HL Deb 06 June 1996 vol 572 cc1419-34

7.17 p.m.

Lord Hacking rose to ask Her Majesty's Government what is their response to the issues raised in the Healthcare 2000 Report.

The noble Lord said: My Lords, my purpose in tabling this Unstarred Question is to draw attention to the Healthcare 2000 Report and to seek the considered response not only of Her Majesty's Government but of Her Majesty's Opposition to the report. I am therefore delighted that the noble Lord, Lord Rea, a general practitioner in London, is speaking from the Opposition Front Bench and, although I am sad that my noble friend Lady Cumberlege is unwell and is unable to participate in the debate, I am delighted that my noble friend Lady Miller is replying on behalf of the Government.

Lord Graham of Edmonton

Hear, hear!

Lord Hacking

My Lords, I am glad to have support from the noble Lord, Lord Graham. Perhaps I may also say that I am delighted that a dental practitioner in London, the noble Lord, Lord Colwyn, is taking part, as indeed is the noble Lord, Lord Butterfield, who has held a number of very distinguished appointments both in hospitals and in academia. Although this report was published in September of last year, this is the first occasion that either House of Parliament has considered it. When the report was published there was comment from the political parties which, alas, was more political than constructive in its response. Perhaps, in fairness to my noble friend the Secretary of State, I should state that he was asked questions somewhat early in the morning on the "Today" programme and probably at a time before he had had an opportunity to give the report full study. Comment from the media was also more of the hysterical than the thoughtful kind. The so-called informed press was more hysterical than other organs of our other press. Indeed, to a leading article in the Independent of 20th September 1995 there was the heading, "Faulty diagnosis … dangerous".

This is not the only report that has been recently issued which expresses concern about the future of healthcare in this country. The Royal College of Physicians published a recent report. In a press release the report is described as saying: The criteria and procedures for determining priorities are inadequate and rationing in the National Health Service should be more openly discussed". The British Medical Association and the NHS Consultants' Association also issued reports.

Therefore, I shall be arguing in my short speech that this is a thoughtful report that deserves and merits a thoughtful response. There have been enormous changes in the needs of patients and in the services of the National Health Service since it was founded in 1947.

The report has been funded by a number of leading pharmaceutical companies based in this country. The composition of the steering committee, chaired by Sir Duncan Nichol, was of very wide composition, consisting of doctors, clinicians, patients associations, academia and healthcare directors. There was also the widest consultation including not only critics of the National Health Service but also of the pharmaceutical industry. No fewer than 50 healthcare organisations were consulted. I make it plain that I have no interest whatever to declare under the rules of the House, including the latest resolutions, but I am most willing to tell your Lordships, as some noble Lords know, that I am in practice as a lawyer in the City of London and among my clients there are pharmaceutical companies.

The thoughtful report begins in Chapter 2 with an analysis of the challenges that face the National Health Service now and in the years ahead. The major advances in surgery and in treatment, computing and information technology have resulted in a widening gap between the provision of resources available to the NHS and the ability of National Health Service patients to receive those resources.

In Chapter 3 there is a very careful evaluation of the purposes and values of the National Health Service. As regards Chapter 2, I draw to your Lordships' attention one very important matter; namely, the analysis of demographic changes. The report identifies the fact that there are 9 million people currently over the age of 65 and 900,000 persons in the United Kingdom over the age of 85. By the middle of the next century, in the year 2050, there will be 15 million persons over the age of 65 and 3 million over the age of 85. A rather graphic way of describing this demographic change is that when Her Majesty first came to the Throne in 1953, I believe that she sent 270 telegrams to those who had reached the age of 100 years. I understand that Her Majesty is now sending nearly 3,000 telegrams, faxes—perhaps she is even using E-mail—to those who have reached the age of 100.

Similar demographic changes have been identified in the United States of America where there are 6,000 more Americans celebrating their 65th birthday as every day passes. By the year 2030 it is calculated that in the United States of America there will be more persons over the age of 65 than there will be persons under the age of 18 years.

