grateful to all noble Lords who have contributed to the debate. My noble friend Lord Carter underlined a number of vital points which I hope will be looked at. The noble Lord, Lord Beaumont, made a very interesting speech. He omitted to mention that I had referred to the HVA, but I have lived with poverty. If he reads Hansard, he may wish to write to confirm that.

The noble Lord, Lord Colwyn, spoke about dentists. Dentists' nurses are equally important and play an important role. The noble Lord, Lord Butterfield, has compelled me to look at the work of the academics. I do not know much about it but he has tempted me to look at the matter. I am sorry to learn that the morale of academic doctors is low. Perhaps when we win the next election that situation will change.

The staff associations are concerned not only about their situations but also about the success of Britain's National Health Service. When they know about the debate held in this House, they will be extremely pleased with this House, perhaps rather more so than they are with the other place. After a very happy, pleasant and sensible debate, I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.