The National Health Service

HL Deb 06 November 1996 vol 575 cc643-709

3.30 p.m.

Baroness Jay of Paddington rose to call attention, on the 50th anniversary of the National Health Service, to the need to maintain the public service values of the NHS and to the case for immediate government action to prevent a breakdown of services this winter; and to move for Papers.

The noble Baroness said: My Lords, it is a great privilege for me to open this debate commemorating as it does the 50th anniversary of the day on which the Act establishing the National Health Service received Royal Assent. As someone who has been fortunate enough to spend most of my life benefiting from the existence of the NHS, I am very grateful for this opportunity to pay a heartfelt tribute to the 1945 Labour Government who created this great service for the whole nation. It is a particular pleasure to recognise the personal contributions of those of my noble friends who sit today in your Lordships' House but who as Members of another place fought a long, hard parliamentary battle to get this Bill on the statute book. Never let us forget that it was not a cross-party initiative. There was no bipartisan co-operation about setting up the NHS. In 1946, the Conservative Opposition fought the National Health Service Bill every inch of the way. Time after time, the Conservative Party went into the Division Lobbies to vote against it.

My noble friend Lord Bruce of Donington was deeply involved in the passage of the legislation as Parliamentary Private Secretary to Mr. Aneurin Bevan. I am delighted that my noble friend is speaking in today's debate. I am sure that he will recall vividly the political struggles of 50 years ago.

My generation owes a great debt to my noble friend and to all the members of the post-war parliamentary Labour Party who gave us, our children and our grandchildren the National Health Service. If we in our turn are to pass on a universal public service funded by taxation and based on need and equity, we must renew those founding values and stop the erosion that has been happening in the past few years. Above all, we must elect another Labour Government to prevent the NHS becoming simply a safety net service for those who cannot afford anything else, which sometimes seems to be the situation today.

After 17 years of policies based on the sovereignty of the market and individual self-help, it sometimes seems a little anachronistic to talk about and emphasise public service and the strength of social solidarity. But one of the most encouraging pieces of research I have read recently about this country was published earlier this year by the Public Management Foundation. Called The Glue That Binds, it demonstrates the extraordinary value which the British public in 1996 puts on public services and particularly on public healthcare.

The report shows that 94 per cent. believe that public services are essential today and 97 per cent. believe that they are there for everyone. The NHS is regarded as the most important public service by more than three-quarters of the population. In other words, people still accept the original values. They do not want their healthcare to be commercialised or privatised. They still want services free at the point of need and provided on an equitable basis. Yet, in the past few years, there has been a 35 per cent. rise in private health insurance and one in five of all non-emergency operations now takes place in the private sector. Why is that? It is because people no longer have the confidence that the NHS, as they have known it, will continue. They have been alarmed by the history of the past few years. They have seen that under the Conservative Government's 1990 National Health and Community Care Act—the so-called health service reforms—the internal market has fragmented the national structure of the service and has introduced a type of commercial competition which works against equity of access. Indeed, the very existence of the internal market has almost by definition undermined the public service values of the NHS. That is why we on these Benches are pledged to abolish it.

It is not appropriate today to reopen the detailed debates we have had often in your Lordships' House about the precise functions and organisation of the internal market. However, it is relevant to remember that it was set up to introduce business methods into the NHS so as to achieve greater efficiency in providing healthcare and above all, it was said, to ensure that competitive contracting between hospitals and other health providers enabled "the money to follow the patients".

What has happened? What has happened is that 400 small business units—the trusts—have been set up at a cost of hundreds of millions of pounds. The trusts have been given spurious independence to negotiate annual service contracts for health authorities and local pay deals with their staff. The internal market has cost £1.5 billion and the result has been 20,000 more accountants and administrators in the NHS, 50,000 fewer nurses and the whole package wrapped in miles of red tape.

At the same time, the Government, in the name of devolved management, seem to have abrogated responsibility both for the trusts' financial viability and for any overall strategy. That abrogation of national responsibility is perhaps one of the most recent worrying departures from the public service ethos. After all, the NHS now absorbs about £40 billion of tax revenue and employs one in 27 of this country's working population. Parliament has ultimate democratic responsibility for that vast public enterprise and yet today Members of Parliament find it more and more difficult to get Ministers to acknowledge responsibility or to provide appropriate information. "That information is not held centrally", or, "That is an issue which must be locally resolved", are answers all too frequently given to specific and legitimate questions about local health services.

In July, my honourable friend Mr. Nigel Spearing asked a Question in another place about health authority deficits during the coming winter, a subject to which I shall return. He was told that the information was "not suitable for publication". My Lords, not suitable. Given the figures that have emerged since, it was probably an appropriate response.

More seriously, general concerns about the lack of public accountability of the health service as a whole were reinforced two weeks ago by the third special report of the Select Committee on the Parliamentary Commissioner for Administration, published on 24th October. Talking about the health service, it said: We are concerned that public and parliamentary accountability are being ignored. If the management is being devolved locally, we believe that one of the prime duties of the NHS Executive is to ensure that Parliament is not thus deprived of information by which it can judge the overall performance of the Health Service".

Of course, the overall performance of the internal market has never been evaluated properly by the Government. Fortunately, for the purposes of this debate, we have the advantage of a timely independent report by two health policy academics, Anna Coote and Professor David Hunter, also published in October. I quote their judgments on the internal market: Market rules & have been found to cause undue fragmentation, to prompt inappropriate managerial behaviour, to carry prohibitively high transaction costs and to encourage a preoccupation with the process, rather than the purpose or outcome, of health care & Staff have become demoralised & by what they perceive as commercial values swamping the public service ethos of the NHS. The general impression gained by patients, practitioners and other observers has been that standards are, at best, holding steady and, at worst, declining dangerously". By any standards, that is a fairly devastating critique of the present system: it is precisely that intense concern about standards and quality of care which is fuelling the growing sense of crisis in the NHS today.

The general agreement is that the financial crisis in the service this year is worse than at any time since the winter of 1987–88 and that patient services all over the country are bound to suffer. Of course, it was the 1988 experience which drove an exasperated Prime Minister Thatcher to set in train the review of the NHS which ultimately led to the 1990 Act and the internal market, which in turn was intended to sort it all out.

Instead, in November 1996 we are facing another precipice—a precipice belatedly recognised by the Government this week as the Secretary of State Mr. Dorrell has been trying to secure a better deal from the Budget. Already 36 trust hospitals have gone into the red, despite a statutory responsibility to break even. The British Medical Association has said that the health service may well be reduced to an emergency service only this winter. The chairman of its consultants' committee, to whom I spoke this morning, reports that non-emergency surgery has virtually ceased in many places and that waiting lists are growing fast.

Just this week the ENT consultants at Addenbrooke's Hospital, Cambridge, reported that they were now offering patients an 86-week wait for their outpatients clinic. They have a backlog stretching to 1988. The Royal College of Nursing for its part is concerned about A&E departments—about accidents and emergencies—and believes that more people going into those departments, as is bound to happen in the next few months, will inevitably increase the number of trolley waits. The college's latest survey of A&E units shows that nearly half have patients waiting overnight for ward admissions, still on trolleys. The National Association of Health Authorities and Trusts has borrowed a macro-economic expression of gloomy resonance and talks of the NHS "overheating" and facing severe financial problems.

In the past few days, as I said, we have had the interesting spectacle of Mr. Dorrell conducting PESC round negotiations in public, "letting it be known", as they say, that if there is no more money the Government will face a pre-election period of embarrassing service breakdown. The rumour now is that some extra resources were agreed at yesterday's Cabinet meeting, but any agreement for next year can have little impact on this winter's crisis. When the Minister, whose integrity is respected by everyone in all parts of the House, replies to the debate, I hope very much that she will not be over-optimistic about the picture now and that she will not repeat the simple, official mantra of statistics about ever-increasing activity in the NHS and ever-increasing funding which, frankly, is becoming very threadbare.

I believe that all of your Lordships who follow these matters know that there have been additional recent cost pressures in the NHS. They have been caused by such things as improved medical technology, funding the new terms and conditions deal for junior doctors and the additional burdens of mental healthcare. But we also know how much money is being wasted in the internal market. We know that the existing public expenditure could have been put to much better use without the costly infrastructure of that market. Indeed, until this week, when Mr. Dorrell made public his bid for more resources, Ministers constantly told us that the "reformed" NHS had become a highly geared, securely funded enterprise enjoying strong and continuing growth.

