The Patient's Charter

HL Deb 22 January 1992 vol 534 cc848-85

3.7 p.m.

Baroness Cumberlege

rose to call attention to the Patient's Charter for those using the National Health Service; and to move for Papers.

The noble Baroness said: My Lords, in moving this Motion may I say how much I welcome this opportunity to open the debate on the Patient's Charter and to express my delight that so many distinguished and knowledgable Lords should choose to participate, and in particular that our deliberations will be enriched by the wisdom and experience of two former Secretaries of State, both of whom I understand claim to have appointed me to the chairmanship of the Brighton Health Authority.

The NHS was born in the time when everything was rationed. But health care under the new Act was a cornucopia for all. It did not require coupons, it was the market leader. In contrast today, everything else is in abundance, but for health care we have to join the queue. The NHS requires reform, not simply to realign it with the reality of today, but to regain that moral elevation of being both abundant and free to all men and women. Like the Book of Common Prayer the 1946 Act was great. But great things give way to the ASB and the Patient's Charter.

The health service reforms are going to give choice and the charter is going to print the warranty. It states clearly our seven existing rights: to receive health care on the basis of clinical need regardless of the ability to pay (that is such an important ethic and one which we cherish and which is enshrined in the charter); to be registered with a GP; to receive emergency care; to be referred to a consultant acceptable to us; to be given an explanation of any treatment proposed. It was interesting recently to see the survey carried out by MIND and the Roehampton Institute which showed that 80 per cent. of people who have used mental health services think that their psychiatrist gave them insufficient information about the treatment proposed.

The remaining rights are to have access to our confidential health records—a Bill was recently enacted in your Lordships' House—and finally to choose whether we wish to participate in medical research or student training. There are no ifs or buts; no exclusions or caveats in fairy writing—just plain guaranteed rights.

From 1st April this year three more rights will be added. The first is that people will be given information on local health services, including quality standards and maximum waiting times. The second, to be guaranteed admission for treatment by a specific date, no later than two years from the time the consultant places us on the waiting list. The third is the right to have complaints promptly investigated, a concern, I know, of the Consumers' Association. The most controversial of these three rights is that everyone should be treated within two years. That will be very challenging for the NHS. What is even more difficult is that it will question established priorities.

As a lay person, I have to be careful not to err into making clinical judgments—that is not my role—but I sometimes wonder about removing redundant tattoos. Should not those with redundant tattoos go to the back of the queue? If it is embarrassing to sleep with Mary when Tracy is writ large over your heart, that is tough; but for someone who cannot walk due to an arthritic hip, life is a great deal tougher. A warranty is a warranty and I do not like exceptions. Tracy should go to the back of the queue.

The charter challenges staff to change deep-rooted practices. I was interested the other day to be talking to a consultant in my region, who said to me that five years ago he would have been considered a very poor surgeon if he did not have a long waiting list. That was his virility symbol. But today he looks at his colleagues with long lists and as a clinical director he says to them "It's time you got your act together". Three years ago, long waiting lists were considered a necessary evil, but attitudes are changing. The majority of clinicians and managers know that lists are unacceptable and have to be tackled.

A year ago there were 71,000 people waiting two years for treatment. Today there are fewer than 35,000. The queue has halved. The number of people waiting for more than one year has also fallen by one-third, and that trend is continuing. In the south-west Thames region in 1989, the region had the second worst list in the country. But by validating lists every six months, by investing in day case treatment, by increasing the number of people treated, by better management and organisation and by using theatres and recovery wards more effectively and efficiently, we have reduced the numbers waiting by three-quarters and we now have the second shortest list in the country. I know it can be done. But I also know that there is a suspicion around that in order to reduce waiting lists people are being denied treatment; that they are not being put on the list for fear of producing poor figures. Although I have searched I can find no evidence in my region that this is happening. On the contrary, as opposed to fewer people being treated last year, more people were treated than ever before.

The charter meets waiting times head on, but it is important that we should not forget that 90 per cent. of the United Kingdom's sick people are treated within six weeks. In our region by 31st March this year, three hospitals are likely to have no one waiting more than one year. That is a local standard being set and I know that others are more ambitious and are working towards six months. Those standards will trigger others to match. We are noticing now that whether or not hospitals are NHS trusts, the reforms have inspired staff to improve services. There is a sense of competition and that is proving beneficial.

It is easy to give people a warranty that is cleverly written, but which means nothing. The Patient's Charter is not like that—it goes on to set nine tough standards. Rightly the standards start by demanding absolute respect for people. When we are ill, we are often weak and vulnerable, and it is at these low moments that our dignity should be most respected. The NHS must serve us according to our wishes. It is our service. People should never be considered "just a case"; or worse still "an interesting case"; or the ultimate degradation "clinical material". The NHS must respect and cater for different religious and cultural beliefs with their requirements for special diets; it must welcome people with physical and mental disabilities; and someone, almost certainly our named nurse, must keep in contact with our family.

The fourth standard is a tricky one. An ambulance must arrive within 14 minutes in towns and 19 minutes in the country. The London Ambulance Service is part of my region's responsibilities, and we all know that London traffic is not always good news for people in a hurry. It is no secret that the London Ambulance Service finds it extremely difficult to meet existing targets, but the service is devising new ways to tackle these problems. It is using rapid response vehicles, a euphemism for motorbikes, with a paramedically trained, well-equipped ambulance person as driver, ready to give expert and immediate aid until the ambulance arrives. Their role is to stabilise the patient.

I understand from my medical colleagues that they refer to the "golden hour". After an accident occurs it is crucial to get trained staff to the injured patient quickly in order to stabilise them—more crucial than moving a patient by ambulance and taking them to hospital. Nevertheless, we want to speed up response times. In fact in the current year we have installed new computer equipment at a cost of £1.5 million. That will relay details to each ambulance. By September of this year it is our aim that 95 per cent. of ambulances should arrive within 14 minutes.

I take full responsibility for the London Ambulance Service and I undertake to ensure that it achieves charter standards. I know that it will not be easy. I have recently appointed a board of directors chaired by a former director of British Airways, in whom I have total confidence. He knows that the next charter standard states that people will be seen immediately on arrival at accident and emergency departments, but that is only useful when we arrive. For the seriously ill the ambulance must not be a weak link in the chain.

The remaining standards concentrate on hospital services waiting times in outpatient clinics, cancellation of operations and the way people are discharged.

There is one standard that I believe is supremely important: it is that everyone going to hospital will be in the care of a nurse, "a named nurse"; not yet a nurse of our choice, but a nurse with a name who can take full responsibility for our care, an initiative very much welcomed by the Royal College of Nursing.

So, my Lords, 10 rights, nine standards. But I want to see this edition of the charter as only the first of many, each one raising standards. I particularly want people to have the right to choose to see a nurse rather than their GP. In surveys that we have conducted we have found that for advice on children, sick babies, bandaging, and the care of elderly people and the terminally ill, nurses are the professionals that most people want to see. I hope that this measure will be introduced and tried locally before being included in the next edition of the charter.

In the tradition of debates in your Lordships' House I hope that this debate will look ahead and move the service forward. Certainly, we must not dismiss the great advances that have already taken place. In an article published in The Times recently, the Shadow Minister, the honourable Member for Peckham, and her colleague, the honourable Member for Strathkelvin & Bearsden, gave a strong and timely warning that the reforms of the NHS must not concentrate solely on costs (though the authors acknowledged that those are important) but that there must be an inseparable link between cost and outcomes of treatment. I think that this concept too should be incorporated into the next edition of The Patient's Charter. But one must not dismiss the advances that have been made. It is interesting to see that medical audit is now embraced by every consultant and many general practitioners. Peer review is an enormously powerful force in improving the effectiveness of treatments. I have long campaigned for those outcomes to be published and I hope that in time that will happen.

One of the existing charter rights of patients is to choose the consultant who will treat them. But how is this choice to be made? We need that information on outcomes. We need that information on length of waiting times. Once we have that information we are in a position to make a real choice.

Who will monitor the charter and the standards? We have 56 million monitors ready to start work, for what this charter does is to give people not only rights but responsibilities. I would urge them to take both very seriously. I hope that they will respond not just by highlighting failures—because I know that there will be failures—but that they will also take just a moment to praise those who deserve it for successes. I believe that more is gained by building on success than chastising failure. As we all know, staff are enormously encouraged by letters of thanks and helpful suggestions.

In conclusion, I urge the House to unite in support of the health service and the new charter and to suggest ways to improve it. With their new found freedom hospitals are eager for suggestions. The new determination of the National Health Service can be summed up in three words—we will deliver. I beg to move for Papers.

3.20 p.m.

Baroness Nicol

My Lords, I congratulate the noble Baroness on her choice of subject. It is a most important one. I also congratulate her on the thoughtful and comprehensive way that she introduced the debate. No one can quarrel with the aims as stated in the charter and, indeed, I cannot quarrel with a single word that she said when she outlined what the National Health Service should be. To that extent we are agreed. But, however attractive the words of the charter may be, we must look at them against the background of what is actually happening today and what is likely to happen in the future.

Over the past few years health authorities have been put into the hands largely of businessmen and accountants. Local representatives have been reduced in number and, in case there might still remain a small flicker of activity as regards local interest, of the last 24 councillors appointed to health authorities 22 have been Conservative, with one Labour and one Liberal Democrat.

It is no wonder that fears are growing that financial decisions are to take precedence over patient care and certainly over patient convenience. It is significant, despite what the noble Baroness said about her wish to see patient choice, that the words do not actually appear in the charter.

In April 1991, the Labour Party published (at its own expense) a charter for patients, setting out a list of 20 rights for patients which we intend to establish. In October 1991, the Conservative Government published at a cost to the taxpayer of £2 million—I do not think that that includes the cost of distribution—The Patient's Charter which we now have before us, spelling out, as the noble Baroness said, seven existing rights and three new ones. It would be interesting to compare the two lists in detail, but I am afraid that I cannot do so in the limited time available to me.

The first item on Labour's list is patient choice; that is, the right of a patient to go to the hospital of his or her choice. That is an extremely important right when it is set against the need for a patient—especially a long-stay patient—to be within reach of friends and relatives, as well as getting the consultant of his or her choice. There is ample evidence to show—I have several A4 sheets of paper with me covered with examples—that patient choice is disappearing as contracts take over and treatment is limited to the hospitals under contract. It is not the money following the patient; it is the patient having to follow the money, like it or not. I could give many examples of the restraints which contracts are imposing but again there is not sufficient time to do so.

