National Health Service

HL Deb 12 January 1994 vol 551 cc123-35

3.8 p.m.

Lord McColl of Dulwich rose to call attention to the case for giving the public accurate information about the National Health Service; and to move for Papers.

The noble Lord said: My Lords, noble Lords will have no difficulty in agreeing with the need for accurate information to be given about the National Health Service, but some of your Lordships may not have appreciated how much distress and anguish are caused by the relentless stream of false propaganda about how the National Health Service is sinking, collapsing, in crisis, and even reports about unnecessary deaths resulting either from lack of funds or from too much or too little management, and so on.

Some would argue that that is all good knock-about political fun, but it is not fun for those who are frail, elderly and may be in need of medical care in the future. Those vulnerable people are frightened unnecessarily by the constant shroud waving which has gone on since the beginning of the National Health Service but which seems to be getting worse.

Needless anguish may be caused by a Parliamentary Question. For instance, a sensational headline in a newspaper was repeated in a Parliamentary Question. It included the unfounded opinion that more than 1,000 new-born babies die each year due to lack of basic equipment and inadequate staffing in the NHS. There seem to be several things wrong with that Question in view of the statement in the Companion to the Standing Orders and Guide to the Proceedings of the House of Lords at page 51 that, It is considered undesirable to incorporate statements of opinion … in the text of Questions". Secondly, there was no evidence that specific deaths could have been prevented. Thirdly, there was no evidence of lack of resources as the cause of death.

A distinguished paediatrician explained the origin of the allegation. In any given year there is a total of about 4,000 such deaths. That, incidentally, is the lowest ever for this country and among the lowest in the world. A report suggested that if a certain treatment regime were followed, the mortality might be reduced by 25 per cent., thus preventing 1,000 deaths. However, that was a guess. Imagine the anguish caused to several thousand relatives when they heard that.

Several politicians have made repeated statements about the crisis in the NHS and how another crisis will occur in four months' time. They confuse prophecy with politics. Those moans have been wailing on for 40 years; and whereas many of us get used to that form of propaganda it constantly upsets the frail, the elderly and the sick who often have difficulty in distinguishing fact from fiction.

An article appeared in one of the Sunday newspapers to the effect that patients were dying while on waiting lists. When challenged, the writer—to give him credit, he admitted it—said that his article had more to do with polemics than facts.

The public are constantly being given inaccurate information by politicians who complain about the long waiting lists. But the number of people on the waiting list is totally irrelevant. What matters is how long they actually wait for their operations. The fact is that half the admissions to hospital are immediate because they are emergencies. From the waiting list, half are admitted within five weeks and 75 per cent. are admitted within three months. Only 2 per cent. wait more than a year.

We have constant moaning that the number on the waiting list now is greater than it was 16 years ago. But at that time day cases were not listed on waiting lists, and neither were patients who had been given a date for their operation. In fact, if one gave dates to all the million people on the waiting list today, there would not be a waiting list. Some patients do not want their operation done for six months or even a year. Waiting lists can also be quite unnecessarily inflated with the names of patients who need to come in regularly every six months. The moment that they are discharged from hospital their name is put back on the list.

The fact is that 3.5 million patients were operated on last year. That clearly indicates that the million patients on the waiting list could be operated on within four months if we started from scratch. So why all the fuss? Why all the fuss about the number of patients on the list? It is the waiting time that matters. If we increase the number of surgeons fivefold the total number of people on the list would actually increase. Therefore, for all those reasons, would your Lordships kindly consider the possibility in future of not talking about the number of people on waiting lists because it is totally irrelevant?

In order to achieve success in preventive medicine it is essential to supply the public with accurate information. Nowhere is that more important than in the field of vaccination of children. In the United States children are not allowed to go to school until they have been vaccinated. In this country we rely on persuasion, which entails a supply of accurate and persuasive information to parents. Some years ago a great number of those who worked in the National Health Service made a supreme effort and managed to persuade a larger than ever number of parents to have their children vaccinated against a particularly unpleasant form of disease. At that time a number of politicians made a few speeches about the danger of vaccination, with the best of intentions. But there followed a fall in the vaccine uptake from 80 per cent. to 30 per cent. which caused a fivefold increase in the incidence of that disease.

