National Health Service

HL Deb 12 January 1994 vol 551 cc145-71

4.34 p.m.

Debate resumed.

Lord Jenkin of Roding

My Lords, I begin by expressing my gratitude to my noble friend Lord McColl of Dulwich for launching this debate and, indeed, for delivering a most effective and interesting speech. He shot a number of arrows into the air. We were amazed by the unerring accuracy with which they found their targets on the Opposition Benches.

My noble friend looked at the picture from a national' point of view. I should like to look at the local scene and what it is like trying to run an NHS trust against the barrage of misinformation which seems to be so prevalent at present.

I have talked about Forest Healthcare Trust before in the House. I shall be brief in its description. We are a whole district trust. We are under considerable pressure. We have the largest and busiest accident and emergency department in London. Capitation has resulted in the trust losing some £7 million over three years. We are under financial pressure. Much of our estate is well-stricken in years and, although redevelopment is under way, we still have many old buildings. But our clinicians practise very high quality medicine, with a great deal of innovation. We have training and consultant posts which are much sought after. We have an excellent reputation for nurse training and, despite having made savings of over 8 per cent.—nearly £9 million—over the past two years, we are now treating at no extra cost 5 per cent. more patients than we contracted for. I can tell my noble friend that we shall meet our financial targets at the end of the year; and I can tell the noble Lord, Lord Ennals, that we do not stick to the one public meeting per year. We have more. On Wednesday last I had a two-and-a-half hour meeting with our entire community health council which I believe was recognised to be an extremely valuable occasion. And yet we work under a veritable deluge of knocking copy. Of course, we do not get everything right. We always try to acknowledge our shortcomings frankly and spell out what we are doing to put them right.

Where does all the copy come from? I can detect four main sources. I start with what I would call the professional knockers who knock the NHS industry. In London there is no doubt that the king of the knockers is the so-called London Health Emergency, a self-appointed group whose sole aim in life seems to be to discredit the system and arouse the maximum anxiety among patients.

Time does not allow me to cite more than one example, but last September a local newspaper carried the headline: "Profits before patients". It said that the Forest Healthcare Trust had been slammed for putting profits before patients: to end its first year with a cash surplus … The Trust has clearly decided to pursue profits, regardless of the consequences for local people waiting for treatment". They are still living in the pre-election period. Somehow it is thought that we are part of the private sector and trying to put money into our own pockets. The matter was answered in the press. But the whole thrust of the article is to try to discredit the system and arouse alarm and despondency. Time does not allow me to give other examples but LHE is by no means the only professional knocker, although it is without doubt the most disreputable.

Source number two is the moles. Every public sector institution has them. The noble Lord, Lord Ennals, will remember that classic leak about child benefit. When I followed the noble Lord at the department, we detected a mole and quietly moved him to another department. The Guardian then accused us of having somehow blocked its source of information. 'That was very satisfactory.

Forest Healthcare suffers from a series of quite clever leaks designed to maximise distress and alarm. Mostly, although not always, there is a grain of truth in what is said and something is happening which lends credibility to the leak. But the essence of the mole's activity and the way in which we suffer from it is the distortion, exaggeration and often invention of: corroborative detail to add verisimilitude to an otherwise bald and unconvincing narrative". A good example of that is what we came to call the ants in the delivery room. What started as a report that two pharaoh ants had been seen on a piece of monitoring equipment in the maternity department ended up as a story of the husband brushing swarms of ants off the mother's legs while she was giving birth. Happily, we obtained a signed statement from the mother to say that the story had been grossly exaggerated. But the mole had achieved his purpose. The headlines were there. As we always say, the lie is halfway round the world before the truth has got its boots on. With a weekly local press, it took a week to catch up with the story.

An even worse case, which had quite serious consequences, was the headline: Pregnant woman catches Hepatitis during Caesarean surgery". There was a long, extremely circumstantial article, almost all of which was substantially untrue. We had had a case of an ex-patient who had been identified as having Hepatitis B but at the time all the evidence pointed to Whipps Cross not being the source. Patients were telling their GPs that under no circumstances would they go anywhere near Whipps Cross because obviously it was riddled with Hepatitis B.

The sequel to that incident—and it was only one of many —was that we arranged for the editor to come to talk to us, together with the journalist responsible for the story. They admitted that they had done it under huge pressure of time, that they had not properly checked out the story and that it was all wrong. The following week a very handsome apology was printed on the front page of the paper. However, I am afraid there is too much of that.

The latter brings me to source number three, and perhaps one of the causes. I refer to the effect that the recession has had on the economics of some small local newspapers. They have reduced revenues, cut staff and the staff tend to be much more desk-bound. They engage in telephone journalism and rely more and more on tip-offs and readers' letters, often anonymous. That sort of compilation of news is a heaven-sent opportunity for anonymous scandalmongers. So a leak about changed rosters for health visitors becomes a wholesale sacking of community midwives; an anonymous grouse by a disgruntled junior doctor becomes a full-scale journalistic assault on the accident and emergency department; and a perfectly true story about 38 planned redundancies (virtually all of them non-clinical) becomes a horror story about the sacking of 38 doctors, including consultants. So it goes on. It is extremely difficult to keep up with such matters. The task of seeking to ascertain the truth and then dealing with the corrections is an enormous drain on management time and effort. Moreover, it does not actually help the treatment of patients one iota.

I turn now to source number four, which is very rare. It is what one might call the Department of Health cock-up, if that is not politically incorrect these days. The worst case of this was the infamous table of surgical deaths that some noble Lords will remember which was published last April and widely publicised in the national press. It showed our hospital to be the second worst in the country. Our consultants simply said that that was incredible. We made quite detailed inquiries but not before the local press had published a horror story under the headline "A Dying Shame"—come to Whipps Cross to die.

What had happened was that the NHS statisticians at management executive level chose not to believe our figures. They claimed to have detected a "statistical aberration". They made unilateral adjustments which converted the figures from being substantially better than the average and among the best in the South East to the second worst in the country. It took 20 column inches of explanation about six weeks later in the local press eventually to get the truth across to the public. A letter signed by the medical director, our clinical surgical director and the director of public health (our main purchaser) eventually put the record right. However, I must tell my noble friend that we could well have done without that episode which was a piece of very bad publicity.

What are we doing about such matters? First, we are making very determined efforts to work with local editors and journalists, but one has to say that there are some journalists who have their own agendas. I believe that they see themselves as budding John Pilgers and are anxious to prove their virility. It is very difficult to deal with the situation.

Secondly, we are publicising our successes—and there are many—and we confess frankly when things have gone wrong. We have much good news and our difficulties should not be allowed to obscure it. Thirdly, we are aiming to improve the service. Indeed, I receive many letters of commendation as well as brickbats. An effective complaints procedure is vital. We do not yet match the Patient's Charter standard for the time of reply, but we are aiming to do better.

Against all the difficulties, our top priority is to seek to engender in every member of our staff—from the leading consultants to the junior porters—the sense that they are working for a damned good service. It may be hard pressed, but it is very effective. They should be proud of their achievements in serving their local community. I have to say that we are not there yet but we are working at it.

4.44 p.m.