The Government's charter correctly points out that the first seven rights already exist. In some areas the requirements are already being met, as I am sure the noble Baroness would agree. It is fair that all areas should be expected to equal the best. It will be interesting to see whether the publication of the charter has the desired effect. I for one hope that it will. I note that the Secretary of State is to discuss performance with the chief executives every year. I wonder whether the Minister who is to respond to the debate can say what form the discussion will take and what sanctions will be available to the Secretary of State where an authority fails to reach the required standard. I can find no mention of that in the charter.

I turn now to the three proposed new rights. The first is that the patient is to be given detailed information on local health services, including quality standards and maximum waiting times. How will that information be made available? For example, how will maximum admission times for each specialty be publicised? Will it be through general practitioners, through the post to patients, through the local press or by circular to every household in the same way as the charter was distributed? It is important for us to know what the Government consider to be adequate standards of publicity. I am sure that the health authorities will also want to know that. Further—and this is most important—if it is to be done by general distribution, who will pay?

The second right is the guarantee of admission for treatment by a specific date no later than two years from the date when a consultant places a patient on a waiting list. Here is the rub: that is all very well, but how long before a person sees his or her consultant in the first instance? The process can take months. Moreover, what if a person comes within the increasing number of categories where patients are no longer accepted for waiting lists? The noble Baroness, Lady Cumberlege, is fortunate if she cannot find any examples of reduced categories in her authority. They do exist. Again I could give such examples.

For example, last year North East Thames—it is not the most recent example that I have but I shall use it because I happen to have the details to hand—has removed varicose vein operations from its waiting list. Varicose veins may seem a slightly frivolous condition but to someone who has a serious problem with them, whether male or female, they are a disability. Indeed, they can prevent a person from following his or her occupation. Therefore, to take that condition off the list seems to me to be a highly unsuitable way to proceed.

Moreover, what happens if the consultant is not adding to his list temporarily in order to keep within the terms of the charter? That, too, extends the two-year waiting period that the patient is entitled to expect. The system of counting patients on waiting lists is becoming remarkably similar to the present system used for counting unemployed people; in other words, if you do not like the result, stop counting a few categories. At least you knew where you stood under the old system, even if you did not like it.

In her response the Minister will no doubt give us impressive figures for the number of extra patients treated in the past year. I shall welcome that news. But before we can truly rejoice we need to see the whole picture of what is happening across the whole range of treatments. The noble Baroness, Lady Cumberlege, said that the queue has halved. Yes, the waiting lists have halved, but for the reasons that I have already given that is not the queue.

I turn now to the third guaranteed right. It relates to any complaints about the National Health Service being thoroughly investigated. The charter states that health authorities and national health hospitals will have to publish details regularly of both the number of complaints received and the length of time taken to deal with them. I welcome that right. But it is only fair to point out that that is already the practice in some areas; for example, for many years Cambridge has published the number of complaints and the time taken to deal with them. The information is given in the public part of the health authority papers for meetings and is examined by the community health council, among others. I feel that we should pay tribute to those authorities which already follow that practice. We should also perhaps hear how the complaints are to be published. Will it be by the method being used at present, or has a better way been found?

The charter is a statement of desirable objectives. I shall not say any more about it except to say to your Lordships that, by chance, I had a telephone conversation this morning with a young mother who had taken her small child, who has recently been diagnosed as having an ear complaint, to her GP to be referred to a consultant. The GP said, "There is no point in sending you to a consultant. You will not be seen in less than two years. Are you telling me that you have no private insurance?". That could never have been said to an NHS patient a few years ago. What have the Government done to our NHS which suggests that that is an acceptable way to deal with a patient? I hope that the electors will rise in their wrath at the next election and throw them out.

3.31 p.m.

Lord Perry of Walton

My Lords, we, too, are grateful to the noble Baroness, Lady Cumberlege, for introducing the debate. The absence of my noble friend Lord Winstanley gives me my first opportunity of speaking from these Benches. It would no doubt be inaccurate to describe my change from Social Democrat to Liberal Democrat as, "crossing the Floor of the House", but change it undoubtedly is. Yet it is difficult to imagine any change in attitude to The Patient's Charter. Everything it says, as the noble Baroness, Lady Nicol, has just said, is unexceptionable.

But even if what The Patient's Charter says is unexceptionable, should it have been necessary to say it? The charter starts by spelling out seven rights that every citizen already has within the NHS. Those rights are embodied in legislation. If they were currently being honoured, there would be no need to spell them out again. For many patients, some of those rights are not being honoured. Usually the patients, while dissatisfied either vaguely or seriously, are unaware that they have such rights and make no complaint. There is therefore no doubt that it was necessary that their rights be spelled out again clearly and concisely.

It is for that reason that the charter is to be welcomed. Yet, if those rights were all being honoured for all patients there would have been no need to spell them out again; so, although it was necessary, it should not have been necessary. In that sense, its necessity is not welcome.

In addition to spelling out the existing seven rights, the charter then goes on to define three new rights: the right to be given detailed information on local health services; the right to be guaranteed admission within a limited time; and the right to have any complaint investigated and answered. Surely any efficient organisation would, after decades of practice, have provided all those rights as a matter of course. Could any school, university or public company be successful without providing comparable rights? Those new rights are also unexceptionable, but it should not be necessary to spell them out.

The charter then goes on to define nine national standards of service and to indicate that there will be many more local standards of service. Many of those are, and will be, specific, laying down matters such as maximum waiting times. That is wholly to be commended. But the first three national standards are very general in nature. They should be rights rather than standards. Rights are guaranteed; standards are only to be aimed at. The three general standards are: to provide respect for privacy, dignity and religious and cultural belief—surely that is a right; to ensure that everyone, including people with special needs, can use the services—surely that too is a right; and to provide information to relatives and friends, subject to the patient's wishes.

Is it not sad that such elementary characteristics of a humanitarian service should need to be stated? Would not your Lordships have assumed, as I did, that such matters had been built into the philosophy of the NHS at the outset? Like everything else, they are wholly unexceptionable.

So, I suggest that had the NHS been the efficient and humane service that its founders intended, almost all of The Patient's Charter would have been a work of supererogation? It clearly is not: it is a very necessary document. That, in itself, is a condemnation of the way in which the NHS has been allowed to deteriorate as a service over the years.

My second question about The Patient's Charter is: if it was necessary to say those things, does it say enough? The answer is clearly, no. The charter deals almost exclusively with the hospital services—with the treatment of disease. It must surely be extended to cover the primary care services. Improved responsiveness and better information in primary care offer the potential for the greatest health gain by preventing illness and promoting health.

Finally, perhaps I may point out that the Liberal Democrats published some three years ago, in a document called Prescription for Health, their own patient's charter; so there are three of them on the books. The Patient's Charter published by the Government bears a close resemblance to that of the Liberal Democrats. It is a watered down version, but it covers the same topics and, not only that, it covers them in almost the same order. Can coincidence be an acceptable explanation?

We on these Benches naturally welcome the sincere flattery implicit in the publication by the Government of The Patient's Charter. We do not believe that it goes far enough. There are other rights that we would add. I shall give only two examples. We would give patients the right to exercise the maximum freedom of choice in selecting the timing of their treatment; and we believe that people should be informed not merely about local health services; they should be informed and consulted about any proposed changes to those services.

The Patient's Charter is a welcome start to the rehabilitation of the NHS. It cannot be implemented without the provision of adequate funding; but not only that, it will not be implemented without a restoration of what was at the outset the extremely high morale of the staff, a morale that today has sunk to a sadly low level. Those are the challenges that await the next Government.

3.38 p.m.

Lord Jenkin of Roding

My Lords, the House will be grateful to my noble friend Lady Cumberlege for giving us an opportunity to concentrate for two and a half hours upon The Patient's Charter and some of the circumstances surrounding it. I welcome the two speeches that have come from the other side of the House both of which applauded the publication of The Patient's Charter. So far from being a matter of criticism, it is something in which we can all take pleasure. Apparently all the parties whose representatives have spoken have thought it worthwhile to publish a list of patients' rights and standards. That must be a gain.

I shall declare an interest. I am chairman of a shadow NHS trust (the Forest Healthcare Trust). We take over responsibility in April. It operates in the area of Waltham Forest and my former constituency of Wanstead and Woodford. The borough contains substantial areas of social deprivation and a large ethnic minority population; and so I am not unfamiliar with some of the problems addressed in the charter.

Our district general hospital, as some of your Lordships may be aware, is Whipps Cross. It has teaching status associated with the Royal London Hospital. It also has a good and prestigious nursing school. It has pioneered some day surgery and it is a national demonstration model for what is called total quality management. So it has some good things going for it.

However, as the list published in the Sunday Times last Sunday showed, Whipps Cross appeared as having a poor record on waiting times for two of the eight specialties listed. I shall say a little more about that in a moment. In an interesting article in the Observer before Christmas, there was an extended profile of the hospital which included these words: wards half-full of patients who don't really need to be there…nurses too rushed to deal comprehensively with the patients who do need to be there". I hope to say something about that. I may also say, as there seems to be a question of morale, that I have an enthusiastic board with executive and non-executive directors of mixed disciplines, with representatives of the ethnic minorities on the board. Like those taking part in this debate, half my members are women and half are men.

I wish to concentrate on three points. We take the Patient's Charter very seriously. We spent two of our initial shadow board meetings defining our aims, objectives and targets and working on our local charter standards, as we are invited to do. We now have a group working on management contracts which will certainly embody key charter standards. I hope that we will be able to devise realistic criteria to have some element of performance-related pay. That has again been very much welcomed by our executive directors.

I have no doubt whatever in saying to your Lordships that setting published standards against which to measure performance is injecting a new and welcome dynamism into the management of the National Health Service.

That brings me to my second point concerning waiting times, on which I wish to go into a little more detail. It has been well catalogued that it is the biggest single cause of dissatisfaction with the NHS. In considering the problem, however, one cannot separate the Patient's Charter from the other NHS reforms. The most far-reaching is the separation of purchasers and providers and the principle that the money follows the patient. As my noble friend said, these have had a marked influence on the way in which providers see their function. This is true, whether it is a district managed unit or a self-governing trust. A good example comes from our waiting times. I make the point that this was before the trust had got into the driving seat.