Chapter 4 of the report deals with patients' need and the great need for better information passing from the health carer to the patient. Chapter 5 analyses the healthcare professions. Page 32 gives a very interesting example of a patient scenario, which I shall read to your Lordships because it describes how, with better integrated healthcare, the patient's position is greatly improved: Alan Christie had been depressed for most of his adult life. He had not consulted his doctor for a few years—not since he had a course of pills that didn't work. When the practice nurse was taking his blood pressure one day it all came out, how he couldn't concentrate, sleep or experience any joy from life. She referred him to the clinic run at the practice by the community psychiatric nurse. Alan attended the clinic and the nurse soon arrived at a diagnosis of clinical depression which needed active treatment. She assessed Alan's case with the family doctor. The doctor saw Alan within twenty four hours and decided, in consultation with the psychiatric nurse, on a plan of shared care. For the first time in years, Alan feels at ease—he no longer feels divided between the inner pain he felt and the mask he always wore to hide it". Chapter 6 of the report analyses the funding of healthcare. Chapter 7 deals with the purchasing and provision of healthcare. It was those chapters that received the most publicity in the media because the report bravely grasped a number of nettles and asked central questions. As I said to your Lordships earlier, it identifies an increasing gap between resources and demand, which naturally brings into place proper questions that should be asked about the future funding of healthcare in the United Kingdom and whether we can continue still just to rely on general taxation as the major source of income for the National Health Service.

The plain facts are that the increasing cost of healthcare goes up year by year. I give noble Lords the figures: in 1970 the cost of the National Health Service was just under £2,000 million; in 1980 it was, in round figures, £11,600 million; in 1990 the figure was £27,760 million. The latest figure for 1996 estimates is that the cost will be £41,427,000. So in the past five years the cost of the National Health Service, despite a number of steps that have been taken to reduce it, has almost doubled in size.

The other fact is that from the outset of the National Health Service every government have had to seek more resources for it. As I have said, the NHS was introduced in 1947 and there were no prescription charges. However, within three-and-a-half years Hugh Gaitskell, who was then the Chancellor of the Exchequer, sought to introduce a prescription charge, which resulted in him being called, if I recollect correctly, "a desiccated calculating machine". That issue also caused the resignations of Aneurin Bevan, John Freeman and Harold Wilson. However, the Labour Party was driven to introduce a modest prescription charge of 5d within three-and-a-half years of the foundation of the NHS and, although the Labour Party abolished the prescription charge when it came back to power in 1964, by 1968 Kenneth Robinson, the Secretary of State for Health, had to reintroduce prescription charges.

An example from the other side of the political divide is that the Conservative Government have recognised the need for other funding within the National Health Service in terms of private health funds and in their NHS reforms. The trouble is that the debate about the NHS has always had a political cloud over it. That point was made by Dr. David Green in his dissenting opinion on page 60 of the report—

Lord Graham of Edmonton


Lord Hacking

My Lords, as I end my remarks—well within the time-frame—I am asking your Lordships for a constructive discussion—

Lord Graham of Edmonton

Twelve minutes!

Lord Hacking

My Lords, according to my note I have 15 minutes, but I am now ending my remarks, so let us not have a debate about whether I have 12 or 15 minutes, which was the time that I understood was available to me for opening the debate.

Let us have a constructive discussion. Above all, let us look at the valuable contribution which this report has made to the debate on healthcare in the future. I shall not read it out because there is not the time, but I draw your Lordships' attention particularly to the moving patient scenario which is identified on page 47. I commend the report to the House.

7.32 p.m.

Lord Butterfield

My Lords, as the lone Cross-Bencher, I am pleased to enter the debate which the noble Lord, Lord Hacking, has so wisely and kindly initiated. The Healthcare 2000 Report comes from a very prestigious committee led by Professor Sir Duncan Nichol, who has produced a penetrating and comprehensive report, which is not surprising because for a long time he was at the centre of the NHS. His committee is a powerful one and its report reflects the growing interest in such matters as the new roles of, and responsibilities for, the well-informed patient and how we are to make patients well informed. It raises interest in the movement of the centre of gravity of healthcare towards community services and it probes the questions of trials in the organisation of medical care and the flexibility of payment.