Lord Bruce of Donington

My Lords, when I saw the Motion on the Order Paper tabled in the name of the noble Lord, Lord McColl, to draw attention to the case for giving the public accurate information about the National Health Service", my first impression was that only the highest sense of public duty in the noble Lord's mind would have induced him to put down a Motion which is so embarrassing to himself. In his opening remarks—and, indeed, throughout the speech with which he honoured us today—a derisory term seemed to appear in every other sentence about what politicians had said, as though the noble Lord is not one of the leading medical politicians in the country. I have had some experience of them. I had experience of Dr. Hill, the radio doctor, and of Dr. Guy Dane who led the original campaign against the National Health Service. I can assure the noble Lord that he has a long way to go before he measures up politically as an avowed Conservative to the skills of Dr. Guy Dane and the sense of humour of the radio doctor.

The noble Lord did not follow in any way the lines of his Motion. He gave us some instances which he called "propaganda" where he alleges misleading or, indeed, totally inaccurate information had been given to the general public by his second-hated species—namely, the journalist—concerning the progress of medical science over the past few years, the various varieties of medical treatment, and so on. However, what he did not do was to address the problem of more accurate information about the National Health Service being available. Of course, that is remarkable.

Speaking personally, I cannot recall having uttered a word of criticism about the medical profession in general, individual medical practitioners, specialists or about nurses. I must agree with the noble Lord that anyone who starts criticising the medical practitioners, the nurses and the people at the spearhead of the NHS will not be very popular. I say that because at the point of contact as regards the medical practitioner, the specialist, the nurse and the patient there is, I venture to suggest, a very considerable amount of confidence in the country. The criticisms are not against them. All the noble Lord did was to put up an Aunt Sally and then knock it down again.

What Conservative politicians, especially Conservative medical politicians of which the noble Lord is a distinguished member, seem to forget—or, indeed, do not seem to realise—is that, despite the excellence at the point of delivery of the treatment and care that is given by doctors, nurses and others, there is a widespread unease about the service as a whole, its administration and the way in which it is going. Of course, there should be more information about that.

The noble Lord, Lord Jenkin of Roding, gave us some instances of gross misrepresentation. I pause to observe that it does not lie in the mouth of a former Conservative Minister to complain about misrepresentation after the gross misrepresentations contained in his party's manifesto for the last election. However, if the noble Lord complains about misrepresentation, perhaps he should take a look at the 63rd report of the Public Accounts Committee in another place—published, incidentally, at the price of £26.10 and, therefore, placing it outside the immediate pocket of those people who are unemployed but who, nevertheless, happen to be interested in such matters.

I invite the noble Lord to look through the findings of the Public Accounts Committee on the investigation into the Wessex Regional Health Authority. There he will find as bad an account of waste of money, bad administration, bad faith, an absence of value for money, gross administrative errors, gross errors of judgment and of managerial incompetence as he will ever see. It is not necessary for the press to enumerate those faults. If the noble Lord takes another look at the 57th report of the Public Accounts Committee which deals with the West Midlands Regional Health Authority, he will find a further example of the waste of millions of pounds of money. That is another case of gross maladministration and gross incompetence within the National Health Service. If the noble Lord complains that these reports misrepresent the position, I should remind him that there is a majority of Members of his own party of another place on the board I am discussing and their decision and their denunciations were unanimous.

We all know perfectly well—the Minister has made it perfectly clear through the noble Baroness, Lady Cumberlege, and through her own words in another place—that one of the principal aims in the reorganisation of the National Health Service was, aside from the objective of improving services to the "customer", the saving of public money. Ordinary human individuals have now been abandoned, it appears, and we have now descended to the word "customer". The reorganisation sought to limit the growing expense of the health service and to match it with what we in the United Kingdom are supposed to be able to afford. In other circumstances and under other time limits I would have addressed that total sum and that would have led me rather outside the subject I am discussing this afternoon.

Surely the principle of saving money and obtaining value for money ought to be written in blood across the hearts of noble Lords opposite. It is their avowed intention to give value for money and not to waste anything. The matters we are discussing should add grist to that mill. But do we hear from noble Lords opposite any demands that the accounts of the regional health authorities—I am talking about accounts and not summaries—or the accounts of the various hospital trusts should be published? We hear no demands for such publication. I should have thought that noble Lords opposite, particularly those who are concerned with expense, would have demanded those accounts as a first priority. However, there has been no such demand. I now demand that we should receive proper accounts and that they should be published in a proper form. I demand accounts that distinguish the sums of money that are spent on management, administration and clerical services and the amounts that are spent on what we will call for the moment the operating expenses; namely, doctors, specialists, nurses, midwives, radiologists and other such specialists, together with the various other ancillary staff. Those accounts should give a numerical analysis which shows how many people are engaged in each of those areas so that we can determine whether the authenticated and heavily documented stories of the gross overemployment of administrators, accountants and people of that ilk are true. If the accounts were published in that form, we could obtain some information on these matters. I shall limit myself to that factor because of the time restriction.

I am sure we could reach an amicable arrangement on this matter. We could be entirely factual as regards the accounts. I am quite willing—I am sure this applies to my noble friends—for one hospital trust to be selected as an example and for all the details of its financial working and the analysis of staff occupations and other matters to be set out. If that were done, we could find out exactly how a typical hospital trust or a typical authority is organised. Surely there can be no objection to that. If that were done, we could make some judgments as regards where the Government's real priorities lie. We could determine whether it is a Government priority to increase the car allowance of regional authorities by 30 per cent. in one year to a total sum of £70 million. If we had the information I have demanded, we could determine whether these allocations are justified.

My next point touches on the impartiality of administration and on the direction of policy. What we ought to be provided with in the case of these organisations, including in particular non-governmental organisations, are particulars of their political make-up. Which avowed parties do these appointees of the Minister, of the boards and of the trusts belong to? I can give an example of that matter from this House. As a result of the searching questions asked by the noble Lord, Lord Bonham-Carter, we know that out of the 13 positions in the National Health Service in the bailiwick of the Minister, there are 13 appointments from your Lordships' House. We also know by collation and comparison with Vacher's that 12 Conservatives in this House received appointments—one of whom had two posts—while there were no appointees from the Liberal Party, none from the Labour Party and none from the Independents in this House. It is widely known throughout the country that appointments to these positions are progressively being governed by party considerations rather than by considerations of ability and drive.

4.57 p.m.

Baroness Seccombe

My Lords, first let me add my thanks to my noble friend Lord McColl for initiating a debate which many noble Lords on this side of the House welcome greatly. We do so not least because it provides the House with a rare opportunity to give proper recognition to the many examples of excellent care provided by National Health Service staff. All too often, it seems to me, when providing information on the health service the media prefer to concentrate on the negative rather than the positive.

One might be tempted to suggest that those who have the good of the NHS at heart should be encouraged by this. There springs to mind a certain adage which points out that in every walk of life it is the exceptional event, not the commonplace, which attracts the attention of the press. In the case of the NHS it is certainly true that the great majority of cases are successfully treated and completed to the satisfaction of all concerned. Yet, in reality, no one is helped when this fact is obscured by the disproportionate amount of attention given to the, tiny minority of cases where patients are not satisfied with their treatment.