Last April in ENT, 200 people had been waiting for over two years—9 per cent. of the total in that specialty. In gynaecology it was 173, in oral surgery it was 118-20 per cent. of the total. That was the situation despite intensive pressure from the region and much effort by local management.

In fact 1991 has seen a dramatic change in that picture, and it is right that I should point it out. In ENT, whereas last April 200 people had been waiting for over two years, the number was 45 at 31st December and we confidently predict that it will be nil by 31st March. In gynaecology the number was 173; it was almost halved by the end of the year, down to 96, and it will be nil at the end of the financial year. The figures are the same for oral surgery: 118 in April, down to 44 by December and our confident prediction is nil by the end of March. There are similar marked reductions in those waiting for between one and two years.

How has this happened? As Dr. Johnson said, the prospect of being hanged in the morning concentrates the mind wonderfully. What has happened is that the risk of the loss of purchasers' contracts has concentrated the minds of everyone: managers, clinical directors, and consultants. They are being told that unacceptable waiting times will lead to the contracts going to other providers.

Perhaps I may quote a few words concerning the ENT department from the report which we received in December: This [waiting list] project has enabled the department to reduce its waiting list by 29% in the first 9 months of the financial year with the proportion of patients waiting over one year dropping from 39% to 12%. Further reductions are anticipated". The report continues: The ENT department has achieved this remarkable success due to the consultants cooperating with managers in reducing the number of long wait patients. It is hoped that this success will ensure that Purchaser contracts for ENT work will remain in future years". The key to the problem has been the consultants. How have they done it? Mainly by at last agreeing to refer many of their patients to other hospitals. Of course, the money follows the patients so that we have been able to pay for them. Also, long wait patients have been targeted and there have been additional theatre sessions over the Christmas break.

Why was the previous pressure not effective? There had been pressure, as any regional chairman would tell us. My noble friend made the point that long waiting lists suited some doctors, not least because not far from Whipps Cross there is a BUPA private hospital where some carry out their private practices. However, now that the Whipps Cross ENT department has faced the prospect that it might not exist in a year or two's time, and that contracts might be taken away and would go to other hospitals, they have performed remarkably well.

In the case of oral surgery, the answer was for one of our surgeons to take his work to the Independent Hospital in Whitechapel where he was able to carry on his NHS practice, using its theatres and wards under NHS terms. The health authority was able to pay for that and the same is happening all over the country.

The reforms are working far better than I dared to hope. The targets and standards are realistic, but I agree that they need to be tightened up. I have no time to go on to other developments but I believe that we must recognise what is happening. I have been living in two worlds: the world of the press and television and the real world of the enthusiastic people who are getting on with the job. I know which the public prefer.

3.47 p.m.

Lord Ennals

My Lords, the question of whether there should be a patient's charter is not controversial. It has been clear that we all have our patient's charters, the Government just happen to have brought out theirs later than the other two parties. However, we shall all welcome anything that improves the entitlement of patients to care of the best quality. Therefore, I very much welcome and appreciate the introduction of the debate by the noble Baroness. Both the noble Lord, Lord Jenkin, and I feel a godfatherly relationship to her. When I appointed her I did not know her politics, but such is the nature of the way in which I carried out my job, that that would not have influenced me against her. She is a very good chairman in her own right.

I should have liked to reply to some of the points made by the noble Lord, Lord Jenkin of Roding, but I wish to concentrate entirely on one aspect which relates to the first right in the Patient's Charter; that is, the needs of the very elderly, and the elderly mentally infirm. This was effectively dealt with by the programme "Panorama" on Monday night, "Getting Rid of Granny".

Perhaps I may first declare an interest not just through my active involvement in voluntary organisations like MIND, of which the noble Lord, Lord Jenkin, and I are joint presidents. There is the Alzheimer's Disease Society, the Council and Care for the Elderly, and Age Concern. I am also a non-executive director of Takare, the leading agency for providing high quality nursing homes. Twenty-two out of our 24 nursing homes have contractual arrangements with district health authorities and set their prices within government limits of income support, so the question of whether people can afford to pay never arises.

It was revealed this week in the programme "Panorama" that three-quarters of health authorities have recently cut back on long-term care. Thousands of people now face the prospect of being forced, when their hospital for the elderly closes, to go private in the sense that either they or their relatives have to run down their own modest savings to top up fees for their elderly relatives. The first established National Health Service right in the Patient's Charter is the right, to receive health care on the basis of clinical need, regardless of ability to pay". I presume that that right applies to people of all ages, including the very elderly. I hope the Minister will confirm that because obviously an increasing proportion of our population falls into the elderly category. At this time nearly 900,000 people in this country are over the age of 85. By the turn of the century that figure will be over 1,100,000. The Patient's Charter contains fine words, but I wish to question the Government on their policy in this respect. If death rates were to decline, the number of patients over the age of 85 would increase. There is also a growing number of elderly people who suffer from mental distress or Alzheimer's disease. Such people have been the victims of the Government's policy to close beds for the mentally ill before proper support services are available in the community.

Such action causes anxiety not only for the frail elderly themselves, but also for their relatives who care for them and care about them. I personally know many people who are desperately worried about what the Government's future role will be in this area. I am sure many other noble Lords know such people. Those people do not wish their elderly relatives to be forced to stay in some of the wholly inappropriate, old, workhouse-type hospitals that exist. They do not wish to see their relatives in such hospitals, but they fear their relatives may be shipped to nursing homes in other parts of the country because their local health authorities have seemingly ended their responsibility for them. Such patients perhaps cannot afford high fees and nor should they have to do so. In the first of the Patient's Charter rights, the Government address that point. They refer to the right to receive health care regardless of ability to pay. In my view that principle should be sacred. That principle is more important to people at the end of their lives than at any other time.

The "Panorama" programme showed what many of us already knew. It showed that too many elderly people live in conditions which deny them human dignity. The Government should say without equivocation that they accept absolute responsibility for guaranteeing the first right in the charter to people of all ages. Yet people are being bussed to private homes from their own communities. It is sickening to hear some people comment that some patients are too frail to know where they are. That is not a good enough excuse.

I believe the conditions in some private homes are grossly unsatisfactory. That fact was revealed in the "Panorama" programme. Many of the private homes are now registered, but nevertheless some of them are inadequately staffed and the quality of care given to elderly people is such that none of us should be proud of it. But what option do patients or their relatives have in this matter? I repeat, the Government should accept responsibility for all these patients. The Government could accept that responsibility by introducing government-run nursing homes that are properly supervised. Alternatively the Government could enter into contracts with nursing homes involving proper supervision by health authorities. I do not mind how the Government tackle this matter as long as a high quality of health care is maintained and the Government accept responsibility for providing the funds to achieve that high quality.

No one should be forced to pay for private accommodation he cannot afford. No one should be forced into poverty and homelessness, as is the case now. Relatives should not be forced to accept a nursing responsibility which may be quite beyond their capabilities. Indeed there are many thousands of carers today looking after elderly people who are carrying out functions they are not qualified to carry out. In those cases there should either be medical services provided in the carers' homes or those in need of care should be in properly supervised nursing homes.

I wish to refer to the Salisbury health authority. Apparently that health authority has closed 49 continuing care beds in the past two years when the need for such beds was growing. This is a huge problem and it affects an enormous number of people. Every year it affects more people. Over the next 20 years there will be a steady increase in the number of elderly people requiring more and more help from the health service. Thank God The Patient's Charter has made a clear statement on this issue although I believe the words "regardless of age" should be added to the first right in the charter.

The Prime Minister has said recently: No one should have to rely on private health care". I am certain that is correct. The Prime Minister must ensure that his Government carry out his wishes. The Government must ensure that no one has to rely on private health care. The Prime Minister must now ensure that every health authority in the country respects that first right in the Patient's Charter. I believe, however, that that right should take account of social as well as clinical need.

3.55 p.m.

Lord McColl of Dulwich

My Lords, I, too, wish to thank my noble friend Lady Cumberlege for introducing this debate. The Patient's Charter is a logical extension of the Government's reforms in the National Health Service. It clearly delineates the targets at which the reforms are aiming. However, it is no use pointing out the targets if there are no incentives to stimulate the 1 million NHS employees to reach them.

Some months ago the noble Lord, Lord Glenamara, told us of his visit to an outpatients clinic in the North of England. He was kept waiting for four hours. As he is a patient, charming and modest man he did not protest. However, when he visited the clinic again two months later he was again kept waiting for four hours. On that occasion his curiosity got the better of him and he carried out a little survey to find out what time the other patients had been instructed to attend the clinic. To his horror he discovered they had all been asked to attend at 9 a.m. All the patients were eventually seen by the end of the morning. That indicates that the cause of the shambles had nothing to do with a lack of resources. It was due to a lack of consideration and courtesy. That is the fundamental problem.

The majority of patients in the National Health Service throughout the land receive courtesy and consideration when they are treated. But the crucial question is how we ensure that all NHS patients always receive the kind of courtesy and consideration which is their due. The answer is quite simply that there must be incentives for good behaviour and disincentives for inappropriate behaviour.

A brilliant idea formulated by Professor Einthoven was to split the two functions of district health authorities. He formulated the idea of making district health authorities the purchasing authorities which approach hospitals and buy the care required to service their populations from the providers. That split is absolutely crucial to these reforms. Professor Einthoven said that having purchaser and provider wrapped up in one entity—that used to be the case with the former district health authorities—would be rather like having a university where students set their own examination papers, answered them and then corrected them themselves. Clearly there are dangers in that kind of system. It is essential to make the split I have referred to.

The noble Lord, Lord Carter, has repeatedly said he does not like patients being called customers. He thinks that is a new phenomenon, but of course there is nothing new under the sun. We have been calling patients customers for 30 or 40 years. We did so because there was a widespread view—was the case with many other nationalised industries—that everything was free and that patients did not have to pay for their care. However, they pay for it in a rather roundabout way through the tax system. To emphasise the fact that patients paid for their care they were referred to as customers. Therefore I do not think the noble Lord should be so opposed to the term.

There is a further shift in emphasis towards giving the patient power by enabling him to change his GP more easily. The reforms are shifting power to where it should be, to the customer—or perhaps I should say to the patient.