There is no doubt that it is very important for all of us who are concerned with the health service that we do not allow the fact that the examination is arduous to mean that people do not even try to take it. I urge noble Lords to read the report because they will find that a wide network of healthcare ideas is incorporated into the committee's deliberations. There will have to be a good deal of debate about the points raised in it well on into the millennium.

We are always concerned about training in the health service and I have been intrigued by the Chinese philosopher who urged that when facing complicated questions, leaders of organisations should always try to find the key link of the net of complexities, because if you find that key link, you can cast your net onto the river where it will settle evenly and enrich the chance of a good catch of fish.

For me, the key link is buried on page 8 of the report. Your Lordships will not be surprised when I say that it reads: It will be important for the caring professions to continue to attract the most able young men and women into their ranks. The growing diversity of need for the different types of professional ability requires people of varying characteristics and abilities". To that, I should like to add that we must ensure that we attract the most ethical and sensitive young people. I believe that that is likely to happen only if the right philosophy lies behind healthcare. Students, whether they are nurses, doctors, physiotherapists or social workers, must be selected from the cohorts of young people who can be expected to put the patient first and not see patients simply in economic or profit terms.

I spoke earlier today to the President of the Royal College of Physicians, Sir Leslie Turnberg, who was involved for a time with the healthcare committee, and he is particularly anxious that we do not allow the funding of the NHS, and particularly the education of workers in the NHS, to fall behind in the eyes of either the public or the Treasury. I agree, but I think that that interest will be maintained only if the demographic problem in particular is constantly put before Parliament and the public.

It is equally important that the students selected for the health service have a philosophy of helping people to stay fit and that they see health promotion not as a bore but as a vital part of their co-operative work with their patients. David Green recognised the increasing burdens of self-inflicted disease on the health system and wrote an interesting note of dissent. As an economist, he was intrigued by the idea that health planners appreciated the power of individuals over the maintenance of their individual health programmes. That brings one face to face with the concept of patients planning their own care. It is expensive and, in my experience, even the rich are not able to work out particularly good health programmes for themselves.

The whole idea of an individual organising his healthcare programme is fairly common in America where the public are genuinely concerned about their personal responsibility for healthcare costs and where people are used to looking over and paying health bills. The idea of choosing the best buy becomes a feasible family procedure in America, but it is a strange sort of occupation for the great majority of the British people. To me, it seems best to leave the responsibility for determining the best health buys over the next 20 years or so to those general practitioners who are fund-holders and therefore have some authority in this area. I think that that is the sort of solution which the British would find most acceptable after 50 years of the NHS. However, I must add that it is important that such matters are debated.

When David Green considers the cost distribution of health between people of different ages, he recognises that the elderly are more expensive, but I do not think that he allows a high enough variation in their direction. I believe that the elderly can cost between three and five times as much as the middle-aged for the very expensive care and therapies that they need.

Of course, when people pass the ages of 60 or 65, they move into difficulties with the healthcare insurance folk. If they want to start a health insurance programme, they find that they can be covered into the future only for conditions which will be new to them. If they are discerning, they will notice that the financial premiums rise at the rate of 3 per cent. or more per annum. In effect, it seems that the diseases with which the elderly have been wrestling as their own weaknesses, such as osteoarthritis, emphysema, chronic lung disease, dementia or incontinence, are the very conditions that will bring them into difficulties with the health insurers who say, "We will be delighted to cover you for new conditions, but not for those which you already have". As chronic diseases last a long time and doctors strive to recognise diseases as early as possible, they are likely to lead to conditions which will put elderly people into difficulties in obtaining private health insurance. There is a great deal of scope for discussion about this matter in future. I suspect that one of the issues to be faced is the reopening of the question of euthanasia. I apologise for introducing that thought. However, the more one hears of the age spread, the more we shall hear about that subject in future.

I conclude by speaking about the role of exercise in staving off immobility, which so often mars old age and adds to the cost of caring for the elderly. In a speech I made in the House last year I believe that I amused one noble Lord by stressing the importance that I attached to the need for all of us elderly people to keep our thigh muscles, the quadriceps, strong and firm to keep us mobile and enable us to get up from chairs and so on.