However, figures published in October in the report of the Health Select Committee on Health and Social Services Expenditure show how bad the real financial situation has become. The report shows that this year's growth for hospital and community services is a minimal and measly 0.3 per cent. That 0.3 per cent. becomes even less lavish—indeed, it is reversed—when looked at in the context of the so-called "NHS inflation index" which, over the past 10 years, has increased by 1.3 per cent. per annum more than the general GDP deflator. Apply the NHS inflation index to a 0.3 per cent. growth and it becomes a 1 per cent. cut, equal in real terms to a loss to the service of £236 million. Equally, if we accept—and the Department of Health accepts it—that the increased demands of an ageing population add, on average, 1 per cent. to NHS costs every year, then, again, this year's so-called "growth" becomes a real cut of 0.7 per cent., a loss in this instance of £165 million.

In that general context it is hardly surprising that halfway through the financial year local trusts and health authorities are already running out of money. The only surprising thing is how long it seems to have taken the Government to realise the implications for patient care.

My honourable friend in another place, Mr. Spearing, has just succeeded in prising out of the Government the figures for projected health authority deficits this year—the information that was earlier deemed "unsuitable" for publication. The projections, based on the first quarter's figures, show that 63 out of 99 health authorities are expected to be in deficit and that several will be substantially in the red. Birmingham shows an £8 million deficit, Merton and Sutton, £11 million, and East London and the City, £16 million. Perhaps, on the basis of those figures, which have now been published, the Minister may reconsider her answer to my noble friend Lady Hayman on 16th October (col. 1681 of Hansard) when she said that she understood that only one health authority was in trouble.

Many of the health authorities and trusts in the worst position are in inner cities where population health needs are often greatest. The London region is particularly badly hit. Many noble Lords will have read recent letters to The Times from London medical and nursing directors expressing trepidation about the next few months. These senior doctors and nurses finished one letter by saying: Throughout the service staff at all levels fear for our ability to continue to deliver a safe service".

Surely that level of concern from dedicated professionals worried simply about the safety of their service brings us back to the first part of today's Motion; namely, the need to maintain the public service values of the NHS".

Over 50 years our health service system has often come through political controversy and financial crisis because of the public service—the extraordinary commitment of the people who work in it. Today, sadly, that ethos is threatened. It is threatened by the bureaucratic methods and the often unsympathetic management of the internal market. Many of those who have been trained in the caring professions feel that they have a vocation to work in the NHS and have been very uneasy about the creeping commercialism of the past few years.

In 1946, on Third Reading of the Bill in your Lordships' House, the Marquess of Reading said that he had little doubt that the health service would be administered in a, lofty spirit of public service and not in a narrow spirit of personal or political gain".

Sadly, that has not always been true in the internal market.

So today the historically excellent standards of the NHS are threatened by staff shortages. Professional enthusiasm is waning. All over the country hospitals have problems recruiting consultants in every specialty. There are vacancies for anaesthetists. There are widespread vacancies for specialists in paediatrics, psychiatry and orthopaedics, as well as for GPs. Sixty chairs of clinical medicine are vacant, with the obvious long-term implications for the next generation of medical students. In nursing, there will be only 9,000 newly qualified nurses starting work next year compared with 37,000 in 1983. Among those practising now, one in five expects to have left the NHS in two years' time.

Those are bleak figures. They represent a loss of confidence in the future. The people who work in the health service seem to feel as insecure as the patients taking out private insurance about where the health service is going and where the service they have grown up with will end up. Will it be privatised? Will treatment be limited by age or by illness? How far will the private finance initiative develop?

No one on these Benches wants to preserve the NHS in aspic. Healthcare and people's expectations of it have been revolutionised since the 1940s. Systems must change and the health service is no use to anyone if it simply becomes a treasured, national monument. But, despite 17 years of Conservative Government, the old values of social solidarity and collective responsibility on which the post-war Labour Party founded the NHS do still exist. We must hope that the health service will survive this winter's freeze and that, next spring, a new Labour Government will restore it to its public service vigour. My Lords, I beg to move for Papers.

3.50 p.m.

Baroness Seccombe

My Lords, I thank the noble Baroness, Lady Jay of Paddington, for giving us the opportunity to debate this important subject today. I begin by declaring an interest, although not a pecuniary one. I am deputy chairman of Nuffield Hospitals. I am delighted to contribute to the debate, although of course it is not possible in the time allowed to cover every aspect.

Fifty years is a real landmark and a time for celebration, particularly for a service which has served us well and which received the Royal Assent in 1946. It is a time to reflect on the past and to look to the future. I am sure that we can all celebrate the achievements of our NHS. I say "our" deliberately as I feel it is a service which everyone in this Chamber reveres and applauds. Our personal experience of the care that members of our families, close friends and indeed all patients receive in time of need is so much appreciated. In a service employing nearly 1 million people the love and professional care dispensed to sick people at a time of crisis is respected and envied throughout the world.

That brings me to the Motion before us today: the need to maintain the public service values of the NHS". We all adhere to the basic belief in an NHS free at the point of use and available to all on the basis of medical need and not ability to pay. Much has changed since the birth of the NHS in 1946. It was thought at that time that if all those who needed treatment received it our medical problems would be more or less solved. But the rapid development of scientific knowledge and the medical procedures flowing from such research were not even dreamed about. Who would have thought that such human repairs as hip replacements and even heart and lung transplants would take place? Today one hears quite frequently of elderly people who have had a cataract operation, two new hips, and now knee replacements. These operations bring great relief and pleasure to patients and enhance their quality of life in their latter years. I marvel at it and can only be grateful to those who make it happen. It is a far cry from the early days when pain, immobility and loss of sight were often part of a pensioner's life.

The big problem is, however, that all these sophisticated and complicated operations are extremely costly. Our expectations have changed completely and we look to government to provide the very best of care for our people. It is for that reason that since 1979 this Government have increased the real resources to the NHS every year. The increase over and above inflation now means that spending on the NHS stands currently at £724 for every man, woman and child in the UK compared with £444 in real terms in 1979. That is an impressive figure by any standards. However, the figures also indicate—and I wish to stress—that this is not a free service; it is free only at the point of delivery. The expertise and dedication of the medical professionals has been recognised. Nurses' average earnings have gone up by nearly 70 per cent. in real terms and doctors' pay has risen by a third in real terms. We should not forget that under Labour both were cut in real terms. One of my saddest memories of the NHS, during the "winter of discontent" in 1978, was the sight of hospital porters standing by their braziers ordering who could or could not be admitted to hospital. There was not much evidence of love and care there as sick people were turned away.

Of course, general standards of health are improving all the time. A child born today can expect to live two years longer than a child born in 1979. Further, the proportion of babies dying in the first year of life has fallen by almost a half. The developments that have taken place and our expectations mean that it is imperative to have a well managed service providing value for money. We believe patient care must come first. That was not always the case. It certainly seemed to me at one time that it was a service geared to those who worked in it rather than to those who used it.

It was a considerable task to undertake the reforms of 1990. It is always difficult to bring about change in an entity employing so many people, but that is even more daunting when it is a change of culture one is seeking: the prime importance of the patient, strong and effective management and value for money. The task continues and the results are bearing fruit with even more patients being treated than ever before. Now I wish to look forward to the next 50 years. There will no doubt be many unforeseen challenges but perhaps the most formidable will be that of the ageing population and the finance required to meet the demand. I was delighted to hear the Prime Minister say at this year's Conservative Party conference, For over 17 years through thick and thin we Conservatives have found extra money for the National Health Service. & So today. I give you a Health Service guarantee. & The National Health Service will get more, over and above inflation, year on year on year on year on year, for the 5 years of the next Conservative Government This of course will be in addition to the £43 billion budget this year.

I am astonished to hear no such pledge of new money from the Labour Party. Its commitment to the minimum wage and social chapter can only succeed in offering less money for patient care. It seems strange that it advocates such a strong pledge to a Scottish parliament and a Welsh assembly with their inherent costs but nothing to the NHS. We on these Benches have tremendous pride in the NHS. It delivers a quality of care not bettered anywhere in the world. In fact those who have direct experience are full of praise for the NHS. But it is the whining of those who run it down who put fear in the hearts of the vulnerable and sick. We are proud of our achievements, making the NHS accountable to patients and taxpayers, taking decision making to local levels, allowing clinicians to become more involved in how the NHS is run, and of course treating more patients. As my noble friend Lady Thatcher said, the NHS is safe in our hands. I celebrate the past 50 years with great pleasure and I look forward to the Conservative Government piloting the NHS into the 21st century.