Perhaps I may take up the point made by the noble Baroness, Lady Nicol, that the method of counting waiting lists is constantly being changed. She is quite right. However, she ought to have mentioned that the greatest change was made by the last Labour Government, which quite reasonably said that all patients who had been given dates for their operations were to be removed from the waiting lists. That is not the situation today. Were we to do that now and give all patients on the waiting list dates for their operations we could reduce the waiting list to zero. Therefore, while the methods have been changed they are not comparable. That needs to be said loud and clear.

The noble Baroness also said that patients' choice has been limited by the reforms. That is a point which must be dealt with because the Labour Party agrees that money should follow patients. It wants all doctors to be able to refer patients wherever they like. That is the eventual aim of the Government's reforms. However, if we had done that from 1st April 1991 there would have been the chaos which the noble Lord, Lord Ennals, predicted so often. That is why the Government did not do that. Instead, they said that we should proceed slowly and keep everything this year as it was last year.

Would the noble Lord, Lord Carter, like to intervene? I thought that he wanted to say something.

The idea of keeping the situation steady for a year was to enable all systems to be put in place so that there would not be chaos. If the noble Lord, Lord Carter, thinks that it would have been better to have chaos, so be it. There would have been chaos if all GPs could have referred all their patients anywhere they liked. It was perfectly reasonable to keep the referral patterns this year as they were last year. It is quite wrong for the Opposition to make such a song and dance over the issue.

It is also wrong continually to imply that to become a self-governing hospital is to opt out of the National Health Service. It is no such thing. Self-governing hospitals are answerable to the Secretary of State in the same way as the boards of governors of the teaching hospitals were in the old days. They have to provide an annual report and financial report. They cannot borrow money without permission from the Secretary of State. Therefore the Labour Party cannot continue to describe the system as opting out of the National Health Service. It is nothing of the kind. We have no wish so to do.

In conclusion, I should like to thank my noble friend Lady Cumberlege for introducing the document and to say what an excellent document it is. It will work because the incentives are in place.

4.3 p.m.

Baroness Carnegy of Lour

My Lords, speaking on 13th January during the final stages in this House of the Local Government Bill the noble Lord, Lord McIntosh of Haringey, reminded us that the phrase "the Citizen's Charter" was not invented by the present Prime Minister or indeed by any present politician but by Herbert Morrison in 1920. The longevity of the idea is interesting. My noble friend Lord McColl has left us in no doubt that the need is even greater now than it was in 1920 to find ways to ensure that public services are as user friendly as they can possibly be.

Many of your Lordships may remember the gist of what Ivan Illich wrote on the subject in the early 1970s. Among other things he pointed out that, increasingly, big institutions such as hospitals, schools and I have to say to the noble Lord, Lord Perry, universities, and the professional people and others who control and run them, although they sincerely believe that they are doing their best for patients etc., in effect tend, because of the way things are organised, to make arrangements which are more and more for the benefit of the providers and less and less for the people the providers exist to serve. One could call it the "what is good for the institution is good for the consumer" syndrome. Illich saw the need in the modern world for deliberate measures to redress that imbalance in order to tip the balance in favour of the ordinary citizen. The Patient's Charter is an attempt to do just that in the National Health Service.

Of course, as speeches in this debate have made plain, printing the charter is the easy part. Behind each right which a patient has and behind each guarantee, mechanisms and good practice must be developed right across the health service to make sure that they are delivered. A good example is the small field of the National Health Service in which I am involved, the right of a patient to choose whether to take part in medical research. That is one of the rights which is contained in The Patient's Charter. Perhaps I may point out to the noble Baroness, Lady Nicol, that the right to choose is mentioned on page 9.

It seems obvious that the patient should have the right to choose. However, to be asked by one's doctor whether one will take part in, say, the trial of a new drug can be quite a threatening question. What does one say? One knows that the research is important; new treatments must be discovered and tried out. One would like to help if one can. If one says "no", will it upset the hospital or the doctor so that they take less good care of one from now on? Life is pretty tough already if one is ill and coping with the present treatment; can one bear to risk extra uncertainty, new hazards or the possibility of it all going wrong?

It must also be said that there are strong incentives for hospitals, university departments and GPs to undertake research and to find patients to take part. There is the incentive of finding better treatments.

Kudos attaches to research. There is also money to be earned for the department or practice, especially if the research is sponsored by a large commercial drug company.

All of that means that a patient's freedom to choose freely and without anxiety or pressure whether to take part in a drug trial is very important. How is that right to be safeguarded in the National Health Service? Part of the mechanism in that part of the charter is the network of local research ethics committees, a number of which already exist and which the new government guidelines suggest should soon be in place within every district health authority and every regional authority in Scotland. Many have been operating for some time. I am the chairman of one such committee. It is interesting to see from both sides of the fence just how important that part of the Patient's Charter is.

When our committee began its work we were interested to discover how difficult it often was for patients asked to involve themselves in research to know what they were letting themselves in for. It was interesting how relaxed researchers were about describing precisely what they planned to do. They were very polite when issuing the invitation, but they were not precise in describing what was involved. They were fairly relaxed about explaining to the committee and very relaxed indeed about explaining to potential participants what the possible hazards might be and what was involved. I know that other ethics committees have had the same experience.

If a person is to be properly free to choose whether to take part in a drugs trial he or she must be supplied with full, clear, easily understood information. It should be written down so that it can be read at leisure. The patient can then have the chance to discuss the matter with the doctor and ask questions. There are all kinds of details that he or she may wish to know. For instance, "What is the purpose of this drugs trial? Why am I one of those asked to take part? How does the drug work? What exactly will happen during the trial? How long will it last? Shall I have any side effects? What will happen if I react badly? Will I be able to ask to withdraw? Will anyone suggest that I might withdraw? If I say 'no' now or withdraw later will it upset the doctors and affect my present treatment?"

The ethics committee of which I am a member will not agree to a piece of research proceeding until it has seen a copy of the written information to be given to all participants and the separate consent form. In that way the committee can check that people understand what is proposed, what will happen and that they can say "no" or withdraw if they wish to do so.

Likewise the committee asks searching questions of the researchers. For instance, "What is the precise objective of the research? Could it be done any other way? Is the research capable of achieving that aim? What categories of people will be involved?" The committee checks carefully the safeguards for patients and so on. And news travels; in the second year of the committee's work there is no question but that circumstances have improved since the first year.

The Patient's Charter may look like a slim volume, but one thing leads to another. In Scotland there is a plan for action which has been developed by 500 people working in the health service. There is every sign that people are realising that in the National Health Service the most health-giving ingredient will be ever-increasing user friendliness.

4.12 p.m.

Lord Holderness

My Lords, I am grateful to my noble friend Lady Cumberlege not only for making possible the debate but also for the excellent speech with which she introduced it. As I expected, there has been a general welcome for the charter. It will not at a stroke reduce all delays and remove all disappointments. Indeed, there is a danger that it might even decrease the urgency with which improvements throughout the National Health Service are eagerly awaited. However, it does one thing of immense importance; it endorses the supremacy of the user. The position and importance of all who work and plan in the National Health Service is clearly recognised, but those of the user are paramount.

I should have preferred a little more boldness. Two years is still a long time to wait for treatment, but I take the point that many people, perhaps most, will not have to wait that long. However, while that waiting time is rightly a matter for concern, the much shorter waiting time of weeks or even days for the result of an important medical examination can cause a misery of anxiety. Such an improvement need not depend on a revision of the charter. I should like to see steps taken immediately not to reduce the thoroughness of any examination but to cut out all dilatory delays for which no satisfactory explanation can be offered.

Nor need a formal change be made to the ninth of the national charter standards. When an attempt is being made to improve collaboration between hospitals and GPs at the time of the patient's discharge, it is a matter of great concern that a hard-pressed general practitioner is unaware of his or her patient's return home. It is too often the case that when the patient eventually returns to the surgery the GP is ignorant of the treatment that was offered and the future treatment that is required, except in so far as the patient can provide sketchy information.

In general there is abundant scope for the introduction of further standards, and the sooner the better, in areas where performance, the supply of goods and the time that is taken can be easily measured. From 1987 until last year a special authority, the Disablement Services Authority, worked towards integration within the National Health Service of the provision of wheelchairs and artificial limbs. After studying the matter closely for almost four years it appears to me to be relatively simple to promise a potential user of a wheelchair or a similar appliance that it will be available within a certain number of days or weeks. Similarly, the man or woman needing an artificial leg should be guaranteed to receive the limb that fits satisfactorily within a specified time after the amputation or the prescription of the limb.

The final and most important issue was the fruit of a recent discussion among the Department of Health Advisory Group on Rehabilitation, of which I am chairman. Several of the group's more expert members pointed out that rehabilitation after long neglect was prominently mentioned in the department's Green Paper, The Health of the Nation. It is hoped that the issue will maintain its place in the forthcoming White Paper. However, the Patient's Charter makes no mention of that. There are hints, but only hints, of rehabilitation among the rights and the standards, but nowhere can I find unambiguous and unmistakable promises that every man, woman and child, whether in hospital or after discharge, has a clear right to continuing rehabilitative care aimed at the fullest possible restoration of his or her capacity. If my noble friend can give an undertaking along those lines I and her advisory group will be greatly relieved.

4.17 p.m.

Baroness Seccombe

My Lords, I am delighted that my noble friend Lady Cumberlege has initiated this important debate on the NHS with particular reference to the Patient's Charter. Health is naturally one of the most high profile areas of government. After all, we all become deeply concerned when our family or friends become sick.

There is plenty of research to show that most people who use the NHS are well satisfied with the treatment that it provides. Their views are quite at odds with the constant criticisms of the NHS which we hear from the Labour Party. The tragedy is that such criticism can cause only alarm and concern to people when often they are vulnerable and most in need of reassurance and comforting support. To hear the Opposition talk one would believe that the NHS is a crumbling service suffering savage cuts. The truth is very different. Funding for the NHS has increased in real terms every year since 1979. The figures speak for themselves. In 1979 £8 billion was spent on the NHS. In 1991–92 the figure is £33 billion. After allowing for inflation that is an increase of 50 per cent. That is a truly impressive record on which the Government can be congratulated.