Lord Ashley of Stoke

My Lords, I am much obliged to the noble Lord for giving way. I was the Member of Parliament who led that campaign to seek compensation for children who were damaged by the vaccines. At the time I made it clear that I supported the vaccination programme but that the responsibility lay with the Government to pay compensation to those families which were damaged—a tiny minority of cases. The responsibility lay with the Government, not with the mothers and the families with whom I worked who were shattered by those few cases. The campaigners were right to seek that compensation at that time. The fault lay with the Government.

Lord McColl of Dulwich

My Lords, I thank the noble Lord for that intervention. I did not mention names. I was stating the facts. The fact of the matter is that because of that campaign the vaccination rate fell from 80 per cent. to 30 per cent. That resulted in a fivefold increase in the incidence of that disease. That is a fact. I did not seek to apportion blame. We all make mistakes. I do not say that the campaign that was launched at that time was a mistake. I simply state the facts. It underlines the importance of politicians and all in public life being careful before they embark on campaigns or make pronouncements because they can so easily harm a large number of patients. Accurate information is essential.

However, on a more optimistic note, the current levels of immunisation are at an all time high: the figures are 95 per cent. for diphtheria, tetanus and polio; 93 per cent. for measles, mumps and rubella; and 92 per cent. for whooping cough. Great credit goes to general practitioners, clinic doctors and nurses. What is the secret of their success? It is in supplying accurate information which manages to persuade the parents. Again, over 85 per cent. of general practitioners reached the higher rate for cervical cytology in 1992–93, which means an increase of 8 per cent. on the previous year. The perinatal mortality rate in 1992–93 was at an all time low of 7.9 per 1,000 live births.

In referring to preventive medicine, and to underline the point that I do not attack any particular party, in a recent debate on the banning of smoking on short runs on the southern region of British Rail, it was extraordinary to hear statements in this House which simply were not true. They were actually trying to deny the work of that distinguished scientist, Sir Richard Doll, Fellow of the Royal Society, who established beyond all doubt that smoking increases the risk of death from cancer of the lung in those who smoked. In that debate some would not even accept that when some asthmatics enter a smoke-filled environment an attack of asthma may be induced. Those who deny such facts hide behind a smokescreen of such slogans as, "The freedom of the individual", or, "These are all matters of opinion only". Such slogans are no substitute for accurate information.

Lord Stoddart of Swinton

My Lords, will the noble Lord give way? I took part in that debate and I certainly did not try to mislead people; nor did I suggest that asthmatics were not affected when they went into smoke-filled rooms. However, if the noble Lord seeks correct information perhaps I may ask him also to see to it that the medical profession and the Government also give correct information in relation to smoking. Is the noble Lord aware that I have just received a reply from Her Majesty's Government which shows that people who die from smoking-related diseases or people who smoke—

Lord Elton

Order!

Lord Stoddart of Swinton

If the noble Lord will allow me to proceed, I shall do so.

Lord Elton

My Lords, will the noble Lord give way? This is a timed debate in which time is of the essence. It is not acceptable for noble Lords to interject speeches of their own into speeches of people who have their names on the Order Paper.

Lord Stoddart of Swinton

My Lords, under those circumstances I shall sit down, but I hope that accurate information will be given on both sides.

Lord McColl of Dulwich

My Lords, I welcome all the interventions. In university circles, where I work, I do not often have the opportunity of doing remedial teaching! When some choirs have a choir practice, they have a custom that whenever members sing a wrong note they put up their hands, so we may have more interventions to come.

A politician said a few years ago that those who needed artificial limbs or wheelchairs would be means-tested and deprived of that essential equipment, but that proposition was not so. Imagine the distress it might have caused to disabled people. It is quite astonishing that MPs will stand up in public and make that kind of statement with no attempt to verify it. A simple phone call to the Special Health Authority for Disablement Services, chaired by my noble friend Lord Holderness, would have put the matter right and the distress would have been avoided. I should declare an interest in this because I was vice-chairman of that authority. During its life, we managed to produce reliable and up-to-date information about the supply of essential aids for disabled people. However, since the work of the authority came to an end a few years ago and the service was diffused throughout the country, it has become increasingly difficult to obtain this information. My noble friend Lord Holderness and I would be grateful to the Minister if she can assure us that a better and quicker form of data supply will soon be available.