3.57 p.m.

The Lord Bishop of Exeter

My Lords, I am grateful for the fact that the noble Baroness, Lady Jay of Paddington, has pinpointed public service values. We know that managing scarce resources is a painful business because of the difficulty of deciding priorities. I draw your Lordships' attention to an area where the allocation of resources has increased, although the value of this particular area is long term and the results cannot be quantified in terms of quick patient cure.

I refer to the way in which in the past five years trusts and authorities have noticeably increased the number of fully funded, full-time hospital chaplaincy posts. I must declare an interest as the chairman of the General Synod of the Church of England Hospital Chaplaincies Council. This increase in posts, which brings the number of Anglican full-time hospital chaplaincy posts to over 300, is an example of treating value in its deepest sense. Here we have an example of treating the patient as a whole person. Here we have an example of appreciating the role of hospital chaplains and of treating them on exactly the same footing as other members of staff. They are members of the whole hospital team. They are under the disciplines of accountability and standards of performance. They play a considerable role in maintaining the morale of staff. Much of their ministry is to the staff, as well as to the patients.

Over the past 50 years great advances in medical technology have had the result of speeding up treatment and reducing the length of patients' stays in hospital. That is welcome but it brings the need for vigilance: to respect the patient's need for quality of human care for the whole person.

Perhaps I may draw your Lordships' attention to the areas of psychiatry and psychotherapy. They do not involve expensive technology. They are treatments for the whole human person. Progress is often slow, but it can prevent stresses which cause physical damage, which in the long run costs the National Health Service far more. Paradoxically it is my impression—in some cases it is my information—that psychotherapy and psychiatry tend not to fare so well in fund allocation compared with the more popular, prestigious but more expensive surgical operations. I wonder why that should be so. Those are factors to be taken into account in any discussion of public service values.

In conclusion, perhaps I may reflect on the word "public". Over the past 50 years our society has become more complex. One of the reasons is greater ethnic diversity. That was reflected in a Department of Health circular a few years ago in which the key phrase in relation to chaplaincy was spiritual care. Trusts and authorities are buying into forms of spiritual care as they judge appropriate. That is now becoming apparent, especially in areas of high ethnic concentration. The hospital chaplaincy organisations recognise that fact. They are organising a national consultation next year to explore values in multicultural societies as they relate to the National Health Service. That will be an appropriate preparation for the celebrations for the 50th anniversary in 1998 of the start of the National Health Service. They are celebrations which, despite the difficult issues of resources and priorities, will have plenty of good things about which to generate pride and gratitude.

4.3 p.m.

Baroness Turner of Camden

My Lords, I should like to contribute to the debate on the National Health Service, so ably introduced by my noble friend Lady Jay, with particular reference to the care of the elderly and especially the disabled elderly. Everyone must have been shocked and dismayed at the announcement by a London hospital that it would not take patients this winter over the age of 75. I believe that it has had to amend that slightly as a result of the outrage it caused. Nevertheless, it is simply symptomatic"of an attitude to older people which fills many of them with dread, in particular those who are alone.

A lot of the assumptions about the cost of caring for the elderly are now turning out not to be correct. Assumptions about a "ticking time bomb" have recently been exploded by the Government's own figures. It is true that there has been a steady rise in such costs, but more recently there has been a decline. Even so, the cost of providing personal social services was only 1.3 per cent. of such expenditure; and now it has dropped to 0.4 per cent.

The majority of old people make no special calls on government support beyond their state pension. But for the minority who need to make such a call the prospects seem dire. It is the worry that they may need long-term care in the future that is a major concern for many elderly people. The state has effectively opted out of the obligation to provide such care. There have been stories about "bed blocking"—a rather nasty way of describing a situation in which elderly people who can no longer be effectively treated in hospital have to stay there because there is nowhere else for them to go. They are not fit enough to look after themselves and perhaps have no relatives who can take on this job. There are no residential homes able or willing to take them at affordable rates.

The local authorities are supposed to provide care in the community. Just how inadequate that often is I know from my own experience when several years ago my late husband became ill and disabled. When I suggested to the very nice woman who came to see me from the local authority social services department that there was an obligation to provide care in the community, she said that while that was certainly true there was a rider: it was "within available resources". In the borough resources were very stretched and it would be obliged if I would arrange to do as much as I could myself. This I was fortunately able to do. I was working and had an income. I could therefore afford to provide the many additional things required by a chronically sick and disabled person. But all those items were costly—impossible for many elderly people living on basic state benefits; and therefore they do not receive some of those necessities.

Had residential care become a necessity, which I always feared might be the case, around £20,000 a year out of taxed income would have had to have been found for anywhere reasonable in the London area—again an impossibility for most people.

The Government's response to that is to suggest that people should take out private insurance when they are young in order to cover the possibility of care being needed at a later age. But only the better off are able to afford that. People are already being told to take out ,private pensions if they are not in an occupational scheme—and, incidentally, a much higher level of pension than the average would be needed to meet the cost of residential care at the level to which I have just referred. If added to that is the requirement to pay out for insurance should incapacity happen when elderly, it can readily be seen that not many people will find that a workable solution. That is particularly so since most will be asked to make those payments at a time when they have the expense of paying off the mortgage and bringing up a family.

But there is no reason why long-term care of the elderly should not be provided by the state. Only about one in five of the elderly population needs such care. The problem has been exaggerated by those who tend to be alarmist about the cost of the welfare state. It is a matter of political will. Neither should it be necessary for elderly people to have to sell their homes in order to pay for such care.

The Government's policies, which have been directed to moving people out of hospitals and institutions as quickly as possible, have meant a growth in the provision of private residential homes. Many, as I have said, are very expensive, and not all of them are as good as they should be. Some no doubt provide excellent service, but not all of them; and I question whether the inspection service is all that it should be. It must be remembered that elderly people are often very vulnerable and, therefore, not always willing to complain if things are not as they should be. In the meantime, that is just one of the problems that arises from underfunding.

The BMA claims that there is simply not enough money. Routine surgery and routine treatments are being cancelled, as my noble friend Lady Jay said, as a result of the cash crisis. In such a situation it is hardly surprising that elderly people rate low among priorities. Many of them know this and are often frightened, particularly those who are alone—and that is a quite common situation. The days of the extended family are over. Families now tend to be dispersed and may live some distance away from a widowed father or mother. We are failing our elderly, in particular our poor elderly, unless we take steps to deal with the situation.

Many older people face the winter with trepidation. The BMA has warned about the crisis that the NHS may face this winter because of underfunding. Our doctors and nurses do a fine job but frequently have to work under intolerable pressures. The so-called reforms to introduce a "market type philosophy" have not, in my view, contributed to improving services; on the contrary. My noble friend Lady Jay explained in some detail exactly what has happened as a result of the so-called reforms. Let us hope that the Government will pay heed to those who work in the service and who speak with authority from their own experience.

The NHS is a priceless asset. People are justifiably proud of it. But for many, particularly the elderly, the service does not seem to be there when it is needed. I urge that something should be done to bring these concerns to the attention of the Government.

I apologise as I am afraid that I shall not be able to stay until the end of the debate; I already have a long-standing commitment.

4.10 p.m.

Baroness Rawlings

My Lords, I, too, thank the noble Baroness, Lady Jay of Paddington, and congratulate her on initiating the debate. It is a special day, being the 50th anniversary of the National Health Service. It is truly a day for celebration and one on which we should be proud.

I declare an involvement, albeit very tenuous. I feel I should mention it even though I derived no financial benefit from it. I trained and became a Red Cross nurse through the Women's National Hospital Reserve. I served for many years, which naturally involved working with the National Health Service. I therefore have a little experience, though I am sure far less than many noble Lords in this House who have a very great specialised knowledge in this field. I have only positive memories of the hospitals where I nursed, of all the staff and the doctors, even though it was many years ago.