On this occasion I feel compelled to bring to the attention of your Lordships, and your Ladyship, a small illustrated booklet—which I hold up and will place in the Library—entitled Exercise for Healthy Ageing. That booklet is published by Research into Ageing, a charity that I had the privilege to help launch in the 1970s. This booklet was first published in December 1994, and by March of this year it had reached its 11th impression. It makes the important point that it is never too late to start exercising. A commitment to stay active and exercised is an investment to help one remain independent.

My gesture in this short debate, which can touch only the tip of the huge iceberg covered by the report of Healthcare 2000, is to place a copy of the booklet in the Library in the hope that it will be a practical contribution to people's health and so to the NHS and the cost of the caring programme. I am not naêve enough to believe that this approach—the provision of guidance—solves the problems. The publication of a booklet only starts the process of health promotion. We are still only at the beginning of what can be done to promote the nation's health and the health of the elderly and, most particularly, to stave off the difficulties and disabilities experienced by an increasing number of people in future.

7.43 p.m.

Lord Colwyn

My Lords, I am grateful to my noble friend Lord Hacking for introducing this short debate this evening. I welcome him to the ranks of the medical speakers of this House. I also welcome my noble friend Lady Miller who is deputising this evening. I hope that my noble friend Lady Cumberlege will be back with us soon and regains her good health.

I read the report and found it interesting, provocative and challenging. Surprisingly, I found myself in agreement with the two previous speakers and much of the note of dissent written by Dr. David Green. In particular, I agree with his regrets that party politics and partisan affiliation are intricately involved in the NHS debate. In one way or another I have been involved in debates on the NHS in your Lordships' House for nearly 30 years. I sincerely believe that successive Governments have provided and always will provide funding and instigate changes that they believe are beneficial to the service.

It was not until I arrived this evening and realised there were so few speakers in the debate that I regretted having prepared only a four or five-minute contribution. I should like to say a few words on integrated care management which features in chapter seven of the report under the title "The Purchasing and Provision of Healthcare". The report states: The integration of purchasing for primary and secondary care will allow the purchasing of a co-ordinated package of care within which a clinical pathway becomes the basis for disease management". I declare an interest as a dental practitioner and the director of a biotechnological company. Disease management is not a concept; it is reality. It is not a marketing tool for the pharmaceutical companies; it is a fundamental change in the nature of managing chronic disease that is happening now and will affect every participant in the health care industry from scientist to manufacturer to consumer. Disease management is the marker and the means for the shift from a component based to an overall integrated approach to diagnosis and treatment. Healthcare is a system, and there will be great financial savings for the health budget if the UK Government are able to use the system's new tools for making much needed improvements. The report states this as a challenge. It states that information technology will increase the quality, quantity and accessibility of information.

Disease management encapsulates the economic and social cost of disease, methods for detection, treatment and prevention. In assessing the cost and benefit of any one product, these issues must be considered by government, industry and patients. I believe that my noble friend the Minister will agree that an understanding of the economic and social costs of disease and a reduction of those costs are paramount in effective disease management. Having identified an illness and a section of the population for disease management, there are many decisions that need to be made. In some instances those decisions require funding to be made available now in order to realise significant long term savings.

Osteoporosis is one disease state which illustrates the point well. In the UK there are approximately 3 million osteoporosis sufferers but, as Healthcare 2000 points out, there are signs that not all patients who would benefit from some new treatments are obtaining them. Only 250,000 are treated at a cost of £640 million annually. The majority of costs occur as a result of fractures. One in three orthopaedic beds is occupied by an osteoporosis victim. It is only after suffering a fracture that an individual can be identified as having osteoporosis. Prevention is too late, and hence the £640 million associated costs follow. If the remaining 2.75 million patients are undiagnosed and untreated, it is only a matter of time before there will be an explosion of costs associated with osteoporosis.

Looking ahead, new innovations which can enable the diagnosis of disease in the doctors surgery must be promoted by the Department of Health. The improvement in diagnostics, developments in medical imaging and access to centres of specialist expertise can take treatment of diseases such as osteoporosis out of the hands of healthcare institutions and back to the general physician. Going the other way, it is my belief that oncology disease management should be taken away from the general physician and placed in the hands of specialised out-patient centres. The majority of general physicians are not comfortable with or completely knowledgeable about competing therapies and their costs. We have recently seen examples where breast cancer patients are treated differently in different parts of the country and have different chances of survival. If oncology patients are treated in specialised centres, I envisage improved outcomes and convenience together with a reduction in costs.