Another politician attacked the Government for closing 10 per cent. of the beds in the previous 10 years, but he must have known that 10 per cent. of beds had been closed in the 10 years previous to that and 10 per cent in the 10 years before that. Every year since 1964, about 7,000 beds have been taken out of service, irrespective of which government have been in power. Beds are not always the safest places; we encourage patients to leave them as soon as they can. Thirty years ago when you had your gall bladder out, you sometimes had to stay in for three weeks. Now patients are hardly in for 18 hours. It is safer to be at home.

A candidate in the last election circulated a pamphlet saying that the local hospital was being sold off and that local people would soon need a credit card just to get in. At much the same time, we saw a television programme showing a little girl crying with ear ache because she had to wait nine months for an operation; but the truth is that children with ear ache need antibiotics today, not an operation in the future, and there is no waiting list for antibiotics. There were constant slogans that trust hospitals had left the NHS and, again, that was patently untrue. All this unsavoury propaganda about the NHS not only frightens patients, but it demeans politicians and brings into disrepute the world of politics as a whole. Of course, the Opposition have a job to oppose and to be constructive, but not to be involved in that kind of propaganda.

We are plagued by a series of half-truths such as, "The UK is fourth from bottom of the 21 OECD nations in our spending on health". But that omits the fact that the UK Government put into health the same proportion of the gross domestic product as do the governments of the United States, Denmark, Switzerland, Australia and Japan. Are these critics wanting the British Government to put into the health service more resources than those other governments, or are they hinting that what they really want is for the UK to follow the example of those other countries and increase the amount of private practice? Certainly some critics have given the impression in private—

Baroness Jay of Paddington

My Lords, there is a question which I must ask. Will the noble Lord, Lord McColl, confirm that we spend only three-quarters of the average EC budget on health care?

Lord McColl of Dulwich

My Lords, I thank the noble Baroness for that intervention. I am talking about what the Government put in, which is about 5.2 per cent.—the same as the American, Danish, Australian, Swiss and Japanese Governments. That is the point. The difference is made up by the private sector. We put in about 1 per cent., the Americans put in 8 or 9 per cent. Incidentally, 30 million or 40 million Americans are not properly covered. The question is: do people want more in the private sector? I do not know.

I am often faced with patients who are about to leave hospital after an operation and who say how much they have appreciated the service they received from everyone there. Then they go on to say: "But what a tragedy it is that the NHS is collapsing everywhere else". When I express some surprise, they explain that they repeatedly hear prominent people on television and at Westminster saying that the NHS is in crisis, that waiting lists are out of control, that people are dying on waiting lists and the Government spend less than any other nation, and so on. Those patients simply do not understand why the politicians so often make statements which simply are not true and which cause a great deal of confusion and anxiety. They ask me how it is that these people, whom they assume are intelligent, can keep on making such statements.

I think that the mechanism is fascinating and I have studied it in some detail. Those politicians put themselves at a disadvantage in a number of ways. First, they seem to have a congenital inability to listen. They will not listen. Secondly, they attack with slogans rather than reasoned arguments. As your Lordships know, "slogan" is a Gaelic word meaning "a war cry", which is, of course, perfectly appropriate in battle where rational arguments in the heat of the moment may not necessarily be appropriate. Although the slogan may be completely untrue, these people say it repeatedly and eventually they convince themselves of its truth. That is why I am sure that the principle is correct that no one should be called a liar, because they actually believe what they are saying.

A slogan may simply be part of people's imagination, creative thinking or something that has been gleaned from the newspapers, or just from common gossip. A slogan is often accompanied by a claim to have a monopoly on kindness, caring and rectitude. Those who really have such an attitude do not need to go around telling everyone else about it, it is obvious. Then, having delivered the slogan, the blind comes down, as it were, and a glazed look comes over their faces which indicates again that they are not listening. So the cycle continues.