Just this week a friend of mine came back from a visit to a hospital in Teesside. She was amazed at what she saw and experienced. Her first words to me were: "How I wish I could take Harriet Harman and Tony Blair by the hand and show them round that hospital so that they could see for themselves how impressive it was. They cannot have visited any hospitals recently when they criticise the National Health Service; or perhaps they are deliberately evading the truth, embarrassed by the encouraging results which are clear for all to see and experience". She said that the reception area was welcoming and attractive, with a friendly atmosphere, the equipment all looked new and the nurses were all cheerful and efficient. The report from the hospital showed that no one waited for more than two months for treatment and there was only a two-week gap between seeing the doctor and seeing a consultant. That is a very different picture from the one painted by the party opposite.

Spending on the National Health Service has increased by 73 per cent. in real terms since 1979. That is my only statistic. I draw attention to it because it is remarkable. I shall not mention any other statistics, as I find that people become bored with them and they no longer carry the weight that they deserve. On the whole, people are uninterested in hearing good news. The statistics on record are indeed good news, and they are incredibly impressive. However, reeled out, they mean nothing to people and even less to a concerned patient.

I am afraid I beg to differ with the views of the noble Baroness, Lady Jay. The idea of the National Health Service was developed during the war and enjoyed consensus across the political spectrum. The Conservatives voted against the Second Reading of the National Health Service Act in 1946 because they disagreed with the way in which Labour was creating the National Health Service, and in particular with the nationalisation of the assets of the voluntary hospitals, not with the concept of the National Health Service itself.

If we compare the National Health Service of 50 years ago with the service today, we see a totally different world. We now live in a world where a heart by-pass or a hip replacement is as common as having your tonsils or your appendix out. Many premature babies, and thousands of 90 year-olds, all have more and more chances of survival. None of that was dreamt of 50 years ago. Some noble Lords might have read some of the ideas in an Asimov novel and would have been severely mocked had they thought that they could ever become reality.

We the Conservatives have a remarkable record in relation to the National Health Service as compared with that of the past Socialist Government. But of course the taxpayer, you and I, and one might even say the Government, have not put enough money into the National Health Service. Why? The simple answer is that no matter how much money is put into the National Health Service, there will never, ever be enough. I was told never to use the word "never" in politics. In this context, however, I am totally confident in what I say: there will never be enough money. And why? Because we have made, and are making, such brilliant advances in medicine that the costs and possibilities are infinite. Prioritisation is surely one of the most difficult decisions that doctors today have to make. New treatments are very expensive and we all live so much longer.

When I first started visiting old people's homes, I remember very distinctly being taken to a hallowed room where one 100 year-old lady lay in bed. I had never seen anyone so old. (I was a great deal younger in those days.) It created a deep impression on me.

A few years ago, I was visiting once again some old people's homes in my constituency and was amazed to find that in every one there were at least six people who were 100 years of age or more. I do not think that that was unique to Essex. Very many British people are living longer and with a better quality of life. However, another funding problem confronts us as the retired population outgrows the declining working population.

There is one other area in which I should like to declare an interest; namely, as a director of the Foundation of Integrated Medicine, which combines orthodox and alternative medicine. I should like to see more preventive medicine of any kind included in the National Health Service. I believe it is right and it can also save a great deal of money.

"He that has health, has hope; and he that has hope, has everything", is an old Arabian saying. Fifty years on, the British National Health Service is still the best in the world, and is still the envy of the world. It will always need to be reviewed and reformed. This is an area where the Conservative Government are truly talented and imaginative. We are exceptionally lucky to have today as Secretary of State someone so dedicated, determined and decisive as Stephen Dorrell.

4.17 p.m.

Lord Butterfield

My Lords, first, I thank the noble Baroness, Lady Jay, for instigating this afternoon's debate. I congratulate her on her sterling presentation of the difficulties that may face us in the short term and perhaps even the longer term, related to the huge demand for healthcare and the remarkable things that my colleagues in the medical and nursing professions can do to help people.

I have spent all but one year of my professional working life under the NHS. I was a terrific enthusiast for it when it came in. Indeed, when on occasions I went to America, I was branded there "a very rabid, socialist kind of fellow". In the United States they were not at all sure that the health service was proceeding along the right lines.

I hope that we are not to have too much party political scrapping over the health service. Wonderful things were done right back at the beginning of my time by Nye Bevan. I remember being introduced to the finer points of policy by Kenneth Robinson, a very remarkable Minister of Health. Later I was much impressed by the philosophy that I learnt from Keith Joseph when he was Secretary of State. I do not want to be drawn into putting my weight here or there. I do, however, wish to make three points which very much follow the remarks made by the noble Baroness, Lady Rawlings, about the need for prevention.

We shall continue to face serious problems of demand exceeding available resources in the health service. It must be sensible to pursue as best we can policies which diminish unnecessary self-inflicted illness. Many noble Lords have heard me on other occasions speaking up for health promotion. I remain unashamedly a supporter of that approach. I am interested in the approach mentioned by the noble Baroness, Lady Rawlings, and am delighted that the noble Baroness, Lady Brigstocke, who serves on the Health Education Authority, is to speak because she does great work on those lines.

I should like to think that we could have an emergency campaign to reduce colds, upper respiratory infections, pneumonia and admissions to hospital this winter because of the severe restrictions on the number of beds in many places. I read the BMA review of hospital needs. Although I know of wonderful hospitals where morale is high, there are also hospitals where there is concern about shortages. I do not know whether I could help the Health Education Authority to mount attempts to improve the statistics for respiratory infections this winter. As an aside, I was impressed by a demonstration that I saw which showed that people finger their noses and then shake hands. If any noble Lords have to give prizes at schools, I beg them to put a barrier on their hands. If they do not, the chances are high that they will have a cold two or three days later. I agree with Jewish people that it is important that we wash our hands before we eat. Many germs are picked up on our hands from our noses and on other people's hands from their noses. There will be a lot of colds this winter and I am sure that we could do much to restrict them.

I am a strong believer in health promotion and anything we can do in that field. I am also a strong believer in research into health promotion because the results of such research freshen the arguments that we can take to people to change their health attitudes. My young colleagues in that field have recently shown that it is an advantage to eat salads during the winter. Statistics show that people who do so have fewer problems with heart disease. Another group with whom I work in the flat lands of East Anglia is fascinated that it seems to be true that red wine contains elements which may protect our hearts against coronary disease. So we do not always go in for dull, harsh, heavy preaching; we sometimes have nice messages to pass on. I hope that we can carry people with us in the whole movement concerned with prevention of disease and improvement of health in that way.

Another point on which I wish to touch, because it worries me and many of us who are involved with young doctors, concerns teaching. That is the problem of inflationary compensation for people employed in university departments who work in hospitals. This year they will receive increases of 1.5 per cent. because that is all the universities can offer them. Their colleagues working beside them on the wards and at the bedside will receive 3.8 per cent. I hope that the Minister might just be able to cheer some of the young men where I come from by saying that steps are being taken and that it is hoped that the perennial problem of pay for those we call the young "academic" doctors has been resolved. When I say "academic" people, I do not mean those working in laboratories but those who are carrying out a straightforward clinical job in a teaching setting.

From my notes I know that there are many points which I should have made but have forgotten. However, I end by saying that I was impressed by the tired-looking Stephen Dorrell, who appeared on television before he went into the Cabinet meeting to find out whether he could squeeze resources out of the Government. I should like to believe that he succeeded. I should also be grateful if, in her closing remarks, the Minister could indicate whether it will be possible to put some of that money into the health service before the year is out, or before the winter is out because I suppose winter will continue to the end of the financial year. It may be impossible and, if so, my cry for health promotion and prevention of disease is all the louder. I am grateful to noble Lords for listening to me with such attention.

4.25 p.m.

Lord Bruce of Donington

My Lords, it is agreeable to take part in a debate which has been so thoroughly introduced by my noble friend Lady Jay. I am conscious that I have but eight minutes to establish one or two of the principles which I wish to be considered, so I shall endeavour to be brief.

As I listened to the noble Baroness, Lady Rawlings, I wondered whether we were in the same world. She invited us to consider a picture where the Conservative Party almost invented the National Health Service. Apparently the whole legislation was agreed across the country and there was rarely a ripple of disagreement. As one who was present at the time, some half a century ago, together with my noble friends Lord Callaghan and Lord Wallace of Coslany and also the noble Lord, Lord Boyd-Carpenter, I assure the noble Baroness that it was not like that at all. In fact, through its representatives in the Commons at that time, the Conservative Party fought the introduction of the National Health Service thoroughly and comprehensively. They fought it at Second Reading, they fought it in Committee, they fought it clause by clause, line by line. They voted against it on Third Reading as well. Moreover, they continued their opposition past the date of Royal Assent, which took place in the Queen's Robing Room in which your Lordships' House was sitting at that time. The Conservative Party continued the fight right until the Act came into force in March 1948, which was vesting day, when the whole apparatus began to swing into action. The Conservatives thought that they were going to prevent it.