To be effective money must be spent wisely. There is ample evidence to show that that is happening and is reflected in widely reported public satisfaction. Several recent surveys have shown that the vast majority of people who use the NHS come away with favourable impressions. In November 1991 the National Association of Health Authorities and Trusts published a survey of patient's satisfaction. It showed that 87 per cent. of people with recent experience of using the NHS were satisfied with hospital in-patient care and visits to their doctors.

I welcome The Patient's Charter. It is an important document which not only draws attention to the seven existing rights and standards of the NHS but also states firmly and clearly the Government's commitment to building on success and creating an even better NHS. In particular I welcome the attention given to appointment times. I know that my noble friend Lord McColl has already referred to it. I too have had experience, as I am sure most Members in this Chamber have, of turning up at hospital for a 9 a.m. out-patient appointment only to find that 20 other people have been given the same appointment time, all sitting in a dingy waiting room, sometimes for several hours, with no explanation or apology given. not even from the doctor when one eventually saw him.

That scenario might be more convenient for the doctors, but surely the prime concern of the NHS should be for the welfare and convenience of the patient. That is where the charter puts its emphasis. It is the patient, the customer—yes, I am happy to regard the patient as the customer—who pays an average £44 a week for a family of four for the service. That system of out-patient appointments is unacceptable. I am pleased that one of the national charter standards is that everyone will be given a specific appointment and will be seen within 30 minutes of that time.

The health reforms have made it possible for the charter to promise that no patient will have to wait more than two years from the day that the consultant places that patient on the waiting list. Dramatic advances have been made. The Merseyside region has already achieved that target. In the first six months of the reforms there was an overall fall of 16 per cent. —a most encouraging success.

The new NHS hospital trusts play an important part in the challenge. In those hospitals attention is being paid to the needs of patients and many more are being treated. It must be a great joy for all the staff of trust hospitals to have the flexibility to adapt their services to the needs of local people. They must appreciate too the fact that their own management is more able to respond quickly and effectively to staffing standards, capital programmes and pay and conditions.

It is interesting to observe that some BMA spokesmen have admitted that GP fund-holding has improved patient care. There is real enthusiasm by many doctors to join that voluntary scheme. By April some 7 million people will be covered in that way. Over two-thirds of fund holders believe that their quality control over hospitals has improved as a result of fund-holding.

The Labour Party will lose a great deal of support by its recent re-statement of its intention to turn the clock back by abolishing GP fund-holding. I am delighted that the NHS is so prominent in the political argument today. The Government have a good and proud story to tell. The agenda for the future is strong and positive. It is this Government which is most capable of shaping and modernising the NHS to meet not only today's challenges but those of the 21st century.

4.23 p.m.

Lord Mancroft

My Lords, it was fitting that the debate today should have been opened by my noble friend Lady Cumberlege. She demonstrated her enormous knowledge and experience of the health service and her grasp of its problems and solutions to the problems. We are grateful to her for the opportunity today to talk about this important subject.

The debate is about existing policy. It is not, as we have previously discussed in the House, a debate on possible options, on ways to go forward, or even on criticisms of the past. That is important. Not only are we discussing existing policy; it is policy spearheaded by brave reforms. Perhaps we are a little premature today in speaking about the Patient's Charter and the reforms. In terms of the National Health Service's history, the reforms have only just begun. It will be years before we achieve the results that we seek. However, there is no escaping the fact that the early signs are very good indeed.

I believe that the Patient's Charter is a tremendous demonstration of the Government's commitment to the National Health Service. Not only that, I hope that it will finally put to bed the Opposition's claim that the Government wish to privatise the health service. I hope, too, as my noble friend Lady Seccombe demonstrated, that it will finally put to bed the claims of the Opposition that the Government have instigated cuts in the health service. Even a party that is led, as the noble Lord, Lord Desai, said earlier this week, by leaders who do not understand economics, cannot fail to grasp the fact that an increase in expenditure from £8 billion to £33 billion is not a cut.

One of the reasons that the Labour Party talks so much about cuts is that throwing money at the health service is the only policy that it has produced. It is not just throwing money; it is throwing money which it does not have and which it could not produce. Its economic policies would not produce the growth that would be required to fund its plans. Indeed, it would be more likely to produce the same result as occurred during the last Labour Government: a Labour Chancellor going cap in hand to the IMF. I doubt that the IMF would produce the sums that the Labour Party wishes to spend on the NHS.

Of course the NHS could always use more money. There is no limit to its requirements. Any government of any description will clearly spend as much as they possibly can. This Government are no exception. They have spent proportionally more than any government previously because their economic policies have allowed them to do so. They have produced the cash. However, in spending that money it has become clear that it was not lack of funds, or anything to do with money, that caused the main problems in the National Health Service during the 1980s. What clearly have been needed—and they have been implemented—are reforms to make the service more cost effective.

As with so many issues, the only real debate about reforms within the National Health Service has been within the Conservative Party. All the different bodies within the health service, and outside it, have been involved in those discussions as is right and proper. There has been acrimony at times; harsh words have been spoken. Indeed, I am sad at the level and angles of the attack that the British Medical Association has entered into. It is pleasing for all of us to see that it is slowly changing its mind. It realises that those reforms are right. I believe that slowly the BMA will begin to convince its members—or its members will begin to convince it.

Only the Labour Party consistently rejects the reforms. It is sad that the Labour Party prefers to continue the system as it was. It is extraordinary that, although it consistently derided the Patient's Charter, it has one of its own—as indeed have the other parties. Everyone apparently now has a patient's charter. The Labour Party's patient's charter is bigger—it would be, would it not? However, it seems strange to me that mention of waiting lists is missing from the Labour Party's charter. That rather belies the claim that the Labour Party puts patients first. It is quite clear to anyone who has any connection with the health service that on a practical basis it is waiting lists which worry patients more than anything else.

Reference to waiting lists is one of the most important components in the charter. It is important in practice because in many ways it is the simplest problem although not the easiest to solve. It is easy to identify the problem. The goal is to reduce those waiting lists. The results therefore are easier to gauge. At present the results are pleasing. My noble friend Lady Cumberlege and my noble friend Lord McColl have referred to cuts in waiting lists within a region, within a trust. It is particularly satisfying to the Government to see how fast the trusts are coming to grips with that problem and are managing to lower those waiting lists. Of course there is a long way to go and it is early days yet, but we are undoubtedly heading in the right direction.

The second and third key components of the charter to my way of thinking—and it is clear that every speaker in this debate has a favourite part of the charter—are costs and standards. Of course the two are interlinked, and that in itself within the health service is a revolution. Previously, cost was called price, and standards were not really talked about too much, but you cannot evaluate the cost until you have the standard and you know what you are aiming at. It is not simply price; it is the end result that is important.

If I may, I shall give your Lordships an example. Some of your Lordships may know that I am particularly interested in one area of health care, which is the treatment of drug addicts and alcoholics. This is a difficult area for the health service. They are not popular patients, and they never will be. They do not easily come forward for treatment and they are extremely hard to treat. I am involved in the voluntary sector through various charities and I have also a commercial interest in it too.

In viewing these two different areas of treatment, two different philosophies of treatment, I have learned some interesting facts. I am a director of a housing association, which is a large organisation which deals with drug addicts. We treat them for £255 a week, which is a very low price. I am also engaged with a commercial operation which treats patients for £250 a day. There is, however, a difference far beyond that when one compares those two figures. Within the housing association the programme is 18 months.

Only 4 per cent. of patients complete the programme and only 2 per cent. ultimately remain off drugs. Within the private sector establishment something like 80 to 90 per cent. complete the treatment, which lasts for a maximum of six weeks. Of those who complete, anything between 40 and 60 per cent. retain their health and remain abstinent from drugs.

It is difficult to be as accurate as one would like to be, but what one can basically say is that at the cheaper end of the market, which has different problems, it costs about £20,000 to get one patient off drugs, whereas at the more expensive end of the market it costs about £15,000 to get someone off drugs. That is the difference between cost and price.

One of the reasons for the differential is that the private sector exists within the disciplines of competition and cost effectiveness. It is constantly evaluating its performance, its results and patient satisfaction, and even more than that GP satisfaction. It is really the GP who is buying the treatment, buying the health care, on behalf of the patient. These evaluations, these performance examinations, have not up until now been used within the health service, but encompassed within the reforms and within the Patient's Charter would be the requirement to do that. I hope, therefore, that we shall see slowly, carefully, and gradually a raising of standards.

I mentioned earlier to your Lordships the price of treatment, but it is worth bearing in mind the tops and bottoms of the scale.

Several noble Lords

Order! Order!

Lord Mancroft

My Lords, I see that I have run out of time.

4.34 p.m.

Baroness Faithfull

My Lords, I join other noble Lords in thanking my noble friend Lady Cumberlege for initiating the debate. As she has said, the Patient's Charter sets out what the National Health Service has to offer. She emphasised that the service is available to all citizens in this land on the basis of clinical need, regardless of ability to pay. I take the point that the noble Lord, Lord Ennals, made that we are still looking at the position with regard to patients suffering from an Alzheimer's disease condition and the elderly.

The long held view "Put the patients first" still pertains. Furthermore, it is the role of the staff of the health service to listen, and not only to listen but to hear the views the patients put forward. I understand that the charter is to be translated into nine different languages. That would enable the health service to be understood by the ethnic groups who are citizens of this land, and it is a wise movement.

I should like to ask my noble friend three questions. First, would she not agree that the charter, to be better understood and more helpful, should surely include the medical running of the community services and the social services and explain the role and link between the hospital and community services? This point was well made by the noble Lord, Lord Holderness. The charter concentrates only on the hospital service, and here I agree with the noble Lord, Lord Perry. The hospitals should work in partnership with the general practitioners, the health visitors and the midwives, and unless there is a partnership between them the health service cannot well be understood by the public.

I remember visiting a health centre in a small town some years ago. It offered a wonderful community service to patients and in some instances performed minor operations. Indeed there were two beds for overnight stays. The work of this community health centre relieved the hospital staff, who were then able to concentrate on serious surgical cases and others needing hospital treatment. In this way the waiting lists of the hospitals were reduced.

As president of the National Children's Bureau my second point concerns health services for children. Should we not be promoting an integrated child care health service? To build up a nation of healthy children is surely the role of our health service, and furthermore is likely to produce a healthier nation who, in turn, will not need the health service to the extent it does at the moment.