Those who work in the National Health Service are at pains to try to make sure that patients are fully apprised of the treatments which are available and the ones that are recommended so that patients can play a significant role in the decision-making process. This involves them giving the patient accurate information about the natural history of the disease itself, the complications that may occur, the length of time off work, and yet at the same time not causing them unnecessary worry. Where appropriate, counselling is provided which underlines not only the need to give patients accurate information but also to make sure that they are given the opportunity to be listened to. Patients do not want slogans thrown at them. They want to be listened to. That is a very important part of the art of the caring professions.

The Patient's Charter informs the public about the specific goals of the NHS. For instance, patients are advised that it is not expected for them to wait more than 30 minutes at a clinic. It also provides information about how patients can give their views on the service. We used to call it a complaints document, but now we say, "This is your service. Tell us how we can help to improve it". Laying down standards like that is certainly the correct policy and it has improved the service. But this kind of openness runs a risk, because it provides the depressive bands of moaners with the opportunity to take even more delight in picking on every possible item that they can to denigrate the NHS. Nevertheless, this policy of honesty and openness about the aims of the NHS has to be right.

The noble Baroness, Lady Hollis, kindly told me of some incorrect information which was given to a colleague of mine in East Anglia. He was told that he had to stop operating on patients from a certain district because of the difficulties with a contract. Being a surgeon, of course, he took absolutely no notice of that incorrect information and went on operating—we surgeons get withdrawal symptoms if we cannot operate. It took him many weeks to straighten out that particular mistake. But it has to be said that while we have people around, mistakes will continue to be made.

My plea today is that those in public life will make a supreme effort to stop making the same mistake time after time—the mistake of issuing false propaganda. We need to concentrate on producing accurate information. I beg to move for Papers.

3.32 p.m.

Lord Ennals

My Lords, while I was delighted to see this Motion on the Order Paper, I must admit to some degree of naivety; I had not quite realised that it was to be moved in the partisan way that it was moved. I had assumed that when the noble Lord, Lord McColl, asked for accurate information, he was also including "more information". Certainly, most of what I want to say deals with having more information. Of course information should be accurate. But if we are simply arguing about whether it is accurate or not, then matters are often very difficult. All sorts of criteria apply. (I am so sorry, I am addressing the noble Lord. I should be grateful if he would try to listen to me.) Setting criteria for what is accurate and what is not accurate is very difficult.

I shall certainly not argue with the noble Lord about whether the National Health Service is in a state of real difficulties, or in crisis. I do not believe that that is the subject of the debate. As I said, in following the noble Lord I shall deal with the question of giving more information, because I believe that the public are often woefully ill-informed—I do not just mean "misinformed", but "ill-informed"—about the health service, what it can do for them and how they should best act in order to minimise the dangers that they will get into in the hands of doctors and nurses and in the health service generally.

I begin by talking about mental health, a field in which I have a very great interest. The National Health Service, and those who work with it, has a responsibility to provide much more information to patient who may be suffering mental distress and who need the maximum amount of information about what is available to them and how they should operate. The families need to know which services are available in order that patients can take the maximum responsibility for the handling of their own condition. Mental health practitioners should be able to provide clear and full information on proposed treatments and care in a form that is relevant and understandable to the service user. They also need to know about the nature of medication which may be on offer.

I give a personal experience. I got "stuck" for 17 years on valium. I never took more than the prescribed dosage; and no doctor ever said to me that there was a danger that I would become addicted to it. The problems of breaking an addiction can be very great and very painful. I shall not go into the subject but no one ever told me about that. Many other patients may be in the same position—though the situation may be a little better today. It was at the stage when, as chairman of MIND, I was involved in launching a campaign for more information about this matter that I realised that I had to get off the habit myself before I could go around lecturing other people. So I want to see much more information available to the public and to the families of those suffering mental distress.

I should declare a second interest: one is as the president of MIND; but I am also joint president, with the noble Lord, Lord Colwyn, of the all party group on alternative and complementary medicines. I believe that much more information is necessary for the public about what is available in the field of alternative medicines. The nation has got itself far too stuck on "a pill for every ill". And too many doctors feel that it is not advice that they must give, but a prescription. People will go home with several items to take. That can be very expensive. Of course, it can be very profitable for the pharmaceutical industry, but it is not necessarily the best thing.