Several things happened. Two of the most important were that, within three weeks of the introduction of the Act, over 90 per cent. of the doctors who had hitherto fought it signed up. Within a further three weeks, over 90 per cent. of the population signed up to the National Health Service. Thereafter, we had no trouble from the Conservatives. They behaved like cooing doves; nothing would be allowed to interfere with the legislation.

Of course, we all know that there are many individuals in the Conservative Party, some of whom are still known to me, who are fundamentally very nice people who support reasonableness when it is presented to them. I hope that I am able to number among them the noble Baroness, Lady Cumberlege.

After that we had a period of what was called "Butskellism". The National Health Service remained undisturbed, with hardly a ripple of disagreement between both parties, with the aid of the Liberal Party, until 1979. In that year a fundamental ideological change took place.

It was correctly apprehended by the noble Baroness, Lady Thatcher, who was the Prime Minister at that time, that the National Health Service was a living example of socialism in practice and that it was based on the ultimate principle "from each according to his ability and to each according to his need". That is a basic tenet of socialist philosophy to which I still adhere and I am very glad that a large number of people in the country do also. But it aroused the enmity of Mrs. Thatcher, as she was at that time. Her avowed purpose was to eliminate socialism from the English language and she did it in characteristic fashion. She had not been in office for two months before she doubled the prescription charge from 20p, at which it had been for eight years, to 45p. There have been 18 changes since then—an increase of some 3,000 per cent.—to bring it to what it is today, £5.40 per prescription.

We do not need any lessons from the party opposite about the health service itself or that party's basic philosophy. It wants to turn the health service into a business. For the party opposite there is little meaning in a vocation—a job which people do because they have a sense of mission, people such as doctors, specialists and nurses. That has no commercial value at all unless it can be made to serve profit of some kind for some of their nominees or generally for the richer part of the population which it is its business to represent rather than the nation as a whole.

So now we have a health service which is two-tier. There is no question about that. If I had more time, I could give examples and quote from various sections of the medical profession and even from the health authorities themselves. Indeed, the noble Baroness is not the only one who goes to hospitals. I do and I can tell her—probably she could confirm it if she were to be frank about it—that one of the first questions that one is asked when one goes to hospital is: "Are you private or are you NHS?" That is asked right from the beginning. The Government know perfectly well that the whole ethos of the health service as it is now is: "Can you afford to pay or do you want to wait a bit longer?"—it is not said how long it will be—"Of course you can have it done under the NHS and we give you the assurance that you will get exactly the same treatment as before in any case". We all know the essential truth of what I say. We should admit it to ourselves.

There is still time for the redemption of the Tory Party prior to the election. It can admit that a health service comprised—as it is—of people who have a sense of vocation rather than those searching for the accumulation of wealth is the only way in which the National Health Service can run. Let the Government admit it now and redeem themselves and I promise that I shall not harry them any more. I shall look upon them with the utmost benevolence, which becomes the attitude of one British citizen to another.

4.33 p.m.

Baroness Brigstocke

My Lords, I speak, as the noble Lord, Lord Butterfield, has already mentioned, as a non-executive director of the Health Education Authority. But I also speak as the mother of a nurse. I am only too aware of the monstrous problems that still face the National Health Service. Every single one of us sitting in this Chamber today cares deeply that the public service values of the National Health Service should be maintained. There are inefficiencies, cases of mismanagement and, of course, dire shortage of money. But at least over the past 17 years this Government have faced the problem and started to tackle the difficulties.

There could never—I use the word "never" advisedly—under any government be enough money to pay for the latest, sophisticated and expensive operation or treatment to be available for every single person in the population. In the words of my daughter, who is a senior sister in a very busy accident and emergency department in a large and justly famous hospital in London, "We, the people, the public, need to be less demanding and accept that we cannot, as of right, have everything. We all expect too much". It is intra-uterine surgery versus an acceptable standard of care for the elderly. For instance, this winter the A&E departments in hospitals will be particularly crowded with the elderly. Many of them—no, I mean many of us—will fall on icy roads and pavements, will slip in the wet or get blown over in the wind, fracturing hips and wrists.

Present conditions in some of our hospitals are unacceptable. They must, and I hope they will, be improved by the recently announced injection of money. My daughter told me how upset she was when she arrived just the other morning in her crowded accident and emergency department to find, I am afraid, that there were 10 people who had been there since the night before, one or two on trolleys. What would have happened if there had been an emergency? There was no space to put any ambulance load of casualties. But, to be fair, that does not happen too often.

Our doctors and nurses remain as the most valuable resource of our National Health Service. I do not know how to say that without sounding trite, but I know what I learned from my daughter and her friends and colleagues. For instance, my daughter has worked as a nurse for 20 years. Her work gives her satisfaction. She is glad that the role of a nurse has, over the years, been extended to include suturing, plastering and blood investigation procedures. But comparatively low pay awards for nurses send them a message that drastically lowers their self-esteem and destroys their morale.

Nurses are managers in a difficult and taxing environment, with huge responsibilities and enormous demands made on them. So to ensure that the hospital services maintain the services that we need throughout the coming winter and into the future, I urge those who manage the National Health Service to set a higher value on the nurses, to listen to their advice and, above all, to pay them appropriately for the professional work that they do.

I turn to the Health Education Authority. It is a special health authority within the National Health Service. As England's national health promotion agency, its task is to help people acquire and maintain good health. It is a key player in implementing the Government's Health of the Nation strategy and its work is recognised nationally and internationally. Echoing the eloquent speech of the noble Lord, Lord Butterfield, I remind noble Lords that treating people when they are sick is not the only job of the National Health Service. Medical services are rightly the top priority, but preventing disease and promoting health are also a vital part of its mission. That is why the Health of the Nation White Paper published in 1992 has been so important. First, it has focused our attention on health and not just on health services; secondly, it has challenged the National Health Service to find innovative ways of improving the general health of the population by adding years to life and life to years; and, incidentally, helping the elderly to live more active lives, less prone to accidents, less likely to have to become casualties in the A&E departments. Health promotion is central to the health of the nation and is an essential public service. Individuals have a responsibility for their own health but they need information, education and encouragement if they are to adopt a healthier lifestyle.

There is good news. The latest progress report on the health of the nation entitled Fit for the Future, published in July 1995, tells us that there really has been progress for most of the targets for which monitoring information is available. It goes on to tell us that there are one or two areas in which we are not making progress. The prevalence of smoking among school children has increased since the baseline of 1988 and obesity has been increasing among men and women since the mid-1980s. Without health promotion we would not see the dramatic successes of our national immunisation programmes. For example, cases of whooping cough have dropped by 95 per cent. in the past 10 years. Because of the HEA's promotion of the Hib vaccine, which prevents a particularly dangerous form of meningitis in children, 92 per cent. of young children in the relevant age group have been immunised. According to estimates, this means that 600 lives were saved last year alone. Britain now has one of the lowest rates of HIV infection in Europe. We have also had the most intensive public education campaigns.

Of course, a great deal remains to be done. The recent report from the Department of Health, Variations in Health, highlighted the differences in rates of sickness and death among socio-economic groups, regions of the country, ethnic groups and between men and women. Given that one of the primary service values of the NHS is equity, improving the health of the least healthy groups to the levels attained by the most healthy groups is a priority for the Health Education Authority. We need to reach young people. I very much welcome the creation of the Young People's Health Network, which the HEA is managing on behalf of the Department of Health.

So as we celebrate the 50th anniversary of the NHS, I ask for the true value of nurses to be properly recognised and I suggest that health promotion and education have an important part to play in improving the health of the whole population, from the young to the old and from the rich to the poor, thus relieving some of the burden from the NHS.

4.43 p.m.

Lord Monkswell

My Lords, I wish to add my thanks to my noble friend Lady Jay for the able way in which she introduced this important debate. In the debate to celebrate the 50th anniversary of the founding of the National Health Service, I want to record that it mirrors my life. I was born at the start of the National Health Service and have lived all my life with it. Like me, it has had its ups and downs. But I want to be hopeful for the future of both the National Health Service and myself.