We can all see the result of this unfortunate imbalance in information. Almost invariably individual patients praise the quality of care they receive. They quite rightly refer to the dedication of the doctors and nurses in the wards and they often notice the impressive equipment available. Many feel that they have received the finest treatment anywhere in the world. But, owing to the discrepancy between this personal experience and the media reports they see, patients often think that their own experiences are the exception rather than the rule. They are not. For example, studies demonstrate that some nine in 10 people who have used the services of their local GPs recently believe that GPs are performing well. Surveys by, among others, the National Association of Health Authorities and Trusts show that satisfaction with hospital treatment is also high. Although its findings were generally reported in a negative fashion, the recent National Consumer Council survey concluded that, for example, more than eight in 10 of those who had used health services in the previous year felt that sufficient attention was paid to their individual needs.

Unfortunately, the national press rarely report such facts. There seems to be a substantial difference of perception between those who actually use the National Health Service and those who merely talk or write about it.

In specific areas, too, we receive only partial information from the media. Perhaps I may take just two recent examples. First, I declare an interest as deputy chairman of Nuffield Hospitals.

Changes in the field of health care have reduced the need for as many hospital beds. It is widely recognised, and demonstrated by opinion polls, that most people prefer to leave hospital the day they are treated, if that is possible. Advances in medical technology mean that to an increasing extent it is. There has been a 10 per cent. to 15 per cent. movement to day surgery each year across many countries. In addition, other patients may have to spend less time in hospital. I understand that the average stay in hospital is now around four days per patient and reducing. That has led to a long-established trend, supported in theory by both major parties, towards fewer hospital beds, enabling the health service to invest the money in other areas of patient care. It would be encouraging to see such facts mentioned by the media when reporting figures on hospital beds.

The second example concerns the talk in recent months about the numbers of NHS managers. We hear less frequently about the fact that the NHS management accounts for a little over 2 per cent. of the NHS workforce, with less than £3 in every £100 spent on administration. Nor do the reports point out that for every 100 patients treated in hospital in the year before the NHS reforms were introduced hospitals expect to treat 115 this year. Improved management of the health service's £100 million a day budget has contributed to that dramatic improvement in patient care.

As a nation, many now appreciate the need to pay greater attention to the important area of health promotion. GPs across the country, North and South, in inner cities and rural areas, have improved dramatically their immunisation and cancer screening services in recent years. Britain's cancer screening services are now among the finest in Europe and we were the first country to introduce nationwide cancer screening programmes based on computerised call and recall. Those programmes have clearly been of particular benefit to many women in this country.

Of course, the best way to obtain balanced information on the NHS is to ask the patients themselves. Fortunately, more hospitals are now embarking on that route. Among members of the medical profession, however, there was once perhaps a tendency to accentuate the negative. Doubtless that was in part at least the product of an understandable but misplaced desire to give greater credence to a particular case for enhanced funding for the department concerned. Fortunately, that tendency is diminishing. The devolution of control to the local level under the NHS reforms—and, in particular, the creation of NHS trusts—has created a renewed sense of ownership in our hospitals and has encouraged all staff to feel part of a team. That has helped to change the attitudes of patients and staff alike.

Finally, there are three related areas where further progress should he made in providing information for patients. First, patients themselves need to be given adequate information on the care they are to receive. That forms a vital part of the Government's Patient's Charter initiative.

Secondly, the public as a whole may require better access to information about health services and health care in general. The new health helpline, providing information on the NHS free of charge, has demonstrated by its success the appetite of the public for such information. Many district health authorities are using their new purchasing role to keep their patients better informed and to involve them in a genuine dialogue about priorities for expenditure.

Thirdly, there is a need to ensure that complaints procedures are efficient and effective so that when problems occur they are acknowledged and, if possible, rectified. The charter has encouraged people to be less passive recipients of services and more active in complaining when things go wrong. Provided they are also active in praising when things go right, that is clearly a beneficial development.

In each of those areas the NHS reforms are proving to be a catalyst for change and improvement. The climate of openness in the NHS and of partnership between patient and provider is to be welcomed. But for openness we need balanced information on the NHS. In providing such information we all have a responsibility to play our part.

5.6 p.m.

Lord Butterfield

My Lords, I glance at the clock. I have been fascinated by the presentations which have arisen out of the Motion for debate tabled this afternoon by my former colleague at Guy's Hospital, the noble Lord, Lord McColl. When the noble Lord sat down I mentioned to the noble Lord, Lord Kilmarnock, that he had had a devastating effect on my notes because he referred to the growth of private medicine and the very important general practitioner service which covers us all and which is so envied by those lovely people in America, where the system leaves the equivalent of the British population without access to doctors. I was a medical student in America and I used to stand up for the health service. I was called a rabid Left-wing socialist who believed in socialist medicine. I suppose I did. That was socialist in philosophical terms. I shall not declare a particular interest with either the Benches on this side of the House or the Benches opposite, if noble Lords will forgive me.

I was also delighted with the remarks of the noble Lord, Lord Jenkin. I remember that when I was a member of the regional board in East Anglia the other regional board members would complain at hospital staff meetings about those dreadful professors and consultants and how they were undisciplined and did not know how much anything cost. A day or two later I would sit with the same professors and consultants and hear them complain bitterly that the regional authorities did not realise where the breakthrough points were and were interfering with the prescribing of new drugs for cancer and so on. I regretted that and did all that I could to improve matters. I used to hold little dinner parties and get the two sides together. They always departed very close friends, but the local press and radio soon showed that they were not such good friends as I thought them to be.

When I considered the Motion in the name of the noble Lord, Lord McColl, calling attention to the case for giving the public accurate information I began Ito think about the public rather than patients. Various speakers have drawn attention to the appreciation of patients of what the health service has provided for them. Among my Christmas reading I was very struck, as I am sure all your Lordships were, by a marvellous booklet issued by the Foreign and Commonwealth Office entitled The European Community: Facts and Fairytales. It explains why there has been so much fuss about straight cucumbers and curved cucumbers, home-made jams not being able to be sold at church fêtes, and so on.

I have only one complaint about the document that I should like to pass in writing in due course to the Secretary of State, the right honourable Gentleman Mr. Douglas Hurd. There are no pictures in it. There is a good, jokey picture on the front. It shows men changing the sign outside Scotland Yard from "Scotland Yard" to "Scotland Metre". That is the first point that I wish to make. In giving factual information it is important that the receivers of the information can interpret it. It is one of the issues about which Ian McColl and I used to talk. We used to talk about it with our students. We were always borrowing patients' temperature charts to draw pictures on the back to explain to students what was going on. I am a strong believer in the notion that people who are in the information-providing service should illustrate that information whenever they can.

I run the Health Promotion Research Trust. We have put out over half a million pamphlets. About 70 per cent. of those have pictures. Some are funny and some are accurate interpretations of foods, drinks and so on. We have been interested to find that the public uptake of the pamphlets that have illustrations is far higher than for those with just turgid prose. We are also fascinated to note that, where we have illustrated the messages that we have sought to get across, the press—I hope your Lordships will forgive my saying it—have been much better in appreciating what we sought to convey. Words get into a muddle in those computers we call brains. Pictures often tell the story that we wish to get across.

Figures, pictures, graphs and tables can be helpful in getting across complex concepts. For example, I have seen wonderful graphs of the increasing expenditure which has come under what is now the Department of Health. But we have to remember that those increases in expenditure cover not only increases in the drugs bill, which has remained a steady 10 per cent. of whatever the total might be—which is not surprising because more complicated drugs have been required for the more complicated conditions that we can now treat—but we have also seen a reasonable increase in salaries for the people who work in the health service. A great proportion of the people working in the health service are nurses and nurses aides. I can remember, as I am sure can the noble Lord, Lord McColl, the shame we felt when we heard how much our staff nurses made compared with maintenance engineers in hospitals. Now, thank goodness, a great proportion of the nurses are seen coming to work in Mini Minors, perhaps with old registration numbers—but they are better off. That has been a great glory of the health service: it has retained a great deal of the loyalty to the service.