I asked a relative of mine whose father had died what she thought he had died of. I thought it was cancer. She said, "No, it wasn't. He died of his medication'. I believe that all too often people die of what is prescribed for them by their doctors—prescribed, I am sure, with the best will in the world. There is much that alternative and complementary medicine can offer, and it ought to be made more available to the public.

It is very interesting that the public are becoming much more accepting of alternative and complementary medicines—and not only the public. I saw from a recent report in the Nursing Times that 96 per cent. of nurses are very, or fairly, interested in complementary therapies; 78 per cent. had used or recommended the use of complementary treatments; over 55 per cent. had purchased essential oils or vitamin supplements, and so on. I believe that considerable progress is now being made on ways in which we can integrate complementary and alternative therapies within the National Health Service. I want the National Health Service and those who direct it (Ministers in particular) to see that such therapies are an important part of treatment, and to help to ensure that people understand the treatments more than they do at the present time.

Having got those two special interests off my back, let me look at what I believe to be the central theme of this debate. One matter that greatly concerns me—and which, I have no doubt, will concern the noble Lord, Lord Jenkin of Roding—is that the gap between the most healthy and the least healthy in our society is getting wider. The noble Lord knew that when I was Secretary of State I established, under Sir Douglas Black, the Black Report, to look at reasons why that was the case; namely, to what extent ill health was due to social factors such as housing, homelessness and unemployment, and also to what extent levels of income affected the health of the nation. Ten years after the report was published—it would not have seen the light of day at all if we had depended upon the noble Lord—

Lord Jenkin of Roding

My Lords, perhaps the noble Lord would be so kind as to give way. Let me scotch that once and for all. A copy of that report was sent to every newspaper, every medical journal and every periodical paper throughout the length and breadth of the land. I am tired of listening to accusations that I suppressed it.

Lord Ennals

My Lords, I have not said that.

A noble Lord

Yes, you did.

Lord Ennals

My Lords, I did not. Maybe the noble Lord thought that that was what I was about to say. He released it on 3rd August, which is a day when, on the whole, people are on holiday. He did not go to great trouble to make it available. Of course he did not suppress it. I was very glad that Sir Douglas and those who produced the report got together very recently and published, in the British Medical Journal of 5th December, a revision which showed that the gap has become wider. It is important that that should be understood.

I am also concerned at the extent to which the reorganised National Health Service has provided either more or less information for the public. As everyone would agree, access to information about the state of the National Health Service is absolutely vital if the service is to be accountable to patients and taxpayers. Through commercialisation and government inaction, in my view public access to information has been curtailed. The chief obstacle to public access to information about the NHS is the internal market. If providers release too much information, their competitors may gain an advantage and beat them in the race for contracts. In the market place, public access to information takes second place to commercial considerations.

I am very glad that the noble Lord, Lord Jenkin of Roding, for whom I have great respect, is in the Chamber because this point relates to trusts. The NHS trusts which were created in the 1990 reforms are only obliged to hold one public meeting a year. I hope that the noble Lord will intervene again or tell me later when he speaks that his trust does much more than that.

I believe that the public ought to have open access to the National Health Service. There are now structures of management which exclude representatives of local authorities and also ordinary people. Management is much more of a management team than it ever was. Perhaps management is better, though I have not seen signs of it. Certainly the amount of information that comes out is less. Trusts are meant to be part of the National Health Service: a public service which is publicly financed and publicly accountable. The public have a right to know the decisions that are made on their behalf.

Under the 1990 National Health Service and Community Care Act the Secretary of State has powers to make all trust board meetings open to the public. I hope that when the Minister comes to reply she will tell us whether she will use those powers. It is very unfortunate that those who take decisions about the National Health Service are now able to do so in a hole in a corner way. I shall give way again if the noble Lord feels that I am being unfair to him. There is a lack of information.