I am the son of a doctor. I have served as a member of a community health council and as a member of a family practitioner committee. I aim to say a few words about the background, examine some current problems and also look to the future.

My father, Dr. Larry Collier, was a GP, a family doctor. For most of his working life he practised in rural Essex. He then moved to London and practised in Hackney. When he retired, he went to work as a medical officer in Falmouth, Jamaica. It was a fine record of public service in the essential elements of the National Health Service.

In Essex during the 1950s and 1960s he treated people in their homes, in his surgery and at the local cottage hospital in Halstead where he lived, although I think the matron carried out a good deal of the treatment herself. He also referred patients to the local district general hospital in Colchester, where he worked with the consultants; he also had the ability, if necessary, to refer patients to one of the big teaching hospitals in London.

One incident which I remember clearly, because it said so much about the National Health Service and my father, occurred when we drew up outside a large country house. My father used to spend a lot of time driving around the countryside doing housecalls and he sometimes took me with him. On this occasion he announced that he was going to visit a lady who was his one and only private patient. I had two questions for him. I asked, "Why does she pay you?" and, "What different treatment does she get?". He replied that she was a very old lady who had grown up believing that she had to pay to ensure good treatment, and seemed happy to do so, and that he gave her the best treatment he could, which was exactly the same treatment he gave every other patient.

The situation is very different today. We have far fewer cottage hospitals and the district general hospital is in some cases virtually no different from the teaching hospital. We have more GPs in group practices in health centres and fewer single handed GPs practising from their front rooms.

Some changes in the National Health Service have been for the better; some detract from the service. Apart from the problem of charges, which in some ways has beset the National Health Service almost from its inception, probably the biggest single change for the worse has been the introduction of the internal market.

Two significant things happened when the National Health Service was set up. Because treatment was on the basis of need, family doctors were free to refer patients anywhere. They had clinical freedom. An army of bureaucrats was demobilised and the cost of service was reduced. As a result, we have been able to have a better health service than other similar countries at less cost. Now, doctors can only refer patients to the so-called "cheap hospitals" and we have been recruiting a new army of bureaucrats—the lawyers to write the contracts, the accountants to count the money, marketing men to sell the products and managers to manage the whole process. The result is a breakdown of the system.

If we measure it in financial terms, we can see that individual trusts which have overspent are technically bankrupt while others are making obscene profits from the treatment of ill people.

If we measure it in terms of treatment, we can see people being discharged too early; we can see people being treated miles away from their homes, which detracts from their treatment; and this autumn, even before winter has fully set in, we can see accident and emergency services on the brink of closure and the knock-on effects of that on other parts of the service. There will almost certainly have to be an injection of cash to keep the system going this winter. The sooner the Government realise that the better.

Looking to the future, there is a better way of running the National Health Service. To start with, we need to go back to the original philosophy. Let us re-establish clinical freedom for doctors and demobilise that army of bureaucrats. Let us think of new ways of doing things. I have several suggestions. Echoing the call of the noble Lord, Lord Butterfield, let us look at a number of ways of disease prevention. For example, let us ban tobacco advertising. You know it makes sense. Too many of our susceptible young people are taking up smoking too early. It creates too much illness for our society to bear. Let us say to the tobacco companies, "It is not going to do you any good to keep paying the noble Baroness, Lady Thatcher, £600,000 a year. She will not be allowed to influence things".

We could provide good housing for all our citizens with adequate heating provision. We could promote home confinement with proper recognition of the role of midwives. We could ban the promotion of infant formula feeding.

The Labour Party has talked for years about the need for arms conversion and for arms manufacture to be converted to socially useful production. Let us convert the army of bureaucrats in the National Health Service to become socially useful workers.

4.50 p.m.

Lord Mottistone

My Lords, I, too, find this a welcome opportunity given by the noble Baroness, Lady Jay, to reiterate from this side of the House unswerving support for the principle of the National Health Service, as agreed by the coalition Government in 1944. That principle is that Britain's health service is free at the point of use and available on the basis of medical need and not the ability to pay.

I and my family benefited enormously from the health service throughout the 1940s, 1950s, 1960s and 1970s. On naval pay such treatment would have been impossible without the health service because in those days the governments of both parties paid naval officers extraordinarily badly. But that is another story.

The great problem for all governments during the past 50 years has been how best to organise, manage and pay for an enormous service providing healthcare for approaching 60 million people with an ever-increasing variety of ailments—ever-increasing because new ailments seem to be discovered almost as fast as earlier ones are conquered. The problem—and I have to say this—has been complicated by the deeply held belief of the Labour Party for most of the past 80 years that the health service can only be effective if nationally owned and administered by well-meaning Ministers and their officials and employees. We have heard from the noble Lord, Lord Bruce of Donington, and the noble Baroness, Lady Jay, that this Labour Party still believes that.

It is to be hoped that the lesson learnt in recent years in all parts of the world, not least in the Soviet Union and even in China, that Adam Smith is a better philosopher to follow than, say, Rousseau, will guide governments in the next 50 years of the life of the National Health Service. It is very important that that message should get through not just to us in this Chamber but to the world at large. A great many people are learning it. In particular, all the efforts of Conservative governments in recent years to decentralise the health service management and minimise the responsibilities of central and local government must be maintained and, where practicable, increased.

Another important complication in the development of the National Health Service has been the splendid skill of doctors and scientists associated with it in developing new methods of curing and curtailing illnesses of all sorts. That is a complication, as other noble Lords have said, because of the ever-increasing costs of giving effect to those cures especially as regards the equipment, the training of doctors and nurses and the number of people to whom a free health service has been guaranteed.

There has to be a limit to the costs of any central government undertaking, however well-meaning. On the whole, governments by their nature are not good at effecting such limitations—that applies just as much to Conservative governments as it does to Labour governments—because in the last resort governments cannot go bust. The iron discipline of balancing the books, so well-known to private industry, seems to be considered merely a useful intellectual exercise by all government departments, central and local, including the Treasury. This increasing expense complication calls for a continuation of Conservative government decentralisation and, whenever practicable, privatisation during the next 50 years. It is essential to keep this splendid service going. What was achieved in the early days occurred at a time when the problems were nothing like so great because knowledge was not so great and doctors, including the splendid GPs and hospital doctors who looked after me and my family between 1946 and 1976, were—let us admit it—more dedicated. They were people who really knew what they had to do. I am lucky because to this day I have always had the good fortune to have a first-class GP in many parts of the country. Those who say that the situation is so dreadful that the service will go wrong and that there will be a crisis this winter cannot be in touch with real life—certainly not in the Isle of Wight. Perhaps people who have the misfortune to live in big cities have their problems, but they always did. I recall going to see a doctor in Manchester who was having an appalling time with young druggies hovering on his doorstep and trying to stop patients from going through his door. However, that is another story. The point is that the health service is working very well and has to be kept that way. The less that government have to do with it the more likely it is that that will be achieved.

In conclusion, I was planning to press the Government, as I have done consistently since 1983, to stop shutting down beds in mental hospitals until there are suitable asylum care facilities for mental patients. The new 24-hour nursing homes may suit some sufferers though by no means all. However, as I was preparing this speech, I read on page 2 of today's Daily Telegraph that my right honourable friend Mr. Dorrell has anticipated me. I now await with interest his Green Paper, which, it is said, will appear after Christmas. I welcome his late conversion because, if he has been properly reported in the Daily Telegraph, he admits that the care in the community scheme has not worked. We all told him that it would not. In the meantime I trust that no more beds for the mentally ill will be shut down until the Green Paper has been fully considered and proper alternative accommodation provided. I wish the National Health Service a very happy next 50 years. I hope that the party opposite has the minimum amount of time to deal with it.

4.58 p.m.

Baroness McFarlane of Llandaff

My Lords, I, too, would like to add my thanks to the noble Baroness, Lady Jay, for giving us such a fitting way of celebrating the enactment of the National Health Service 50 years' ago. I started nursing 18 months before the appointed day when the service came into being. I can remember now standing by a fountain at Bart's with a group of medical and nursing staff wondering what kind of calamity would befall us since we had had our autonomy taken away.