The Faculty of Community Medicine wrote: For many years the general consensus of opinion has favoured an integrated health service for children in which the promotion of child health, the prevention of disease, the early detection of remedial abnormality, the treatment of illness and the care of children with disabilities and support for their families is accommodated within the basic structure of our system of medical practice". Under the chairmanship of a well-known doctor, Professor Philip Graham, a report was published in 1987 called, Child Health 10 Years After The Court Report, Investing in the Future.Would my noble friend not agree that the charter might be even more helpful to parents and children if there were an integrated health service for children?

My third point concerns the management system. The charter will not be fully implemented without good management. I would submit that the present management structure needs reappraisal. In industry, commerce and the services policies are issued from headquarters, but the detailed methods and ways of carrying out those policies are left to the local managers. Would the Minister not agree that much bureaucratic time and money spent on issuing detailed instructions and expecting a reply is wasteful? I understand that the trust hospitals have cut out this tier of management and as a result show shorter waiting lists and a better service to patients.

We should rightly be proud of the National Health Service of this country. I pay tribute to the nurses, doctors and ancillary staff for the service which they give. Under the Patient's Charter I believe that they will be able to give an even better service.

4.40 p.m.

Baroness Eccles of Moulton

My Lords, I begin by thanking my noble friend Lady Cumberlege for giving us the opportunity to discuss this most important document and all that lies behind it. In the health authority where I work we waited in some trepidation for The Patient's Charter. However, we were relieved to find that the rights and standards it sets out, although varying in the demands they make, are all attainable. My health district warmly welcomes the charter and is able to make good use of it. It is already becoming a familiar document to staff and patients alike.

The charter flows naturally out of the mainstream standards required through the reforms. Therefore there is no temptation to sideline its demands. Each contract that, as a purchasing authority, we agree with our providers has quality requirements and continuous monitoring of performance is an integral part of a purchaser's job.

Some of the rights and standards are an echo of what is already happening and I should like to give some examples in a moment. Others cannot be achieved immediately but are being worked towards, and yet others have to depend on the contributions and co-operation of other agencies. The whole provides a focus, stimulus and aid to management. However, we do not see it as a document making demands which we must meet, tick off and put on the shelf. We see the charter's standards as minimum, again with the proviso that some are harder to achieve than others. In some instances we have anticipated and even exceeded them, in others we aim to improve by some considerable degree on the minimum.

Setting aside the external agencies, it must be said that two kinds of co-operation are essential for success. Within the hospital or community unit management cannot deliver to the highest standards without the wholehearted and enthusiastic participation of clinicians, as was stressed by my noble friend Lord Jenkin. My health authority has already witnessed this participation. Also, it is essential that purchaser and provider co-operate in accepting and recognising the problems and work together to solve them. The internal market does produce creative tensions—that cannot be denied—but it can have very positive results. In spite of this, we must never lose sight of the fact that we are no more than part of a system spending public money on a single aim.

An example of our response to one of the three new rights which could not have been achieved by management in isolation is the dramatic reduction in waiting times in Ealing. Clinicians and managers working together have eliminated all on the two-year waiting lists. However, in pursuing the principle that the minimum is not good enough, it is our intention that by the end of March we will have reduced all waiting times to less than one year.

However, waiting times are influenced by other factors. For example, if the ninth national standard—and that standard has been mentioned previously—cannot be fulfilled, that is, if continuing health or social care outside hospital is not available, then the bed that continues to be filled keeps the next patient on the waiting list.

It is also very important that we do not concentrate entirely on the time taken for people to move through hospitals. For somebody waiting for domiciliary treatment, assessment or support, several months can seem a very long time and can reduce significantly the quality of life.

Not only is it essential for hospital doctors and managers to work closely together, but it is equally important that the hospital and GP interact. Where standards embrace both parts of the service—for example, in referrals, explanations of treatment or discharge home—it is necessary that hospitals and GPs play by the same rules. One way in which hospitals can help GPs to provide a better service is by frequently circulating up-to-date waiting time information so that patients can be referred where lists are shorter.

In Ealing we are already paying regard to the first of the new rights; that is, the requirement for detailed information. Local health services are detailed on an at-a-glance A4 card with easily read information, such as a list of the 40 hospitals with which we have contracts and the improved services available. GPs can refer to that at a glance without having to wade through a tome. At the same time we published similar information in the local press.

As regards the monitoring process, the wide-ranging rights and standards cover the tangible and the intangible. Some are easily described in a contract and easily measured in the monitoring process; for example, clear and concise information for patients, such as why they are in hospital, what treatment they can expect and an understanding of their illness. My noble friend Lady Cumberlege mentioned that there will be the provision of a named nurse for each patient on the ward or within the community—wherever the need exists—for the necessary length of time, which can easily be measured. The monitoring of the less tangible rights and standards has to depend on such methods as patient satisfaction surveys. The outcomes of the initial surveys should form the baseline "level of satisfaction" for the hospital. In order to promote higher standards the purchaser will then set a higher target for the hospital to achieve in future years.

I was going to give your Lordships an example of the way in which we are raising standards across hospital and community care but, in view of the time, I shall omit that. I have tried to give your Lordships an idea of one health district's support and enthusiasm for the Patient's Charter on behalf of the patients and the population for which we are responsible. I have given one or two examples of how it is already taking effect.

However, I end by stressing once more that we do not accept those standards as the best that can be achieved. They provide useful benchmarks but we must continue to try to do even better.

4.48 p.m.

Baroness Brigstocke

My Lords, I too am most grateful to my noble friend Lady Cumberlege for instigating this debate on the Patient's Charter. As a member of a health education authority and the mother of a nursing sister who works in a very busy accident and emergency department, I applaud both the Government's efforts to improve and modernise the nation's health service and their commitment, as expressed in the Patient's Charter, to ensure that those efforts are successful. I was also greatly reassured to learn from the noble Baroness's clear and informative speech how the regional health authorities are implementing the charter's rights and standards. I only hope that all health authorities are sufficiently and professionally managed as is the case with the South West Thames Health Authority.

Today I speak not for the health education authority but for a far wider constituency which makes up 50 per cent. of the population—that is, the female population. In passing I note that over 50 per cent. of the speakers in today's debate are women.

One of the seven rights in the charter is the right which each one of us has to be referred to a consultant who is acceptable to us. Moreover, the first of the nine national standards assures respect for privacy, dignity and religious and cultural beliefs. Many women patients prefer to have a woman GP; I certainly do. Many women would find a woman consultant more acceptable than a man. The details of breast or cervical cancer, the after effects of chemotherapy, the psychological stress associated with certain operations—many women, though not all, want the choice of discussing such intimate details with a woman consultant. They want "privacy" and "dignity", in the words of the charter's first standard.

Moreover, women from ethnic minorities often need a woman consultant because of their religious and cultural beliefs. It is good to know that the National Health Service wants to respect the dignity, privacy and religious and cultural beliefs of us all—women and men. However, at the moment there is a great difficulty for the National Health Service in fulfilling its promises in that respect. There are nothing like enough women at consultancy level in this country. Women hold only 15.5 per cent. of all consultancy posts; only 3.2 per cent. of consultants in surgical specialties are women and the percentage of women in general surgery is shamefully low—less than 1 per cent.

I shall not waste your Lordships' time by offering anecdotes about crude prejudice and bias among some members of the medical profession—only some—who in the past have claimed that women are not up to it, get too emotionally involved or even that they are, too caring to be surgeons. Imagine! There has been discrimination against women reaching high posts as consultants. Let us hope that that is now a thing of the past. I know that the National Health Service Management Executive is taking up the Project 2000 challenge to increase the quality and quantity of women's participation in the workforce.

The figures tell an interesting story. I know that medical schools accept only students of the highest calibre and quality: 51 per cent. of those students are female. I am told that the women do better (perhaps I should not say that) in medical school than men. They continue well in the early years and are fairly equally and proportionately represented until registrar level. From then on women are proportionately unrepresented. Even at senior house level only 37 per cent. of senior house officers, taking all specialties, are women, and of senior house officers in surgical specialties only 17 per cent. are female. I have already given the dismal figures at consultancy level, yet women are naturally fitted for surgery. Not only are they dextrous but they have smaller hands which can reach more easily into certain body cavities.

Fortunately the Department of Health, in collaboration with the Royal College of Surgeons, has devised a scheme to help women come through this glass ceiling of promotion. The Women in Surgical Training scheme identifies women who wish to train as surgeons. Those women are then invited to join the scheme. The Royal College of Surgeons has set up surgical advisers in every region to be mentors to those women. The Department of Health is funding mutual support groups. I must emphasise that there is absolutely no question of positive discrimination in favour of women, but appointment committees will know when a woman candidate for a consultant's post is part of the scheme and that her performance and progress are being monitored. Bringing in the new shift and partial shift system in hospitals will also help women with children as it will allow for part-timers. This year £1.3 million is being spent to fund a vast increase in part-time training posts at registrar and senior registrar level. That could help men too.

Let me conclude with a short anecdote. The Department of Health recently published an excellent document entitled Women Doctors and their Careers. On the front cover are four women clearly working in an operating theatre. One of the Department of Health's secretarial staff—a woman I am afraid—when she saw the cover said, "What a nice picture of four nurses". The picture was of four extremely senior surgeons. There are a few first-class women surgeons and consultants; more are needed in order to fulfil the assurance of the Patient's Charter.

4.55 p.m.

Lord Harmsworth

My Lords, almost exactly three years ago I bought for a small publishing operation a computer. It cost not much over £3,000. It was intended to run a complex and comprehensive sales ledger. It was also intended to handle some intricate and difficult typesetting. At the time the computer, in its power, was a quantum leap ahead of its counterpart of the year before. Even so the applications to which it was to be put would stretch the then state of the art. Now it is used for typesetting, business ledgers, payroll—complex and time consuming otherwise for the layman—letter writing and record keeping of mathematical and literary kinds. Despite its then vast memory—I thought it would last me 10 years—it ran out of space. I therefore bought another. The new one cost not much over £2,000. It stores three times as much and performs even more complex functions in a fraction of the time.