However, it has to be explained to people that what is thought to be a massive increase in injection of funds is in fact much absorbed by salary increases and so on. I scribbled some notes on the rises. Seventy per cent. of those in the NHS used to be salaried; the figure is now 82 per cent. The amount of money going into salaries has risen by 15 per cent. If one considers the volume of work done by the NHS for money, one finds that between 1971 and 1991 the actual purchasable volume of work has increased by only 40 per cent. If one looks at expenditure one sees rises of 200 or 300 per cent. However, that figure has been taken up with all kinds of inevitable discounts.

In our work we have found it immensely helpful to use figures in comparative data. I am very bad on pie charts; I do not find them much use. However, I find vertical and horizontal columns of information helpful. The proportion of the NHS expenditure as a percentage of the gross domestic product in 1973 was 4.6 per cent. In 1993 it was 6.5 per cent. That is a 41 per cent. increase in the proportion of GDP, which is very close to the increase in the volume of 40 per cent.

There is no easy way to inflate the amount of work that one can have in the health service. It is a salaried service and inevitably has a high salary bill. But in addition to the 6.5 per cent. there has been a marked growth in private medicine. That has caused concern about such matters as double standards, and so on. When I was last in Guy's I went on to the private ward. I was intrigued to find that the first patient I came across" was a policeman; in a nearby room was a docker. They both had cover with BUPA. Therefore, we have to be careful before we are too critical.

Figures and graphs are helpful in explaining such complex problems as waiting lists. The noble Lord, Lord McColl, referred to the way in which people always say that the health service is disintegrating and the number of beds falling. If one considers graphs of the number of beds in the health service over the past 30 years it looks like the beginning of a waterfall. That is because living standards are improving and a patient does not want to lie in a hospital bed if he can go home and enjoy his wife's cooking.

I have ascertained most of the figures in my remarks from a Compendium of Health Statistics. It refers to the Office of Health Economics. The compendium is researched and written by an economist called Robert Chew. I should like noble Lords to know that I have ascertained that there is a copy of this compendium in the research room of your Lordships' Library. The compendium includes much of the information for which the noble Lord, Lord Bruce, asked about trusts. It shows the figures and facts for the whole country. I believe that that is the kind of information that persons such as myself and the noble Lord, Lord McColl, have to convey. There is an enormous amount of statistical information and, oh dear, why can we not get many of the people who are misinforming the public to see how serious their misinformation is by looking at general national statistics?

5.18 p.m.

Baroness Gardner of Parkes

My Lords, I am grateful to the noble Lord, Lord McColl, for bringing this interesting debate before us. I have been asked by the Consumers' Association to raise some points which it finds of particular interest with regard to the health service. One relates to the lack of patient involvement in the GP decision-making process about which hospital the patient should go to and which treatment should be considered. The Consumers' Association research shows that many people would like to have more information on that.

The association refers to another point—I shall go into it in more detail later; I have my views on it too—on failure of communications and how many complaints arise simply because of that. It is not because the patient has a real grievance; he simply wants more information.

Mistakes are made in medicine. Very sadly, we often hear about them afterwards only because they become apparent later. I refer to the recent radiotherapy doses which were wrongly calculated many years ago; the patients are suffering now. There is, too, the long-term assessment of how many more endothelioma cancers will arise due to asbestos. It is all very well taking preventive action now, but people were never aware of the risk and nothing therefore was done in advance.

It is natural for the public to find it fascinating reading such matters and that is why we tend to read the alarming stories about the health service. All the time in life we uncover facts that we did not know before. There is a case for publication eventually—and I do not believe that we have reached that point yet—of league tables of results of treatment at different hospitals. In the London context, when we discuss whether to keep this or that hospital, many patients would be happy to go to one of the two hospitals if they knew it gave a greater prospect of living a longer and healthier life afterwards. Many who feel a great personal attachment to a local hospital would perhaps view it differently if they knew that there might be a different outcome afterwards. That is where league tables would be good, but it may be some time before they are suitable. For example, if someone has a road accident, they are much better off going to a major trauma centre than just going into the local cottage hospital when they will probably have to be moved on afterwards. All those are areas in which the public would like to be better informed about the choices available so that they may think about them.

As a dentist, I am only an offshoot of medicine but in medicine we must always be aware that patients do not understand jargon. Every profession, trade or business has its own jargon; we all use initials and words that mean nothing to people. We must be sure that whatever information we provide is in a form which people can understand. In his speech the noble Lord, Lord Ennals, commented on the various areas of social problems which have difficulties.

I am a member of the North-East Thames Regional Health Authority, and we have areas of high ethnic communities. Those areas have different health problems from other parts of our region and there is a need for information to be in languages that local people will understand. Research has shown that the information should not be in all languages, but it should be in the major languages used by the community.

Earlier this afternoon I spoke to my noble friend Lady Flather on that subject. I had never thought of it and I was grateful to her for raising the point. She said that it was important for leaflets to be in the local language and in English. She said that some people only knew certain words in English and not in their own language. but for others it was the reverse. In addition, people are learning the language and improving their English if they have the texts side by side. I know that in European meetings often we want to see the original just to see how good the translation was. The same applies to other languages, and that is an important point.

Information must be simple. As a dentist, I found that patients understood certain things I said but with other instructions they had no idea what I was talking about. One man had rather bad after-effects from an operation and I put him onto antibiotics. His wife came round two days later and said: "I've come because he is not well enough to come". I asked whether the tablets I had given him were helping and she said "Oh no, he hasn't taken any of those". I asked why not and she said: "The instructions said 'take after food' and he hasn't felt like eating". That was a simple point, yet it prevented the man's treatment having any effect. He had put the tablets on the shelf until he felt like eating. After that I reached the point where I was careful to tell everyone: "Whether you eat or not, still take the tablets". That is important.

Other tablets in the dental sphere are good in terms of prevention and we may tell people to take half a tablet, but many patients think: "If half a tablet is good, a whole tablet will be better". Of course, a whole tablet would be hopeless and possibly even dangerous. So it is important to explain matters fully and accurately to patients.

The noble Lord, Lord Ennals, said that people should take as much responsibility as they could for their own treatment. He was speaking about mental health cases, but the Consumers' Association makes the point in more general terms. Patients expect a prescription and they almost feel cheated if we do not give them one. I should like to see the day come when patients will question: "Do I need a prescription? Do I need a tablet? Could I do without them?" That is when we shall see an improvement and a sign of success in preventive treatment.

The opening of meetings to the public was raised. Our regional health authority meetings are open to the public and we even move them from the morning to the evening to enable more of the public to attend. I believe that public attendance is between two and six people. One person is always there, at every meeting. Usually there are two, unless there is an item of particular interest, when there may be a whole busload of people from a particular hospital. We deal with the region and I have spoken to chairmen of trusts who have told me that they are quite willing to open their meetings to the public but when they do, no one attends. They said that they were waiting for the public to ask for meetings to be open to them and then they would be. I can speak only for some authorities; I cannot make a general statement for all.