Disease management is no longer a concept. The Government must accept its arrival and take advantage of the new opportunities it will offer. Diagnostic and therapeutic tools exist today which have the ability to put disease management into practice and new developments in the same must be carefully assessed for their ability to contribute to the reduction of healthcare costs.

I hope that my noble friend will have time to comment on some of Dr. Green's remarks. The report believes that patients should be given statutory recognition along with clinicians and management. I agree with Dr. Green that giving patients statutory recognition is irrelevant to the exercise of personal responsibility and assumes that we are not capable of any personal responsibility and must have all aspects of healthcare managed for us. He refers to the Government's Health of the Nation report, where some of the national targets set by the Department of Health give officials responsibility for matters which should be strictly personal.

Declaring another interest as President of the All-Party group for Complementary and Alternative Medicine and the Natural Medicines Society, I agree that to a large extent our health status depends on our lifestyle: on what we eat, how much we exercise, and whether we smoke and drink. I agree with the noble Lord, Lord Butterfield, that this has to be a personal responsibility. I was sorry not to have seen anything in the report about the increasing national interest in complementary medicine and nutrition and the role that they will play in the future. I suppose that that is not unusual for a report funded by the pharmaceutical companies.

In conclusion, the report is a useful document to encourage discussion. I congratulate the members on their comprehensive analysis. Disease management and managed health-care are factors about which we will hear much more in the future. I feel sure that many of the recommendations are likely to be considered by the Government, and I look forward to hearing what my noble friend has to say.

7.52 p.m.

Lord Rea

My Lords, I am grateful to the noble Lord, Lord Hacking, for giving us the opportunity to discuss the report, although I am sorry that he chose today, because today is my birthday and I was perhaps hoping to do something else this evening. There is still time!

When the report was published, it received, as the noble Lord said, a great deal of publicity, but much of it was critical, from the Left to the moderate Right, including, as he said, the Secretary of State. As the noble Lord said, the matter has not been raised in Parliament except as an Unstarred Question in your Lordships' House on 17th October last when it occupied precisely three minutes. Clearly it had not exactly excited the House. An explanation for that may be that it was the first day back after the Summer Recess.

The noble Baroness, Lady Cumberlege, said on that occasion that while not agreeing with all the conclusions, it was a useful contribution to the health debate. I would put it the other way and say, "While agreeing with some of the conclusions, it is not a particularly useful contribution to the health debate, despite the time, trouble and expense obviously given to it". The report was financed wholly by the pharmaceutical industry. The authors however claim: It is entirely independent of both its sponsors and of any other sectional interest either within or without the National Health Service". Therefore a great deal depended upon the outlook of the steering group and its chairman, Professor Sir Duncan Nichol, wearing his academic hat for the publication—which did not, incidentally, mention that he is also a director of BUPA.

My broad brush criticism of the report is that it barely touches on how the health of the nation could best be improved but concentrates almost entirely on how the health service can best respond to a demand for care which is painted as virtually spiralling out of control. One sentence refers to the fact that: Alleviation of poverty, improvements in housing and environment rather than the NHS, may be the best way of improving the health of individuals". It went on only to dismiss that as impractical since: all political parties are committed to sustaining and increasing the funding of the NHS". That suggests that these major, highly desirable and necessary improvements in the fabric of the nation can be achieved only by cutting the percentage of GDP going to health.

One of the deficiencies of the report leading to such a mistake may be that of the 68 experts who were consulted only two were public health specialists or epidemiologists, and one of those told me that his evidence was not used in the report, although his name is given as one of the advisers.

In 12 minutes, it is impossible to do justice to a 70-page report. The best way to tackle the task may be to address one or two of the areas which the briefing for the report kindly sent to us by the publishers suggests the Government and opposition parties should be asked to clarify. First, do we agree about the pressures on the NHS? The answer of course is yes, in so far as those are due to an increase in the number of elderly people, increasing technology, and increasing public expectation, but those will not continue to escalate for ever. They will eventually tail off.