To me one of the most impressive statistics in Duncan Nichols' extremely encouraging half-year report on the first six months of the newly structured NHS is the figure shown for computerised GP practices. In 1989–90—around the time I bought my own computer—47 per cent. of practices were computerised. In 1991-92, when I bought my second computer, 75 per cent. were computerised. Imagine: fairly small country practices, not to mention large busy London practices, can quickly, cheaply and comprehensively log all their patients, recall specific groups for smear tests or immunisation and know that their records are accurate and all embracing.

They can dispense more knowledgeably both on price and indications. They have a long-stop, a failsafe, on side effects and contra-indications, for the computer can be programmed to bleep if a drug is contra-indicated for any specific patient. They can run appointments systems and generate relatively effortlessly information of a more demanding nature than in previous years and pass that information on to the FHSA. And more. And there will be more to come. All that ensures that time with patients is not eroded; that the quality of service is on the upgrade.

The Patient's Charter is a solid guarantee. My hope is that the need for it as a safeguard will turn out in practice to be ephemeral. My hope is that it will not be long before all its provisions—basic, desirable and eminently worth while though they are—will become a total commonplace. To the great credit of all who run the NHS, they are largely so already. The seven existing rights are deeply grafted on to long-standing NHS lore. The three new rights may soon represent no more than history to those charged with delivering first class health care. The first nine national standards are largely met. The local standards are much to be welcomed.

The National Health Service is truly blessed. It has reached a juncture in its distinguished and important history of service, a juncture at which it is now in desperate need of a change of direction, only to find that that essential element or tool which will free a massive organisation from becoming hidebound, is at hand. The technology so necessary to benefit the patient is cheap, powerful and far easier to use. It is getting massively better by the month. It will surely not be long before the benefits to the patient, already evident, and so skilfully structured and guaranteed through the 1990 health Act, will become even greater marvels to the public. Already patient satisfaction is widespread. That friendly screen on the doctor's receptionist's desk, in the hospital or on the GP's desk can spell reduced waiting times for operations, efficient appointments registers, less hanging about in surgery waiting rooms, accurate and comprehensive testing and immunisation programmes and a knowledge of safety in prescribing.

For those who deliver the service the advantages are again manifest and complementary in prescribing, appointments registers, screening programmes, patient records, immunisation programmes, financial accounting and in the handling of queues.

My sincere hope is that the work of the past few years—namely, the charter, the 1990 Act and the new GP contract, to mention but three—will be built upon. A new technology-based NHS has been born. There is one all-important beneficiary: the patient.

5.1 p.m.

Lord Carter

My Lords, like other noble Lords I wish to thank the noble Baroness, Lady Cumberlege, for enabling us to have a very useful debate. We have all agreed that the whole concept of a patient's rights is now firmly on the political agenda. That is a very welcome development. I congratulate the Government for pointing out at the beginning of The Patient's Charter that seven of the 10 rights are existing rights and that they have been in existence for some time. It is certainly important to underline and emphasise them. My noble friend Baroness Nicol pointed out that the Labour Party produced our Charter for Patients in April 1991 in which there are 20 patient's rights. I am glad to see that some of them are repeated in The Patient's Charter which the Government published in October last year. I am sure that we can all agree that there is much more joy in Gallup over one sinner who repenteth.

However, there are a number of areas in which we believe that the Government's document can definitely be improved. I believe that we can all agree that there should be a guarantee of admission if the first operation is cancelled. The patient should not have the double anguish of two cancellations before being given a guaranteed admission date. In passing, one can point out that the time set in The Patient's Charter for ambulance response is less tough than in the existing ORCON standards which require that half of all calls are met within eight minutes.

The limit of two years' waiting time from outpatient appointment to operation is of limited value unless there is a limit on the waiting time for the first outpatient appointment. I do not apologise for repeating a point which I made in the debate on Monday. I quote from The Sunday Times of last week: Statistics do not always reveal a true picture. There is evidence that some hospitals and health authorities are manipulating them. Just because there is a short waiting list for an operation does not mean there will be a short wait for an out-patient appointment. In some areas, hospitals are reducing recorded waiting times by delaying appointments with the consultants or opening waiting lists for the waiting list. The clock starts the day the consultant decides treatment is needed. For example, Southmead hospital"— which is in the 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'". The article continues: Similar tactics were reported last week at other hospitals". An article appeared in the Guardian on 3rd December which states: Evidence is emerging that patients who have been waiting two years or more with relatively minor conditions are being given priority over more pressing cases. A memorandum to senior doctors from a general manager of a hospital in North London says, 'This will mean that, in some instances, patients will need to be treated in preference to some patients who clinically are a little more urgent'". Perhaps I may repeat a specific question that I put to the Minister on Monday which could not be answered at the time: namely, does the department have any information on the length of pending lists and on the length of the waiting lists for the waiting list?

The biggest omission from The Patient's Charter is the right which is the very first of the Labour commitments: The right to choose in which hospital you are treated". There is no point in knowing which are the best hospitals for particular treatments if health managers or GP fund holders will not pay for the patient to go there. GPs, including my own, are now producing examples of health managers overriding doctors' medical judgments and refusing extra contract referrals.

Right No. 4 refers to the right, to be referred to a consultant, acceptable to you", and should be re-worded. It should read, the right: to be referred to a consultant, acceptable to you, if the internal market allows it". If the Government were to give patients the absolute right to go to the hospital of their choice, that would drive a coach and horses through the internal market.

I now turn to the detailed rights in The Patient's Charter. There has been a deal of confusion over the meaning of the word "rights". It is a point that I raised at Question Time on 5th November when I asked: My Lords, is the Minister aware that there is confusion over the use of the word 'rights' in the Patient's Charter? Are those rights enforceable at law? Will the patient receive compensation if the rights are not met? The reply from the noble Baroness was: My Lords, there are seven existing rights which are enforceable at law and through the additional channels that are being provided. From April of next year there will be three important new rights". [Official Report, 5/11/91; cols. 144–5.] The implication is that all 10 rights are enforceable at law. I was puzzled about that and I raised the subject again when I wound up from this Bench on the third day on the debate on the Loyal Address. I received an extremely helpful letter from the noble Baroness on 26th November. I am extremely grateful for that letter. It deals with the point of the actual enforceability of the rights in The Patient's Charter.

As regards the first and the third rights, referring to receiving health care on the basis of clinical need and receiving emergency medical care at any time, the noble Baroness said that they, are not generally enforceable through the courts at the suit of a particular patient". Therefore those rights are not enforceable at law. As regards Rights Nos. 2, 3 and 4; namely, the right to be registered with a GP; to receive emergency medical care and to be referred to a consultant, she said: They are enforceable by patients through the Family Health Services Authority complaints procedures, which can result in the withholding of amounts from the GPs remuneration". However, it is not spelt out what the patient's redress is in those circumstances.

I have already mentioned Right No. 4 referring to a consultant acceptable to the patient. I am not sure how that squares with the freedom which is supposed to come in the internal market. Above all, it is worth repeating that Right No. 1, to receive health care on the basis of clinical need, regardless of ability to pay is not, according to the Minister, enforceable at law. That is why the whole of the country is concerned about the creeping privatisation of the health service. As regards Rights Nos. 5 and 7—that is, to be given a clear explanation of any treatment proposed and, to choose whether or not you wish to take part in medical research"— the patient will have to seek redress through common law. The patient might have an action for damages in the courts.

Right No. 6, which is the right to access to health records, is the only one which is legally enforceable through a particular statute. The letter from the noble Baroness goes on to say, (Access to health records) derives from the specific statutory duty imposed by the Access to Health Record Act 1990. It is legally enforceable by the patient through the courts". The letter continues: The three new rights arc in the nature of duties to be imposed on health authorities. Anyone who feels they are being denied one of the Rights may write to the Chief Executive, Duncan Nichol, who will be responsible for investigating the matter and, if a right has been denied, for taking action to ensure that this is corrected". So, of the 10 rights which we were told were enforceable at law, only one—that is to say, access to health records—is clearly and directly enforceable through a specific statute. Four of the rights are not directly enforceable at all by the patient; two rely on litigation at common law and three involve access to the complaints' procedure, with final recourse to the health service ombudsman. However, the Consumers' Association has pointed out that it regrets that, on the one hand, no specific targets have been set for dealing with complaints, despite the promise in the Citizen's Charter White Paper, while on the other, deadlines exist for the time in which a consumer must make a complaint.

I can assure the Minister and the House that this analysis is not meant to be carping or unconstructive. I was concerned at the Minister's reply in the House last November regarding the enforceability of rights. I hope that the House will agree that it is important, if we are to understand the implications of the Patient's Charter, that the patients are fully aware of the exact meaning of the word "rights" and their enforceability.

I shall deal briefly with the point made by the noble Lord, Lord McColl, when he referred to the pattern of referral. In the debate on Monday I gave three specific examples relating to GP fundholders and the pattern of referrals and to the provision of hospitals in London, where the Government have stopped the reforms working. In my view that is because they are extremely anxious about the electoral consequences.

This has been a useful debate. I should like to repeat my thanks to the noble Baroness for giving us the chance to debate this important subject. We on these Benches look forward to the time, which will not now be long delayed, when a Labour government will be putting into operation the 20 patient's rights which are set out in our charter for patients.

5.10 p.m.

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

My Lords, the symphony of support for the Patient's Charter has been most agreeable. Perhaps the one or two discordant notes struck by Opposition speakers only served to emphasise how few of them there were. After the strictures thrown at this side of the House last week and widely reported in the press, I find it extraordinary that only three out of the 17 speakers in this debate came from the Labour Party.

I, too, take the opportunity to thank my noble friend Lady Cumberlege for bringing to our attention the publication of the Patient's Charter in October last year. That was a significant step forward in the Government's drive towards the better quality public services envisaged in the Citizen's Charter. The charter has been very well received by health service staff. The summary of the Patient's Charter, has, as has been said, gone to every household in the land. In England alone almost one million members of the public have asked for copies of the full charter. That is a measure of the importance of the charter and of the health service to the ordinary citizen.

Why was it necessary to publish a charter? I was asked that question by a number of noble Lords opposite. They went on to refer on the one hand to the Labour Party's charter of rights and on the other hand the noble Lord, Lord Perry of Walton, reminded us of his party's prescription for health, so clearly they thought it was necessary to issue some sort of charter.