There is a need for research in order to provide accurate information. In North-East Thames, we are fortunate in having a general practitioner professor who is assessing the needs of patients in our region and the application of particular research to general practice. That is valuable. In London, there is a need for a major culture change in that people tend just to go to casualty rather than to their GP. I know that I am the same, there is no difference.

A most important feature of life is the counselling service. Recently a dentist died of AIDS, and the FHSA in, I believe, the North-West Thames region spent the whole weekend available on a helpline. On the first day 100 patients phoned in expressing great anxiety, and the calls continued for many days afterwards. People need the opportunity to obtain advice and assistance from those who can answer their questions calmly, quietly and in a way that is personal to patients' needs.

People want more information, but they want it at the time of need and not in the abstract. The volume of attendance at public meetings of health authorities shows the degree of interest people have in the abstract. There are a few dedicated souls. However, the moment it comes to a point where you or your loved ones, or even a friend, requires treatment, the health service is expected to be there ready to provide the necessary treatment adequately and well. Again, I am the same, I should expect that.

It is most important that one should know immediately where to go for the relevant information. That must surely be the first priority to the GP or to the community health council. Those councils do a good job of acting as advocates and sources of information. In North-East Thames, which is unique in London and possibly in the country, all CHCs have computer databases which are regularly updated each month by the regional health information service. Thus, each CHC in the region has access to all the information that others have. One could go to Hampstead and find out what services are available to one's mother in Southend, and that is good.

The Patient's Charter has now been extended. We know all about that, so I shall not go into it. One of the most common criticisms made recently was that waiting times in outpatient departments were due to the late arrival of consultants, so the consultants have something to look at there. However, the practice charter for general practice is still on a voluntary basis and it varies very much from weighty tomes to just a chart on the wall of the doctor's surgery. At least every GP has to have a practice leaflet which gives valuable information. Like all dental practitioners I was horrified to see that there was a leaflet on how to complain. I am pleased that it has now become more constructive and the usual form is for comments, complaints or compliments, and that is a positive and good way of looking at the problem.

Returning to the comment of the Consumers' Association, it says that the first improvement is better communication. Most people who have made a complaint are really attempting to get information or an explanation and therefore it is good to have more as well as accurate information.

5.30 p.m.

Baroness Robson of Kiddington

My Lords, I join other noble Lords in thanking the noble Lord, Lord McColl, for introducing this subject. When I read the terms of the Motion I thought that we were to discuss information services in the National Health Service. We have listened to many wonderful speeches eulogising the work of the NHS, with which I agree, or condemning other things that it does, with which I sometimes also agree. We are really here to talk about whether adequate information to the general public exists—at least, that is what I thought we were to discuss.

I agree with the noble Lords, Lord McColl and Lord Jenkin, that it is deplorable that so many scare stories can appear in newspapers, both local and national, which quite frequently turn out to have no truth behind them, or are based on misinformation. If we deplore that, we must look at the reason behind it and why it is that people believe what they read, knowing, many of them, that the service provided by the NHS has stood them in very good stead.

It is also interesting that the recent Audit Commission report What seems to be the matter shows that problems in communication within the NHS usually come at the top of the list of patients' concerns. An analysis of the complaints received by the ombudsman shows that the most common complaints relate to poor communication and lack of information. So there must be something wrong with what we are providing.

To be effective, communication must become more than a mechanical process. Effective communication must reflect a common purpose and integrate the common goals of the service. That requires much thought. It also necessitates an understanding that communication is a two-way system which includes listening, and observing and understanding the other point of view.

Much has been said, particularly by the noble Lord, Lord Ennals, about public access to information being one of the victims of the Government's health reforms. Like the noble Lord, I too am concerned about the openness of the NHS trusts. After all, they are required only to hold one public meeting a year. I appreciate, from the remarks of the noble Lord, Lord Jenkin, and indeed I know, that all trusts do not hold to just one statutory meeting. They communicate with their local community in quite a different way. But there are many that do not do so, and that gives rise to the feeling that we do not have enough communication with people in the community.

The health authorities get upset when the public do not appear to understand the reason for a hospital closure because the right information has not permeated through to the community. They become defensive about their decision. That is not good for communication and for creating support for the changes in the NHS. I believe that much more thorough attempts must be made to involve the public, patients and carers in dialogue and partnership in the running of the services—which in one sense they owe. That can only be done by providing better quality information.

I am disturbed that under the new reorganised system there is less communication with community health councils and local self-help groups than there was in the past. In the days when I was a regional chairman—the noble Lord, Lord Jenkin, will remember this—we had cumbersome, almost unworkable, authorities which were very difficult to run. On the other hand, on those authorities were representatives of almost every interest within the community. I do not say that we should go back to those cumbersome boards, but we should make certain that those same interest groups can have an input into the decision making.

I have a further suggestion which might help particularly the general practitioners. There is without doubt a feeling in some quarters that fund-holding GPs will be cheeseparing about what tests they are prepared to pay for. That view is probably completely wrong, but such ideas exist in the minds of many people. I do not see why the general practitioners should not have one annual general meeting a year with their patients to explain their attitude, their programme and their plans. That would not be too much to ask, and it would be terribly helpful for putting across their ideas. Given the right information, people will support the decisions that are taken. People are not stupid, but they need more information than they have been given in the past.

The noble Lord, Lord Ennals, referred to Written Answers to MPs. On each of 57 occasions the information requested was not available centrally. I approve of disseminating the decision-making process as closely as possible to the community. But that does not absolve the department from keeping statistics which can be given as information to MPs. When in desperation most members of the community will turn to their MP to try to find out what the real answer is. That information should be available.

I welcome and look forward to the completion of an experiment which I hope the noble Baroness the Minister will tell me will be allowed to continue. There are two pilot schemes running at the moment, one at Brighton Healthcare Trust and the other at Frenchay Healthcare Trust, where a special new post has been created for a "patients' representative". I believe it to be a genuine step forward in helping to communicate with the community and the patients that attend the hospitals.

That patients' representative will have responsibility for providing detailed information of the health services available. He or she must ensure that clear explanations are given of treatments proposed, including risks and any alternatives, before patients agree to treatment. He or she also has the responsibility of liaising with local community groups and building good relationships. There are a number of strengths to the appointment of a patients' representative. I can talk to a GP and am not so over-awed by his expertise that I am not prepared to say what I think. But this country is full of people who stand in such awe of the medical profession that they dare not ask a question. The appointment of a patients' representative who is not involved in the care of the patient could go a long way toward helping patients feel more relaxed about asking the questions that they want answered. It is important that such a person should have direct access to the chief executive and the chairman of the trust or the district authority. This experiment is in its first year and has a second year to run. I hope that it will be successful and that we see many more such appointments around the country.

5.40 p.m.

Baroness Jay of Paddington

My Lords, I should like to offer my thanks to the noble Lord, Lord McColl, for introducing the debate this afternoon. I echo the words of my noble friends Lord Ennals and Lord Bruce of Donington, who were surprised that he presented the facts which he wanted to relay in what I can only describe as a somewhat partisan fashion.

Of course there is a need for greater information for the public in the health service. More information is needed about the health service for people who use it as well as those who work in it. Like the noble Baroness, Lady Robson, who has just spoken, I expected that this afternoon we would discuss the questions of whose responsibility it was to give that information to the public, how that information could most usefully and sensibly be facilitated and to where members of the public could go for the kind of simple and accurate information that everyone desires. Several speakers this afternoon mentioned the responsibilities of local authorities within the health service. The availability of information and the openness of meetings of trusts were also discussed.