Another effect of the internal market is that health authorities have become purchasers rather than providers of care. They no longer have a direct interest in some aspects of service provision and do not bother to collect data. As a result, the degree of information available to the Department of Health and parliamentarians, and thus to the press and the public, has fallen drastically. Any study that we make of Written Answers to Questions shows that more and more often Ministers say, "This information is not centrally available" and "No, we do not know how many ambulances there are in England. No, we do not know the number of psychiatric patients being treated in the private sector. No, we do not know the number of community nurses in Wales."

I want the Minister to assure me that in the newly organised National Health Service she will make the maximum effort to ensure that information is not restricted and that it becomes more open so that the public get their entitlement to know.

3.45 p.m.

Lord Kilmarnock

My Lords, I believe that the call made by the noble Lord, Lord McColl, for more accurate information is indeed timely, if only to counter the constant stream of accusations against the current reforms as a betrayal of the basic principles of the National Health Service. As he said, doom merchants have been announcing it for many years, but doom has not come yet and need never come, if we look at our health arrangements openly and honestly and decide rationally how they can be sustained and improved.

With some visiting Americans I was recently at a seminar in which a discussion took place on the proposed Clinton reforms. It is evident that, although the main burden of finance will lie, as it does now, on employers, in other respects the Clinton Administration is seeking to replicate some of the strengths of the National Health Service and in particular its success as a large monopsony purchaser in keeping down costs. The main aim of the proposed regional purchasing boards in the States, as I understand it, is to emulate that aspect of the National Health Service.

If others envy our basic structure, it is clearly worth preserving. So it cannot be repeated too often that it is nonsense to talk about "creeping privatisation" undermining the whole principle of the National Health Service. Contracts are drawn and services are subcontracted within the envelope of public finance. In my view there is neither public support nor political will for a fundamental change in our tax-based financing arrangements. But if a backlog of operations can be cleared by contract with the private sector, or new facilities can be brought on stream more speedily with the aid of private sector finance, those are matters of congratulation and not recrimination. Good care should not founder on the rocks of ideology.

Much of the shroud-waving to which the noble Lord referred is, as he said, a kind of shadow-boxing or phoney war. The record of the two main parties on the National Health Service is remarkably even. It is not good form to quote oneself, but perhaps I may extract a few facts from my speech of 9th June last in a debate introduced by the noble Baroness, Lady Jay. In the period 1974 to 1979, under a Labour government, government expenditure on health as a percentage of GDP was just under 5 per cent. Under Tory governments from 1980 to 1990 it was just over 5 per cent. I believe that the noble Lord said that it was just over 5 per cent. now. Likewise, central government expenditure on health as a percentage of total government expenditure has varied very little over the whole period from 1974 to 1990. The differences are not large but marginally the Conservatives have spent slightly more.

Sadly, it would be naive to expect, on the basis of that record, a willingness to lay down arms and depoliticise the health service. The Labour Party sees it as its strong policy suit, and will continue to attack the reforms, particularly in London, though it is salutary to remember that it was the Labour Party which put in place RAWP (the Resource Allocation Working Party), with the precise object of equalising resources across the country.

No magical transformation in the NHS is going to come about after a change of government, if and when that comes. Public expenditure currently stands at 45 per cent., which is not all that far short of what it was in 1976 when the IMF moved in. Moreover, though one might be forgiven for thinking otherwise, when health buffs are in full cry, there are other departments of state than the Department of Health and other rather pressing claims on public resources. A government of any party, or a coalition of parties, will be faced with exactly the same constraints as the present Government, indeed' possibly greater constraints if they are committed to raising expenditure in other areas.

Therefore, any sensible government will have to look very carefully at costs and outcomes. It is impossible to pretend any longer that all procedures can be justified without limit at the expense of less surgically and clinically glamorous requirements. The Government's reforms have brought such ethical dilemmas out of the woodwork, where they always existed, so that we can discuss them openly. It is high time too.

I should like to make a couple of suggestions in connection with the use of scarce resources and outcomes. The first concerns management, a point which was mentioned by the noble Lord, Lord Ennals. There is a very good case to be made that the NHS was and possibly still is under-managed. But the very idea of management is anathema in certain circles. The notion is still widespread that the National Health Service is a kind of huge, benign and cuddly monster, whose inner workings it is rude, if not sacrilegious, to probe. I do not share that view. I believe that the Government have failed to get across to the general public the need for tighter management. They are in danger of losing the debate, fanned by the press, in which increased expenditure on senior management is contrasted unfavourably with a relative decline in expenditure on clinicians.