What makes this patient's charter so relevant now is the fact that it is seen and must be seen as an important and specific part of the Citizen's Charter. I regret to say that it has also been proved necessary for the National Health Service to clarify an area where innocent and concerned members of the public have been made unnecessarily anxious and fearful as a result of the campaign of confusion and misinformation carried out by the party of the noble Lords opposite, who chose to target this hugely important area of public service for electioneering purposes. In case of any doubt that may have been sown by the contribution of the noble Lord, Lord Ennals, I can confirm that the first of the seven existing rights—which is to receive health care on the basis of clinical need, regardless of ability to pay—means exactly what it says.

I do not need to reiterate in detail the 10 rights and nine standards which have been referred to by most or all speakers this afternoon. However, perhaps I may dwell a little on the three new rights to be introduced in April of this year.

The first of these, the right to more information, is in the true spirit of the Citizen's Charter. Health authorities and individual hospitals will have to publish detailed information about services. This will include information on maximum waiting times for outpatient appointments and on admission for treatment. District health authorities will also have contact points—with named people—so that patients can consult them about the availability of services. That will be publicised locally. To help with the spread of information a national network of telephone helplines is being set up. Patients and staff will be able to dial a single, well-advertised number and be connected to their local information point for easy access to information on waiting times and self-help groups.

The second new right deals with admissions. It does not deal with all admissions because over half of the admissions to hospital—some 7 million in the past year—are immediate because they are accident, emergency or urgent admissions. When I say this to friends and colleagues from other countries, such as Denmark, they recognise that that means that half the admissions to our National Health Service hospitals are in fact a larger quantity of people than the entire population of their country. With regard to those other admissions—where planning takes place before the patient is admitted—again, the great majority of patients are admitted for treatment speedily—half within five weeks of being placed on a waiting list and 90 per cent. within a year. This afternoon we have heard some good news on waiting times from people involved in and responsible for the provision of services in the National Health Service. I congratulate them and thank them for all that they are doing in this important task. This is not a new problem. Waiting lists have existed in the National Health Service since its inception, but now for the first time all patients are to be given a guaranteed waiting time for admission. I reassure my noble friend Lord Holderness that two years is very much a maximum. This is just a starting point which we intend to improve as quickly as possible.

The third new right is to have any complaint about NHS services thoroughly investigated. This again is not new. But for the first time health authorities will have to publish details of the number of complaints received and how long they took to resolve. Much more publicity will be given to complaints procedures. Complainants will receive a prompt written reply signed by the general manager. If they are dissatisfied by the answer from the general manager about the administration of a National Health Service hospital they can take the complaint to the National Health Service Commissioner.

On the subject of redress, about which I was asked —particularly by the noble Lord, Lord Carter—patients who think that they are being denied a charter right can as I have said, write to the Chief Executive of the National Health Service who will investigate the matter and, if appropriate, ensure that corrective action is taken. Some of the basic charter rights are founded in statute or common law and can be individually enforced by the patient through the courts; for example, access to records, consent to treatment or research. Once the Chief Executive or any senior member of the National Health Service is alerted to a breach of a right, the matter will be dealt with immediately. Health authorities are expected to ensure that national and local charter standards are achieved as speedily as possible.

I have dealt to some extent—time does not permit greater detail—with the rights aspect of the Patient's Charter. With regard to standards, let me emphasise that the standards listed have all been generated from within the profession. They will be set at both national and local level. They are being set in areas which we know to be of particular concern to patients because we know that failure to provide information, and waiting around causes anxiety and frustration. However, they are and do represent merely a starting point. For instance, the first standard is, as has been quoted, respect for privacy, dignity, and religious and cultural beliefs. Having a room in which staff can speak privately to relatives; not being addressed by one's first name by people who do not know you, without agreement; providing interpretation services; proper choice of meals which do not contravene religious taboos, are all things which greatly add to the quality of a patient's life. We have very recently issued new guidance to ensure that hospitals and health services are conscious of the fact that all faiths should be considered in the context of spiritual support to patients.

The second standard is to ensure that everyone, including people with special needs, can use services. We want to make sure that all buildings are accessible for people who have to use wheelchairs, or who have sight problems, and that services heavily used by disabled people are not tucked away up two flights of stairs. My noble friend Lord Holderness asked for the specific inclusion of rehabilitation services in the charter. I can say to him that I believe that this is implicitly covered by the first right, which is to receive care on the basis of clinical need. But, as I have already said, this charter represents a starting point.

The fourth standard deals with emergency ambulances. My noble friend Lady Cumberlege gave a welcome pledge regarding the London Ambulance Service. I too know of its efforts to improve standards. Perhaps I may answer the specific question raised by the noble Lord, Lord Carter. The standards in the charter are identical to the current ORCON standards. The additional standard to which the noble Lord referred—50 per cent. within eight minutes—is included in the supplementary guidance on the Patient's Charter which we issued to the service authorities earlier this week.

The sixth standard is also important because it addresses one of the major causes of frustration for patients. I refer to waiting time in outpatient clinics. We are calling an end to the old system of block booking under which the patients arrived together and spent hours waiting because the overriding priority was ensuring that the consultant was fully occupied. The patient is paramount. The charter standard is that patients should have a specified appointment and receive a full explanation and apology if they are kept waiting for longer than 30 minutes. That is an important start in the right direction. Health authorities will be strongly encouraged to set additional local standards which reflect the views of patients on local priorities.

It is true that the charter is largely hospital related and deals with aspects where we have had evidence of concern from patients about matters that affect them when they are at their most vulnerable. That is why we took the hospital as a starting point. However, primary health care, including dentistry, is definitely on the agenda for future and further action. In this respect the points on information technology referred to by my noble friend Lord Harmsworth are also extremely important. New technology is also vital in measuring progress and performance and in ensuring that the efficiency indicator is as accurate as possible. That is essential if the vital task of monitoring is to be effective.

I am surprised that no noble Lord drew attention to page 22 of the charter document. It is headed "How you can help". Sometimes when underlining people's rights we forget that they also have responsibilities. A number of important issues are listed on that page. People are asked to remember that where appointments are made they should not be missed without some kind of warning. With around 40 million patient appointments each year this is a problem even if only a small proportion of patients do not let the hospital know if for some reason or other—or no reason at all —they cannot attend. People are also encouraged to remember that organs such as kidneys are urgently needed and to remember to carry their donor card. They are also reminded of the need for more blood donors and of the need for voluntary helpers, the example given being to help in hospital shops.

My noble friend Lady Brigstocke reminded us of the important role of women in medicine. As the National Health Service is the largest employer of women in this country and in fact in the whole of Europe we are and have been extremely concerned to ensure that the needs of women in employment are properly catered for. So far as concerns opportunities for women in the medical profession, we have been active in terms both of the working party on part-time training, which will review and develop the present arrangements for part-time appointments for senior registrars, and of the working group for women in surgical training to which my noble friend referred. It aims to encourage women actively pursuing a career in surgery by establishing regional advisers and providing information on the career progress of women trainees.

Monitoring will be vital to this exercise. The National Health Service Management Executive is fully committed to the successful implementation of the Patient's Charter. A team of senior health service managers has been appointed to help take forward work on the charter to ensure smooth implementation and to help hospitals and health authorities to work on their own initiatives designed to deliver high quality services to patients. This is a popular idea. Not only are the national standards and the local standards envisaged in the charter document for 1992 coming about, but many hospital units have voluntarily responded to the idea by issuing their own charters. This must prove that the Patient's Charter is an integral part of the Government's plans for an even better health service, a health service which puts the patient first, provides high quality services and offers first rate value for money, a health service that we can continue to be proud of well into the 21st century.

Lord Ennals

My Lords, before the noble Baroness sits down, she said in regard to the first right that elderly patients had that right, regardless of their ability to pay. How will health authorities ensure that right if they have cut down drastically on the number of beds available for continuing care?

Baroness Hooper

My Lords, I am grateful to the noble Lord for raising that because it is a point to which I meant to refer in my response. The noble Lord, Lord Ennals, and other noble Lords referred when giving an example of need to the BBC "Panorama" programme. That programme was a travesty. It used spurious research to reach distorted conclusions. In the words of the Guardian yesterday: Ministers have genuine grounds for complaint about the programme". Indeed, only about a quarter of health authorities provided information for the survey and only long stay beds were included. Methods of treatment and care are always being revised and are always changing. However, what is important to remember is that the National Health Service now treats 84 per cent. more elderly patients than it did in 1979 when the noble Lord, Lord Ennals, ended his term as Secretary of State. We are continuing to improve services for elderly patients.

5.28 p.m.

Baroness Cumberlege

My Lords, I thank all noble Lords who have taken part in the debate for the valuable contributions they have made in testing the boundaries and in developing new thinking on the charter. I understand that it is not the convention of the House for me to sum up fully—that is perhaps a mercy—and neither do I have the time. However, I should like to make one or two brief points.

Although I have some sympathy with what the noble Baroness, Lady Nicol, said—I should like to go through some of the points with her—I cannot agree with her about the leadership of the National Health Service. She expressed concern that all the new people being appointed to the boards of the authorities and trusts were coming from industry and commerce. That is not strictly true. My noble friends Lord Jenkin of Roding and Lady Eccles of Moulton, both chairmen of hospitals or of potential trusts, have illustrated in the debate the kind of dynamic leadership which we need in the health service and which is already bringing results.

I should also like to share in the sympathies expressed by many speakers, including the noble Lords, Lord Ennals and Lord Perry of Walton, and my noble friends Lord Mancroft, Lady Seccombe, Lady Faithfull and Lady Carnegy of Lour. They all stressed that the charter is only the first step. I absolutely agree with that. As the noble Lord, Lord Ennals, said, it is essential that we get into the community care side and also into primary care. I was disappointed that time did not allow my noble friend Lady Eccles to explore some of the primary care charter standards which are being introduced in Ealing, and I know that in the Trent region there is much development work being undertaken on this.

Finally, I should like to thank my noble friend the Minister for her very thoughtful, courteous and full reply. I shall read Hansard with great interest. I have absolutely no doubt that in her position of authority she will ensure that the charter is monitored and delivered. However, I should like to stress that it is for the people of this country to deliver the charter. As the noble Lord, Lord Carter, and other noble Lords have said, we must ensure that the standards are widely published so that we can all make sure that the charter is monitored and delivered. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.