I agree with those who feel that it is inadequate for meetings of trusts to be held on an open basis only once a year. My experience of local health authorities is rather different from that of the noble Baroness, Lady Gardner. The local health authority on which I sit has to limit on the basis of the size of the room the numbers of people—members of the public—who can attend. Certainly local participation has never been lacking. I see no reason whatever for not making trusts as open as those district health authorities which have established a regime of open communication with their local people on the same basis.

One matter that has not been spoken of this afternoon is the availability and accessibility of staff within the health service to provide the public with accurate information. I have raised before in your Lordships' House the notorious so-called "gagging clauses" for some local health trust members. Indeed, questions were asked last summer about whether or not some rather inappropriate advice given by the Department of Health to local health authorities in fact challenged the constitutional rights of members of staff of local health authorities to do what is called colloquially "whistle blow". I understand from the reply given to me by the noble Baroness, Lady Cumberlege, earlier this year that that advice has now been rescinded.

However, there is a sense in which there is now a culture of secrecy within the health service in terms of both the staff and trust meetings being held in private. As has also been mentioned this afternoon, there is the issue of commercial secrecy. That is a phenomenon which I find distasteful; namely, that it is regarded as uncompetitive for local trusts to reveal particular facts and figures about their own health care because of perhaps losing a commercial advantage.

But it is in Parliament—again this point was raised in the debate—where we look for responsible, accurate information about the health service. The unavailability of statistics and the lack of centrally held data were referred to by the noble Baroness, Lady Robson, and mentioned also by the noble Lord, Lord Ennals. That is absolutely extraordinary. We have a National Health Service which is publicly financed and nationally accountable. Surely Ministers must take responsibility and have the ability to answer questions relating to all parts of the country.

It is there that the root of the problem about obtaining accurate information lies. I believe that my noble friend Lord Judd (who is not present this afternoon but has given me permission to raise this matter) is usually regarded by your Lordships as an amiable person. He wrote a very angry open letter to the noble Baroness, Lady Cumberlege, during the Recess just before Christmas. He released it to the Oxfordshire media because he was so frustrated by the nature of her reply, abrogating responsibility for knowledge about what was happening in Oxfordshire. That letter ended by stating that her reply: made him tremble not only for the NHS but for the quality of democracy in this country". Frankly, I do not believe that he exaggerated. It is not surprising—no doubt the noble Lord, Lord McColl, will call what I say sloganising—that confidence in the Government on health matters has dropped to the extraordinarily low figure of 13 per cent.

However, this afternoon we have been given a golden opportunity. The noble Lord, Lord McColl, invited us to consider the issue of accurate information and to search for it. There seems to be no easy way to achieve that, particularly as I suppose I could qualify for both groups of people who came in for particular criticism for propaganda by the noble Lord, Lord McColl. I qualify as a politician and as a journalist, at least manquée.

Perhaps I could just adopt the attitude or position of a user of the health service and ask some of the questions which the noble Baroness, as the Minister responsible for a national service, will, I hope, be able to answer. They are on the kinds of matters about which the public are seeking accurate information. First, I am registered with a local general practitioner who is not a fund-holder. But my current anxiety is whether I should try to move to a fund-holder practice in order to obtain a more privileged, fast-track service if I need hospital treatment. What would the Minister advise?

Strictures have been laid on us by the noble Lord, Lord McColl, to the effect that we should not ask questions which include opinions, at least not personal opinions. Therefore, I shall quote from a survey carried out last month by the BMA. It showed that 42 per cent. of hospitals give preference to patients who are referred by fund-holding practices. That is an already developed practice. It is bound to go further as more GP fund-holders come forward and are encouraged by the Government to adopt the system. I do not feel that it is inaccurate or in any way propaganda to describe the result as a two-tier system which undermines the basic NHS principles of equality of access and treatment on the basis of need. That information has been published. It should be better known. It is not a piece of propaganda to ask, as an individual user of the health service, what is the situation about GP fund-holders.

My next question as a patient and member of the public, whether or not I am registered with a GP fund-holder, is: will I have to wait a miserably long time for a hospital appointment or treatment? Again, the noble Lord, Lord McColl, spoke of the irrelevance of waiting lists. But to many people—particularly the frail and the elderly, whom he described so vividly as being the victims of propaganda —it is not an irrelevance when they are waiting, often in pain and in considerable difficulties, to have treatment.

It is true, whatever noble Lords opposite may say, that waiting lists have increased by 100,000 people in the last 18 months and have now reached a record figure of over 1 million. The number of people waiting for treatment for over a year rose by a quarter in the first six months of the financial year since April 1993.

All those "waiters" are individuals. They are "real people". They are members of the public and each one is a person who is separately counted. But counting people is no longer the way in which the Government calculate their figures for the so-called outstanding performance within the reformed National Health' Service.

We are constantly told—it is not propaganda; I am quoting Ministers—by Ministers (and it seems to be the standard first sentence of any reply given to any question about the NHS) that more people are being treated than ever before. But their figures are based on counting so-called "completed episodes of consultant care". They are not based on counting people. For the past three years patients have not been counted as they were in the past when they were discharged from hospital but each time they pass through any one part of treatment within a hospital stay. In some hospitals that may mean that a patient is counted each time he moves to receive one type of specialist care, if he moves from one ward to another and even if he returns to a different bed after an operation. Each is a different "activity", an episode of care, recorded in the statistics. No wonder levels seem to be rising. But is it not dishonest not to make it clear to the public that "increased activity" does not mean that more individual patients are receiving the treatment that they need more quickly? Sir Duncan Nichol, chief executive of the NHS, said that counting hospital activity was a crude and one-dimensional way of measuring the performance of the NHS. That is the type of accurate information which the public needs.

I return to my odyssey. I am not going to my GP, I am not seeking to visit the outpatient clinic and I am not seeking elective surgery. Let us suppose that I am knocked down in a road accident, or have acute appendicitis, or need any other kind of emergency hospital care. In those circumstances I expect the extraordinary casualty and accident services of the NHS to be at their superb best. But even in that respect, as a member of the public, I am beginning to be doubtful and concerned. Again, the Government apparently cannot tell me how many A&E departments there are in NHS hospitals because, according to an Answer in Hansard on 1st December, the information is not collected in that form.

But local research is alarming and suggests that one in five A&E units closed during the past year. An independent authority, the Royal College of Nursing, reported this week that in one-third of the A&E departments that are still open patients face overnight waits in the casualty department because of the bed shortages in wards. It states that in London that figure rises to nearly one-half. The Royal College of Nursing states that its staff have difficulty providing proper care in those circumstances; there are mattresses on the floor, patients are left on trolleys and the patients have little privacy. That is more information that the public are entitled to know.

The question of league tables was raised. I do not believe that there are major difficulties about some of the questions on the limited sets of data which hospitals have been asked to give, and which will be given from this summer. But of course they do not include the quality of service, which is difficult to measure. We should not be too bemused by the notion of league tables or assume that they will be the answer to every requirement for public information. The other questions about surgical performance and mortality also seem to ignore some of the basic problems, as is the case in schools. Often bad school exam league tables partly reflect the socio-economic composition of the population in the area. I suspect that that is bound to be true in hospitals. Of course, they do not deal with the important factor that where centres of excellence take on difficult cases the levels of mortality will be higher.