In answer to a Parliamentary Question that I recently put down, the noble Baroness, Lady Cumberlege, told me that general and senior managers now make up 2 per cent. of the total workforce and that their salaries represent only 1.3 per cent. of the total budget. That sounds pretty modest; indeed, low administrative costs are one of the great arguments in favour of a tax-based system. But in a sceptical climate of public opinion I would like to see general administrative costs, and senior management as a proportion of these, more clearly defined and openly available. As the noble Lord, Lord Ennals, said, Parliamentary Questions on these matters tend to be stonewalled with the classic formulae that the information is not available centrally or can be provided only at a disproportionate cost.

That may well be a legitimate and natural result of decentralisation. Even so, Parliament and the public have a right to that information because some reports that management is growing out of control have caused widespread anxieties. Is there any system for information gathering in this field? Has arty work been undertaken by the Director of Research and Development in this area? Some of your Lordships will recall that that post was set up as a result of a recommendation of a committee of this House chaired by the noble Lord, Lord Nelson of Stafford. In its first report the new Research and Development Division acknowledged the lack of and need for operational research; that is, research into the organisation and management of health services. Has that been followed up and, if so, with what results?

The second area that I want to touch on briefly is general practice. The general practitioner is at the heart of the reforms. Through a historical accident we have this unique system of family doctors as the first and often the only port of call in our health system. Only 10 per cent. of GP consultations lead to referral to specialists. That is a very important statistic. While the United States is desperately trying to boost its relatively low percentage of general physicians entering the profession we actually have them en poste: on the ground.

The whole thrust of the reforms is to strengthen this end of the healthcare spectrum. There are enormous opportunities here to improve preventive medicine and primary care and to reduce pressure on hospitals. Health cannot be measured by the number of beds. Beds are a measure of ill health, which simply puts in a slightly different way what was said by the noble Lord, Lord McColl.

However, we have to face the fact that hospitals, especially ancient ones such as Bart's, are the temples of a secular age. And there is, and will continue to be, great resistance to their closure or change of function unless the Government are able to project more successfully their own vision of a new balance between hospitals on the one side and primary and community care on the other. I doubt that the rationale of this change of emphasis has got through to patients and consumers. And many GPs—by no means all but still a lot—remain lukewarm.

I was very much against the BMA's original kneejerk opposition to the reforms and I hope that it has adopted a more sensible attitude. I believe that it has. But that said, it is crucial for the Government to get general practitioners fully on board, just as they had to get the teachers back on board in education. This is partly a question of finance. Obviously there needs to be bridging finance to bring on stream improved GP premises and a wider range of services, including special information, before anything comes in from the closure and sale of old sites, especially in London. What funds are available for that purpose, and is that part of the Government's strategy on course?

While the United States is worried that its expenditure on health, which stands at about 14 per cent. of GDP and is heading for 17.5 per cent. by the end of the century, is far too high, some may feel that our figure of only 6 per cent. of GDP is too low. They believe that it should be increased to, say, 7 or 8 per cent. If so, there are two options. The first is for political parties which are of that opinion to go to the country proposing a tax increase for that purpose, as the Liberal Democrats did for education at the last election. Or they could propose even a hypothecated tax so that people can see the true cost of the service and decide whether they want to spend more or less on it. That proposal was made by my noble friend Lord Owen. The other route is to maintain public expenditure on health at about its present level and to introduce more private-sector finance and allow the private sector itself to grow somewhat, thus slightly changing the present public-private mix. I believe that political parties in a democracy should be open about these options and let the people decide.

But whatever route, or perhaps mixture of routes, is chosen it is nonsense—and dishonest nonsense at that—to suggest that we are on the brink of some kind of disaster in the field of health. We have a unique and successful structure of healthcare in this country with very good potential for development. I believe that that will equip us well to deal with the needs of our population in the decades to come.