For 50 years that apprehension did not seem to be fulfilled. But in the light of what has happened in the past two years, I wonder whether the apprehension was not prophetic. However, I do not want to open that wound again. I wish to give my thanks to the noble Baroness, Lady Jay, for so rightly drawing attention to the need to maintain the public service values that underpin the National Health Service. Some of us add to those public service values values from our own professions, such as the scientific values to which we operate when carrying out research that tries to add to our ability to work with evidence-based practice. More recently, we have come to recognise that we have to operate to economic values. I refer not only to value for money but to the value of making ethical choices in resource allocation and to the difficult choices associated with an ageing population and with the increasing costs of high technology medicine and research.

Although many of those values are enduring, values change from time to time. Representatives of the medical profession met in 1994 to consider what should be regarded as the core values of the profession in the next century. As I see it, the values operating in the health service have undergone considerable change since its inception 50 years ago. Some value changes have been due to changes in societal and professional values. We have heard that we are now all much more demanding. However, as Dr. Sandy Macara suggested, many of the changes are a response to government strategies and to the economic values which now drive the service. I think that it is for society to subject those changes in value to critical examination from time to time and to look at the values that we should like to see in the future.

I am one of those who subscribes to the view that many of the changes that have been made in the past 50 years in the health service have been to the public good. I was sceptical when market principles were introduced, but two years as a non-executive member of a district health authority served to impress me with the progress that we had made in being able to cost items of service far more effectively than in the past. At the same time, I regret what I perceive to be the monstrous army of accountants and managers involved in that exercise and, alongside that, the reduction in the number of trained nurses and the dilution of skilled manpower in the workforce. The values to which I give priority are those which enhance direct care for patients.

It is interesting that market pressures are now felt by all parts of the service. Health promotion and health education have already been referred to. I wonder whether market forces might profitably be employed in those areas. At the beginning of the week I picked up the latest edition of the journal of the Institute of Health Education which contained an article advocating the use of market forces in order to address perceived weaknesses and to encourage creativity with new opportunities. The journal advocated that market forces could be useful in the areas of health promotion and health education.

The 1946 Act, which we celebrate today, defined the principles and objectives of the NHS very broadly. The duty was laid on the Secretary of State to provide a comprehensive health service to secure improvements in physical and mental health and in the prevention, diagnosis and treatment of illness in England and Wales. However, when in 1976 the Royal Commission on the National Health Service (of which I was a member), considered the objectives of the National Health Service—incidentally, the Royal Commission was set up at the suggestion of the noble Baroness, Lady Castle, and as a response to yet another crisis in the National Health Service—we felt that we wanted to be more precise. We therefore suggested that the objectives should be to encourage and assist individuals to remain healthy; to provide equality of entitlement to health services; to provide a broad range of services of a high standard; to provide equality of access to those services; to provide a service free at the time of use; to satisfy the reasonable expectations of its users; and to remain a national service responsive to local needs.

I should like to consider that principle of equity. Many indices show that there is still a north-south divide in the provision and allocation of resources in the National Health Service. The North West Surveys Research Group in Manchester has shown that many of the indices, such as the standardised mortality ratios and the geographical incidence of coronary heart mortality, are adversely weighted to the north and that the allocation of resources in the north is not adequate to meet those greater needs. In July the Select Committee on Health in another place suggested that the allocation of resources should be weighted by need. I wonder whether the Government intend to implement the recommendation to redress the imbalance between north and south. There is still an inequity in general practitioner distribution in the north. We need 700 GPs to move from the south to the north if there is to be equal access to a GP. In terms of the value of equity, we should be looking at such matters.

5.6 p.m.

Lord Winston

My Lords, I must first declare an interest as a medical academic and as a clinical professor who practises both research and clinical medicine. Unlike most of the speakers today, I cannot say that I am particularly grateful to my noble friend Lady Jay for introducing this Motion. I had to interrupt an experiment to come here. Sadly, we have temporarily abandoned it but I hope that we shall be able to return to it. I make the point because some time ago it was suggested that I was neglecting my patients by coming to your Lordships' House, so I hope that noble Lords will see that we carry out experimental work as well as working with patients.

Much of my time is spent trying to get a budget for research experiments. Those of us who are trying to claw tiny sums of money from the Medical Research Council from its totally miserly budget of less than £300 million might be forgiven for observing that, in order to apply successfully for a grant for an experiment, we expect there to be some pilot data. There needs to be a fair review of the literature and other data to support an application for the work. There also needs to be a continuous audit of that research experiment. It is also customary for us to cite referees who will be called in to look at the experiment. Sometimes, we need overseas expertise also. Above all, our results are published for peer review.

Your Lordships must forgive me if I, as a medical academic, feel, together with many other medical academics, an extraordinary anger at the total failure of probably the largest experiment in the history of medicine. I am referring to the internal market. The internal market was brought in without pilot data or any attempt to see on a small scale whether it was desirable. There were no proper ongoing data or review of what was being done under the internal market. There has been a wholly inadequate audit of what has happened and huge wastage in administration. If I were applying for a research grant to the Medical Research Council that would be quite unacceptable. There is still no peer review. The Government's defence to this charge is to bring in irrelevances.

I understand that the rules of the House forbid me to quote precisely from Hansard in another place. But I may be forgiven for feeling extremely flattered that on 23rd October in a short speech the Prime Minister quoted me by name. He quoted a speech that I had made in the House of Lords which suggested that I was wholly in favour of the internal market. He quoted the one paragraph in my speech where I pointed out the advantages that the internal market had brought about: the fact that it had improved outpatient facilities, comfort for patients and waiting times for clinics. It strikes me as extraordinarily shallow of the Government to cite a wholly critical speech in the defence of the internal market.

I should like to draw to the attention of the noble Baroness, Lady Cumberlege, the plight of academic medicine. I believe that here there is a need for special pleading. It is a little odd to stand here and ask the noble Baroness for a pay rise, but I ask for some kind of commitment to clinical academic salaries. The noble Baroness will be aware that in February 1996 the review body recommended a rise of 3.8 per cent. for senior clinicians and 5.3 per cent. for junior clinicians. So far the universities have been able to offer only 1.5 per cent., for the simple reason that their financing has been cruelly cut back. Some face an effective loss of budget of up to 30 per cent. Parity in salaries is essential across the health service. Clinical academic salaries are the key to much of what is excellent in our medicine. Without that underpinning of clinical academic medicine we will be in a very serious position.

Currently one in 10 professorial chairs in this country is vacant. Recently my unit advertised for a clinical research fellow. Modesty forbids me to tell noble Lords the reputation that that unit enjoys. Five years ago over 80 applicants applied for that one fellowship. This year for the same post there were four British applicants, only two of whom could be seriously considered. There is a severe paucity of applicants for such posts where we try to promote the best of healthcare.

On the whole, clinical academics give about 50 per cent. of their time to the National Health Service and represent 10 per cent. of the consultant workforce. Many units in this country are run wholly by academics. For example, in the Wessex region the liver service in Southampton is wholly academic. In Oxford and Cambridge renal transplantation is largely an academic-derived service. Many pathologists in the health service are academics.

Today, many noble Lords on both sides of the House have repeated their respect for and commitment to the health service. We are proud of the health service because of its academic interface with teaching, innovation, research, which is still world class, and excellence of treatment. I promise you that that cannot continue if academic medicine is further undermined.

Finally, if one considers where this country should focus its aims, one of the areas in which it has a clear lead is biotechnology. That is an outstanding achievement which contributes very greatly to this country's wealth in all kinds of ways, not least in the pharmaceutical industry. If we undermine that aspect of the National Health Service, we will not be able to continue in the next 50 years as we have in the past 50 years.

5.15 p.m.

Viscount Bridgeman

My Lords, it is always a pleasure to follow my colleague the noble Lord, Lord Winston (if I may dignify the relationship by that name as a mere special trustee of the Hammersmith Hospital). There are many noble Lords of a more suitable age than I to speak in this debate on the 50th anniversary of the founding of the National Health Service. As I understand it, 50 years ago two assumptions were made in good faith which did not come about. The first was that the nation would achieve an acceptable standard of health and it would then be largely a matter of care and maintenance. What was not appreciated then was that people's health expectations would similarly rise. The second matter, which was certainly not foreseen, was the huge and rapid rise in clinical technology and the huge costs that that would involve. Governments of all parties have been faced with the expenditure problem throughout the life of the service.