In conclusion, I accept the terms of the Motion that the public has a right to know and a right to have accurate information. I also accept that the primary responsibility for this must lie with the bodies which organise and manage the health services. My assertion is that the new systems and reforms make that more difficult. In particular they make it more difficult because through the new systems the Government have succeeded in abrogating responsibility for the kind of information which the public must have. There must be ministerial responsibility for what, after all, is still a public service funded by public money.

5.54 p.m.

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

My Lords, there could be no more fitting person to initiate this debate in your Lordships' House than my noble friend Lord McColl. He is a surgeon of great distinction who has been the Chairman of the Department of Surgery of the United Medical and Dental Schools of Guy's and St. Thomas' hospitals since 1988 and has had a great influence on the NHS both through his academic work and his clinical practice. During the course of this debate, with other members of your Lordships' House, he has made a persuasive case for providing more and better information to the public. It is an issue which has a high priority in all public services and one in which the Government are determined to make continuing progress.

The publication of the Citizen's Charter marked the beginning of the end of the "one size, fits all" public service. The noble Lord, Lord Kilmarnock, in his thoughtful speech, rightly said that the NHS reforms, the Patient's Charter and a range of other initiatives which the Government introduced have begun to instil into the culture of the NHS principles of choice, quality and above all openness. I thank the noble Lord for his congratulations.

I consider the NHS to be the epitome of all that is best in Britain today. It embraces the ethics that we value the most: loving your neighbour; to each according to his needs. They are principles of very different antecedents, but combined they are the most powerful force for good.

Good things are precious. At a time when the country is debating what is right and what is wrong the Government believe that people of all parties can agree that the underlying ethic of the NHS is superb and a catalyst which unites us all. But if for political gain or out of sheer cussedness we denigrate the service to the point where people lose faith in it, we will destroy the NHS.

My noble friends Lord McColl and Lady Seccombe are right to say that people who have just had successful treatment are grateful but then continue to believe that they are the exception and that no one else can have the' same good treatment. This is, of course, untrue, but a cause for concern because ultimately when people lose confidence in the service they may then unwittingly destroy what they love the most.

To meet people's aspirations the NHS has to change. But change is difficult to bring about, especially in an organisation which has a near monopoly. Without competition there are few incentives to encourage responsive attitudes to patients. Through the reforms and the internal market the Government are actively promoting competition and a policy of patient participation. We want people to influence the service and to make decisions as to the type of health care that they want.

We have published a strategy to achieve this entitled Local Voices. Today my right honourable friend the Minister of Health, Dr. Brian Mawhinney, has written to purchasers, health authorities, asking them for details of the progress that they have made in carrying out this strategy and the efforts that they have made to involve community health councils, voluntary organisations, GPs, interest groups and members of the public in influencing contracts and purchasing plans.

The Government are aware that the public cannot make a valid contribution without good information. We would open these efforts to ridicule if the public had to fall back onto anecdote or sentiment when the provision of health care is so complex and changing at great speed. The Government are also conscious that people are content with the notion that "the doctor knows best". There is no intention to undermine the faith that people have in the medical profession, but there is every good reason why people should be concerned with the quality and quantity of the provision made and to be realistic about the total budget that can be allocated to the NHS.

The noble Lord, Lord Kilmarnock, raised the question of management costs. We share his view that the NHS should not be ashamed of its investment in better management. That view was also shared by my noble friend Lady Seccombe. The noble Lord asked how the information could be made available. It is available largely through the annual reports and the financial statements that are produced by the trusts. These documents are available for public scrutiny.

The noble Lord, Lord Bruce of Donington, rehearsed the debate on the Wessex computer systems. I would be concerned had the noble Lord, Lord Bruce, been unable to raise the issue because he was unaware of it and that it had been kept secret. But it was a topic of public knowledge long before the Public Accounts Committee report was published. In fact, we welcome that report. The noble Lord will know that the chief executive of the regional health authority has taken extensive action and prior to the report he called in the auditors and stopped the project.

The noble Lord, Lord Bruce, was also concerned that hospital accounts would not be published or would at best be skimpy. But, as I said in answer to the noble Lord, Lord Kilmarnock, there is a requirement to publish those accounts. Both the National Audit Office and the Audit Commission keep a close, independent watch on financial probity and value-for-money.

I am sure that my noble friend Lady Gardner will be pleased to know that next June we shall be publishing the first set of NHS authoritative and comparative league tables. These will be discussed and verified with the service prior to publication, to avoid the repetition of—I believe the word used by my noble friend Lord Jenkin, was—a "cock-up". They will cover six areas, five of which are contained in the Patient's Charter. First, immediate assessment in the accident and emergency departments; secondly, a waiting period of less than 30 minutes in out-patient clinics; thirdly, the cancelled operation standard; fourthly, the emergency ambulance response times; fifthly, waiting times for admission for treatment and, lastly, the proportion of day surgery performed and certain procedures.

This will be vital information for the public, for the Consumers' Association and for other voluntary bodies, for management and for the Government to use, but more importantly, it will inform purchasers. They are charged with commissioning the best services for their populations and, informed by Patient's Charter standards, they will be able to place contracts with greater certainty. As my noble friend Lady Gardner so rightly said, hospitals do vary in their performance and it is right that this information is widely available.

Bacon's adage that "knowledge itself is power" has been adopted as a major theme for the department's activities in supplying information. Like the noble Lord, Lord Ennals, and my noble friend Lady Seccombe, we have welcomed initiatives taken at local level to inform people about their clinical care. I am sure that the Consumers' Association mentioned by my noble friend Lady Gardner, will be pleased to know that it is our policy to involve patients in their treatment and for clinicians to discuss with them the alternatives of different forms of treatments with their differing outcomes. I agree with the noble Lord, Lord Ennals, that it is particularly true of mental illness where medication may not only improve a person's condition but also worsen it.

Looking to acute services, many clinicians are tackling this issue with imagination. Some provide leaflets and information sheets to patients. I know, for example, that St. George's Healthcare Trust has provided cancer patients with personalised information guides; others are using audio tapes and interactive videos to encourage patients to be active partners in their care.

There is, however, a lack of reliable research-based information on many of the services which we provide. By that I mean information which is drawn from systematic reviews of well conducted research. We have been addressing this need and have commissioned a series of effective healthcare bulletins. We have supported the setting up of the Cochrane Collaboration at Oxford which collects validated research worldwide in key areas such as pregnancy and childbirth, and makes it available to the public. We have supported the new central clearing house in Leeds which provides a comprehensive source of information on outcomes and the effectiveness of different treatments.

Although much of this information is aimed at purchasers, we have ensured that patients also have access to it. For example, we have made the effectiveness bulletins available to the public. We are reviewing them to make quite sure that they are easy to read and in layman's language. We are increasing the range of topics which they cover.

A new unit is being set up at the University of York to increase the research information available to the NHS on effectiveness and cost-effectiveness of health-care interventions. Through the unit information will be spread to professionals, users and user groups. Information officers at the unit will help the public who wish to use that service.

We are also working on a national register of research. We have launched an initiative to make better use of research-based evidence about clinical effectiveness.