Only one elderly person in four is in need of care. Although more people are surviving to 85 plus, they are now much fitter. Technological improvements can lead to reduced costs as well as increased costs. However, I agree that the balance is likely to be upward. Some of those extra costs are excessive. The Government need to continue to be firm in their pricing negotiations with the pharmaceutical industry and in their efforts to reduce prescribing costs.

Yes, public expectations are bound to rise. What is interesting however is that better off and better educated people are fitter and use the NHS less than poor or less educated people. That applies even to those who do not use any private care. They live longer, but they are more self-reliant. As society has increased its standard of living, a higher and higher proportion of the population moves into the professional and skilled sector. It is those who are left behind who have the worst health and the greatest burden of illness which falls on the NHS.

Dr. Richard Wilkinson of Sussex University and UCL has shown in a series of papers that the health of a country improves in proportion to the equity of distribution of income between the better and less well off.

The second question the briefing asks is: do we agree with the conclusions of the report? In brief, those relate to patients' views, healthcare professionals and funding. We feel that current avenues can be developed rather than that a new system be brought in to discover the views of patients. The community health councils need to be strengthened. The CHC members must have a right to be present and speak at all meetings of health authorities and trusts.

The membership of trusts and health authorities needs to be more representative than it is now. We spent many hours in this House talking about the membership of health authorities as the National Health Service and Community Care Bill went through the House. I thoroughly agree—this is the best part of the report—that healthcare professionals should explore the merits of a common core curriculum and greater flexibility between the professions.

It is the funding proposals with which we have the greatest problem. The report suggests that more private resources should be brought into the NHS; that those who wish should be able to buy certain extras within the NHS. The reason given for that is that it is unreasonable to expect the public sector to go on increasing its share of taxation revenue when other countries have a higher proportion raised privately.

In the table on page 34 of the report, four other countries which are wealthier than the UK are shown to have a higher proportion of healthcare spending in the public sector than we do. In fact, it is not given in the report; but they also have a higher proportion of their total GDP spent on health as a whole. The countries are Norway, Luxembourg, Sweden and Iceland. All of them have health statistics equal to or a little better than the United Kingdom. There is no great move that I know of in any of those four countries to change its system. I dare say that governments are in difficulty all the time about keeping up with the costs of those health services, but their health service systems are effective and popular.

To conclude, this expensively produced report is, to my mind, flawed because although some of its suggestions are excellent, it is inconsistent and cannot claim to be representative. It has not consulted widely enough, nor does it properly represent the views of the professions who work in the National Health Service. That is a great pity because the report took a great deal of time and expense to produce.

8 p.m.

Baroness Miller of Hendon

My Lords, my noble friend Lady Cumberlege is very disappointed that she is unable to be here tonight for this debate, as it was she who originally replied to a Question by the noble Lord, Lord Dean of Beswick on 17th October last year. However, it has given me the opportunity of listening to this interesting debate, and I would like to thank my noble friend Lord Hacking for making that possible. He started his speech by saying that he hoped I would give a thoughtful reply and I very much hope that he will consider that my reply is a thoughtful one.

Also, while I am making these pious wishes, perhaps I may say that I hope that the noble Lord, Lord Rea, enjoys the rest of the day, and we all wish him a very happy birthday.

Noble Lords

Hear, hear!

Baroness Miller of Hendon

My Lords, while not agreeing with all its conclusions, Her Majesty's Government consider the Healthcare 2000 report to be a useful contribution to the debate on the future development of health services. It is timely that we are debating this issue on the day that the annual NHS Priorities and Planning Guidance is issued. This provides the overall national framework and the context for the planning and delivery of health services in England for the coming year. Comparable guidance is also issued elsewhere in the United Kingdom.

As my noble friend Lord Hacking told us, the report UK Health and Healthcare Services, Challenges and Policy Options was published by the Healthcare 2000 Forum in September last year. The forum was established and funded by Pharmaceutical Partners for Better Health, an international group of research-based pharmaceutical companies.

The Government do not accept the report's central contention that the need for healthcare will necessarily increase faster than the availability of tax funding. I know that the noble Lord, Lord Rea, agrees with that. Nor, therefore, do we accept that we face a stark choice between increasing user charges and/or patient co-payments and reducing the services provided by the NHS. The Government are firmly committed to the founding principle of the NHS—that it will remain open to all on the basis of clinical need and regardless of ability to pay—and we would not contemplate any system of funding that jeopardised this.

The other main issues raised in the report, which I will address in turn later, are: a proposal for a statutory body to represent the patient's voice at national and local levels; consideration of a common core curriculum for all entrants to the healthcare professions; the development of integrated care management to allow the purchase of packages of care; and consideration of the introduction of competition between health authorities and a mix of public and private franchises in healthcare purchasing.

This Government are justly proud of our record on NHS funding. I note that my noble friend Lord Colwyn felt that all governments do their very best to put whatever is necessary or whatever they are able to into the National Health Service. Since 1978–79 spending by the health service in the United Kingdom as a whole has increased by more than 70 per cent. in real terms. At the same time we have greatly improved value for money in the NHS. In England, for example, efficiency in Hospital and Community health services has increased by over a quarter between 1978–79 and 1994–95.

The report is probably right in concluding that pressure on health service resources is likely to grow. One key pressure arises from demographic change. However, it is a pity that there is no acknowledgement in the report that demographic pressures are relatively modest for the next decade or so, giving us a window of opportunity before the real challenges of the second and third decades of the next century.

The long-term growth in demand for hospital and community health services from demographic pressures is expected to be lower over the next decade than over the last. Demographic pressures are expected to add only around 0.5 per cent. per year to costs for the next 10 years compared with 1 per cent. a year in the past 10 years. Again, taking figures for England, at a time when demography was adding 1 per cent. a year to demand pressures, real resources for hospital and community health services were rising by 3.4 per cent. and activity was increasing by 2.6 per cent. per year. Recent experience therefore is that extra money used more efficiently has not only enabled the NHS to accommodate the pressures on it but to increase the level and range of treatment that has been provided. In relation to demographic pressures, this task should be easier over the next 10 years than over the last.

The Government welcome the rapid development of medical science, which is contributing enormously to improvements in healthcare. The rate of advance may well accelerate but this will not necessarily mean an acceleration in cost pressures. The impact of medical advance on overall healthcare expenditure is a complex one. Some highly effective innovations increase both treatment costs and overall expenditure. But others can reduce expenditure across the health sector as a whole and also enable us to improve quality in healthcare while simultaneously reducing resource pressures.

To enhance our knowledge of such significant clinical advances, the United Kingdom was the first country in the world to establish research and development as a core function of public healthcare. Since 1993 over 300 studies have been funded by the NHS Executive under this strategy in priority areas, including mental health, heart disease and stroke, cancer and the links between primary and secondary care and health technology assessment. Related activities have also taken place throughout the United Kingdom. The Government will continue to monitor the impact of medical advance on overall healthcare expenditure. There is so far no evidence that the pressures will prove to be unaffordable.

Although we recognise that priority setting is a fact of life, we reject the centrally determined approach to priority setting that appears to be proposed by Healthcare 2000. Instead, the Government favour priority setting at three levels: Ministers set out a framework of national priorities and targets for improvement; health authorities (or health boards in Scotland and health and social service boards in Northern Ireland), and GP fund-holders assess the needs of their population and the services required to meet them; individual clinicians decide the most clinically appropriate treatment and clinical priority for each patient. This overall approach was endorsed last year by the Health Select Committee in its inquiry on priority setting in the NHS.

Improving the effectiveness of NHS clinical services has been a central objective for a number of years now. An example of this is the NHS Executive's approach for England which is set out in Promoting Clinical Effectiveness and was launched in January this year. Similar initiatives are also under way in Wales and Scotland. The Healthcare 2000 Report also rightly refers to Health of the Nation, with its aim of reducing avoidable ill health and premature death and promoting longer and healthier lives. Similar strategies are being taken forward in all four home nations.

Health Ministers and officials regularly meet patient groups in a wide variety of different contexts. We do not see a need to create a statutory body to represent the patient's voice at national and local levels as Healthcare 2000 proposes. This would compromise the independence of patient groups and could present a false and bureaucratic picture which underplayed the great diversity and richness of their views.