In the new era of openness in public services, the Government strongly believe that people are entitled to good quality information about their health, about services and also about how the NHS is performing. Spending increasingly large sums of taxpayers' money brings with it increased accountability and a heightened need to explain, to communicate and to justify. But I disagree with the noble Lord, Lord Ennals, that there is less information. My experience, as a previous old-style DHA chairman, was that although in the 1980s we had open meetings, we had very little other contact with the public. I listened to what my noble friend Lord Jenkin said about the trust and the way in which he is involving the public in its activities.

That is not unique. Now health authorities and trusts are producing newspapers; they are using local radio; holding public meetings and forming interest groups. They are working with voluntary organisations and individuals as never before. I can reassure the noble Baroness, Lady Robson, that things really are improving. It is no longer good enough simply to give information or to ask questions about hospital catering or waiting times. The public are being asked much more about profound issues such as the setving of priorities. That means talking a new language about the health service and not just about beds, manpower numbers and percentage real-term growth in spending. It is about quality, effectiveness and better health. We have no doubt that these issues will become more difficult and more pressing as the capacity of modern medicine increases. The answers are not abstract ones about resource allocation formulae. They are based on a shared understanding of what health services can achieve involving patients, health professionals, managers, politicians and the media.

There are other important reasons for giving the public accurate information. On occasion there is the need, as my noble friend Lord McColl illustrated, to set the record straight and by doing so to recognise the very real achievements of NHS staff at all levels in the service. I agree with a number of your Lordships that there are also very important issues surrounding the answering of parliamentary questions. But I totally refute the suggestion that the Government are reluctant to reply to these questions. In the 18 months prior to December the department received 6,500 parliamentary questions, 5.7 per cent. of which it was unable to answer. I believe that that is a tiny percentage, especially when one looks at the obscurity of some of the questions which were asked. It was difficult to define of what value they were.

A number of your Lordships have mentioned the media; the noble Baroness, Lady Robson, and my noble friend Lord Jenkin in particular. Health is a topic of great interest to the media primarily because it is of interest to the public, but also because there are now only a few state-run industries whose activities are open to government attack. These attacks the Government are robust enough to repel, but governments are ephemeral. One presumes that people's healthcare is for ever.

There is all-party support for the NHS, but attacks on a strong government must not ricochet into the NHS and destroy it.

On the reporting of medicine—in this context I do draw the distinction between medicine and services—the media is usually accurate and well researched. I believe that point was made very effectively by the noble Lord, Lord Butterfield. Apart from some notable exceptions, reporting might only be criticised for raising false hopes. The wonder cure is an easy bait with which to catch the gullible reporter, but peddling the elixir of life has a long history. But medical reporters are usually factual, fair and well qualified.

However, as my noble friend Lord Jenkin illustrated, reporting the health service is quite different. That tends to concentrate on bad news, sometimes with little or no foundation. My noble friend rightly pointed out the pressures on local papers. But in the race to sell more papers it would be folly for them to forget that the NHS employs almost a million people. They nearly all care very deeply and they are all fallible. They are dealing with hurt, sick or anxious people who are sometimes drunk, violent or abusive. Crises may occur in the middle of the night when no one is at their best. But the vast majority of treatments are correctly done and the outcomes are successful. It is only a tiny minority which fail and get a disproportionate amount of media coverage.

The noble Lord, Lord Kilmarnock, raised the question of management costs and particularly the research and development programme. I know that that was an initiative raised in your Lordships' House. Your Lordships' were very anxious that it should be operational research. That is under way, but it is early days and we have yet to get comprehensive results.

The noble Lord quite rightly paid tribute to general practice and primary healthcare teams. We endorse his view that they are central to the National Health Service. With GP fund holding and our recent initiatives, we are anxious to place them right at the centre of care. We have invested over £40 million in capital schemes in London alone, to enhance their practice. Those schemes are listed in Hansard volume 551, No. 19 at column No. WA8.

My noble friend Lord McColl asked a specific question—

Lord Rea

My Lords, I thank the noble Baroness for allowing me to intervene. The statistics which she mentioned were given in answer to a Question for Written Answer that I asked her at the end of the previous Session just before Christmas. Is she sure that the capital schemes for inner London which are listed will cope with the problems among the population of London that will occur as a result of the diminution in the number of beds which has resulted from the closure or running down of London's hospitals as proposed by the Government's policies? Has enough research of the kind that the noble Baroness mentioned been carried out in order to ascertain that?

Baroness Cumberlege

My Lords, I think that we could have a full debate on this issue and I am conscious that I am trying to beat the clock. Those schemes are to go ahead. It is a question of "How long is a piece of string?" When do we know that we have sufficient services to serve all the needs of the population of London? The balance between acute services and primary care is a difficult question and I am happy to go into it on another occasion.

My noble friend Lord McColl particularly asked advice on the disablement services and whether the information that the authority used to produce is now lost to the service. The department publishes a booklet containing the information. It is comparative. I shall ensure that my noble friend receives a copy.

The noble Baroness, Lady Robson, asked me about patients' representatives in Brighton and Frenchay. Perhaps I can agree with the sentiments which she expressed that they are extremely valuable. We are funding a study to ensure that that valuation is based on a scientific basis. Subject to that, we shall see whether the scheme should be more widely introduced.

The noble Baroness, Lady Jay, raised the issue again of the two-tier system concerning GP fund-holding—or the allegation that it was a two-tier system. The purpose of fund-holding is to drive up standards of care. Our aim is to level up to the standards of the best, not to level down. There are numerous examples where the advantages gained by GP fund-holders are shared by the patients of non-fund-holders. Indeed, the opposite has happened where DHA purchasers have now achieved a quality which the GP fund-holders then share. Again, I think that that is a subject for another day.

In conclusion, to inform the people is to be open; to be open is to be honest and the Government are increasingly instilling a culture of openness throughout the NHS. The health service belongs to the people and armed with information they can both have the best chance to stay healthy and the knowledge to control their own treatment and make an effective contribution in organising their NHS.

We are determined that the NHS should succeed; but success depends on public support. Support is generated through a well informed public. The fact that millions of people work or contribute voluntarily to the service is good evidence that they are committed to the service and this Government are their staunchest supporter.

Lord Bruce of Donington

My Lords, before the Minister sits down—

Noble Lords

Order, order!

Lord Bruce of Donington

My Lords, I think that I am in order. Before the Minister sits down, will she deal with the question that I raised on which she has not passed any observation, and with the challenge which I renew about the whole question of political patronage in the health service?

Baroness Cumberlege

My Lords, I think that I have only to look across the Chamber to see a member of the Opposition Front Bench who is a member of a health authority and takes an active part in the National Health Service. She is not alone. Other members of the Labour Party are closely involved.

6.14 p.m.

Lord McColl of Dulwich

My Lords, I should like to thank all noble Lords who have taken part in this fascinating debate. I am sorry that the noble Baroness, Lady Jay, does not understand the waiting list problem: 75 per cent. of all people are admitted within three months of being put on a waiting list, so if we gave them all a date for their operation, that would reduce the total number on the waiting list to 0.25 million, which might please her.

I freely admit that I am prejudiced. I am unashamedly prejudiced in favour of the patient, whom I shall continue to defend in a very robust way against the onslaught of the propaganda which denigrates the NHS. My Lords, I beg leave to withdraw my Motion for Papers.

Motion for Papers, by leave, withdrawn.