However, the Government welcome the report's emphasis on improving patient information and representation. I know that the noble Lord, Lord Butterfield, is concerned about this. In England, for example, it is one of the six medium-term priorities for the NHS to: Give greater voice and influence to users of NHS services and their carers in their own care, the development and definition of standards set for NHS services locally and the development of NHS policy both locally and nationally". We are also developing a programme of action throughout the United Kingdom at both national and local level, building on the Patient's Charter programme. We are seeking to foster a variety of local good practice and avoid inflexible national blueprints.

Under an information systems strategy for NHS research and development, arrangements are in place to make information from research findings accessible to patients, carers and self-help groups. This is being addressed in different ways. The NHS Centre for Reviews and Dissemination is tasked with reproducing research findings in a user-friendly way to the public by, for example, publishing information leaflets on maternity services. I have other examples, but in view of the time, I must move on.

Like the noble Lord, Lord Rea, we welcome the report's suggestions about the developing role of healthcare professionals as a valuable contribution to an ongoing debate, and I know that that is of interest also to the noble Lord, Lord Butterfield. We are encouraging and promoting inter-professional learning opportunities. We have commissioned a survey of inter-professional learning initiatives in England, the results of which will be shared when available. The NHS Executive has also commissioned a major programme of research into human resource effectiveness and one key strand is the issue of role boundaries of healthcare professionals and the educational implications. Comparable work is under way elsewhere in the United Kingdom. But it is a matter for individual university medical schools to determine their own undergraduate medical curriculums. The noble Lord, Lord Butterfield, is right to say that we must attract the best people into the medical profession.

Among the competencies required of the next generation of doctors are: flexibility and appreciation of the benefits of multi-professional working, which both noble Lords opposite mentioned; better communication skills; an ability to empathise with patients and colleagues; a greater appreciation of the opportunities and challenges of primary and community care; and a greater understanding of ethics. The noble Lord, Lord Butterfield, was so right to mention that. These are major developments in undergraduate medical education which will not fully work through until well into the next century.

I turn now to the report's proposals for integrated care management. These are precisely what we are aiming to achieve through a primary care led NHS, the aim of which is to empower patients and primary health care teams to oversee the entire programme of care for particular patients or groups of patients. However, unlike Healthcare 2000, the Government wish to see the primary healthcare team, with their better understanding of an individual patient's needs and requirements and the ability to make appropriate links to social services where necessary, playing the leading role in purchasing and managing integrated care.

The noble Lord, Lord Hacking, referred to a gentleman who had a problem with mental health services. Yesterday I had the great pleasure to stand in for my right honourable friend the Secretary of State at the opening of a GP fund-holding practice. It was extremely good to see counsellors present in the practice.

Lord Rea

My Lords, before the Minister sits down, she implied that the fact that the counsellors were with that practice was because of its fund-holding status. The practice with which I have been involved has had counsellors present for something like 15 to 20 years.

Baroness Miller of Hendon

My Lords, I am very glad to hear what the noble Lord said. That makes it even more interesting.

We are extremely proud of our National Health Service. It provides patients with treatment and care which are both clinically effective and a good use of taxpayers' money. We were extremely pleased to see that the Royal College of Nursing's parliamentary brief for this debate endorses that view. The National Health Service will continue to strive to meet the needs of individual patients and will adapt as their needs change and as medical knowledge advances.

Lord Hacking

My Lords, before my noble friend finally sits down, if I understood her correctly, she said that the pressure of demographic changes on health costs will be less during the next decade. Perhaps she will tell the House what is the basis of that assertion, particularly in view of the figures which I gave to your Lordships which indicate a substantial increase in health costs year by year and that there has been an enormous increase between 1990 and 1995.

Baroness Miller of Hendon

My Lords, my understanding is that we do not accept the figures in the report on this matter. We believe that demographic pressures are expected to add only about 0.5 per cent. per year to costs for the next 10 years compared with 1 per cent. per year for the past 10 years. However, if I am not correct about that I shall most definitely write to the noble Lord.

Lord Hacking

My Lords, but I am asking what is the basis for that assertion.

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