I am encouraged that the noble Baroness, Lady Jay, says that the health service must not be preserved in aspic. There can be no disagreement about that. The question is how it moves further forward. Where we differ is that I and members of my party suggest that there is a greater role for the private sector. Until two years ago I was director of a healthcare company which was the parent of the British Nursing Association. It had a fine view of both the public and private sectors. Twenty years ago, for purely doctrinaire reasons, agency nurses were banned from working in National Health Service hospitals. That was not good for the nursing profession in those hospitals, and it very nearly brought my company to its knees.

About eight years ago I took a consultant friend of mine to see another of the company's operations, of which it was very proud: the doctors' deputising service in Liverpool. For reasons of principle, that gentleman did not have a private practice, and he was certainly not in sympathy with the aims of my party. He reluctantly agreed to go. Having seen it, he was generous enough to say that people ought to know more about it and that without the private sector service family practice in Liverpool would not work. I am happy to say that since then matters have moved on. We now have the 1990 Act, and there is a much healthier partnership between the public and private sectors. I was recently reminded of the private funding initiative of a major London hospital. It is regrettable that every time a private initiative in the National Health Service is announced there are cries of creeping privatisation.

I should like to refer to the Patient's Charter. It was much derided as a gimmick. However, it has served its primary purpose, which is to give patients a yardstick as to what their expectations should be. It has also provided much greater transparency of facts and performance on all aspects of the National Health Service. Surely, a league table is one of the best disciplines for getting rid of fat management in hospitals.

I believe that the greatest disservice is done to the National Health Service by the media. Politicians are not innocent of occasionally associating themselves with that. A prime example is the closing of hospital beds, which is almost always portrayed as a matter of economy or staff shortages. The fact is that beds have been reduced under every government since the inception of the National Health Service in more or less a straight line, for the basic reason that there has been an advance in technology, day surgery, microsurgery and so forth. It does no service to the patients. It discourages patients and staff.

Many compliments have been paid to this country's nurses. I should like to add my thanks to them. There can be no finer nurses in the world. Perhaps I may in passing say how much we owe to nurses from Australia and New Zealand and, happily and more recently, South Africa, all of whom come from a training tradition which derives from our own.

There are many initiatives within the NHS at the moment which encourage innovation of all kinds and experiments. The noble Lord, Lord Winston, is an example of that. The nurses, of whom there are too few, and who will never be well paid, play a large part in it. They are better educated and better trained and wholly flexible when dealing with the technical demands made upon their services.

Perhaps I may leave my noble friend the Minister with one thought. There are many centres of excellence where medical men and their staff work as a team and are thoroughly motivated. There are other places where one might say there is a two-tier service. It is not a two-tier service as usually understood. The noble Lord, Lord Bruce of Donington, mentioned this. It is a two-tier service not due to social reasons or resources but because of personalities. I hope that with their current initiative for the encouragement of excellence within the service the Government will pay attention to the less successful who need so much encouragement.

5.22 p.m.

Lord Prys-Davies

My Lords, my colleagues have already described the principle and the public value of the NHS. On that I have nothing useful to add, except that I have a passionate belief that a national health service is as essential today as it was 50 years ago. Everyone is a patient or a potential patient. For those of us who do not make private insurance provision a strong NHS is one of the essential foundations of a civilised life without which life would be very raw and short.

There have been many changes and crises within the NHS since its founding. However, I believe that it is widely recognised that of all the changes imposed from above on the NHS the most significant are the so-called reforms which have been taking place since 1990. We believe that they are the most significant, because, for the first time, they attempt to create an internal market within the NHS. This afternoon we have had the benefit of the informed opinion of one of our colleagues on the internal market.

I hear from doctors and nurses that competition is replacing co-operation. Competition produces losers as well as winners. My noble friend Lady Jay, in a notable speech from the Front Bench and others have described the present NHS scene. I shall not traverse that ground, except to recall that some of the trusts are now facing bankruptcy, or were at least until yesterday.

In about 1990, when the first trusts were established—thereafter there was a wave of trusts—few predicted that such a result was possible. Some of the so-called reforms are coming back to haunt the Government with a vengeance. It is an astonishing position that trusts should be facing bankruptcy.

As my noble friend Lady Jay demonstrated in her comprehensive speech, many points can be made in this debate. I have an interest in many of the issues which have been raised; for example, health promotion, the future of clinical medicine and the deeper ethical issues which arise. Keeping my eye on the clock, I propose to mention just four matters.

First, with almost 500 trusts in England, Wales, Scotland and Northern Ireland, pursuing to a substantial extent their own separate ways, as they see fit, it has become clear that the NHS is in grave difficulty in seeking to embark upon a strategic plan for its future as a whole. Within the new structure, there is too little scope for strategic planning and co-operation, but too much scope for needless duplication and bureaucracy. With each trust in charge of its own destiny, who is in charge of the NHS? It was against that background that in 1994 the chairman of the BMA argued: There is no longer one National Health Service. I come to my second point, which has been touched upon. There are now 20,000 more senior managers in the NHS than there were in 1988. Spending on management has almost doubled since then. I cannot help contrasting that with the fact that there are 50,000 fewer nurses in the NHS than there were in 1988. As we have heard, it is now becoming more difficult to recruit the nurses who are needed by the NHS. I asked the Minister how the department justifies that remarkable contrast.

My noble friend Lady Jay referred also to the improper behaviour of some senior management members. I have a question for the Minister on that point. Is there power at present to remove an incompetent trust board director who can be shown to have failed in his task, or to disqualify him from holding a senior NHS management position in future, and possibly to order him to pay towards the trust's liabilities for which it can be shown he has some responsibility? Having imposed upon the NHS a management model which is derived from industry—in my view an inappropriate management model—I do not see why the consequences that I have just mentioned should not follow where the trust board director is incompetent, as is the case with an incompetent company director.

I come to my third point. I should like to put on record one issue which has not been mentioned. Sadly, there are some signs of two different standards of service emerging within GP services—one for the patients of a fundholding practice and a different one for the patients of a non-fundholding practice. If that be true, it is unjust. It is also contrary to the general public expectation of the NHS. What we want is one class of service for all patients, and that should be of top standard. That is what a strong NHS is about.

I come to my last point, and I shall be brief because the point is self-evident. It is clear that we need a Labour Government for the defence of the NHS.

5.30 p.m.

Baroness Masham of Ilton

My Lords, I thank the noble Baroness, Lady Jay of Paddington, for instigating this most important debate. When an individual or family is involved with serious illness, especially when it has long-term results which need ongoing treatment and care, there is nothing more important to them than the National Health Service, especially when they have a permanent disability.

So many things happened around the time of the start of the National Health Service which advanced the treatment of severely ill patients. Antibiotics became available to help combat many infections. As a paraplegic, I have been very grateful for them over the years.

Following on from our debate on Monday about infections which become resistant to antibiotics, I wish to ask the Minister a question today. Many doctors and scientists are concerned about a rumour that there may be plans to privatise the Public Health Laboratory Service, which they fear could increase deaths and serious infections from preventable diseases. Sir Donald Acheson, the Government's former Chief Medical Officer and now President of the British Medical Association, recently told the BMA Council that privatisation of this global flagship must be resisted.

The PHLS detects linked infections early and investigates and assists with the introduction of control measures. If the function discharged by the PHLS ceased to exist, there would be significantly higher morbidity and mortality rates due to infections. If any service needs to remain public I strongly suggest that the Public Health Laboratory Service is the one to do so. With so many complicated infections and viruses flying around the world and being brought among us, and with so many complicated farming diseases emerging, this public service is now in the front line. I mentioned to the Minister that I would be raising this matter today, so I hope that she will give the House an assurance on this important issue.

It was in 1944, before D-day, with the expected casualties from Normandy, that Dr. Ludwig Guttmann, a neurologist who had fled Germany before the war, was asked by the chief of the medical staff of the Army to open the first spinal unit at Stoke Mandeville Hospital. Patients who suffer spinal injuries resulting in paralysis from the lesion down lose both sensation and movement. They need specialised treatment. Dr. Guttmann, later knighted for his pioneering work in paraplegia, developed routine procedures such as turning patients every three hours in order to avoid pressure sores; management of paralysed bladder and bowels; the understanding of autonomic dysreflexia (treatment of blood pressure, unique to high lesions due to the complication of the condition of being paralysed without sensation); and rehabilitation from a physical and a psychological aspect using sport to help regain lost confidence.

That all means that the staff—medical, nursing and therapy—need special training. With the coming of the National Health Service, civilian patients were admitted to the spinal unit at Aylesbury. Prior to that it was under the Ministry of Pensions. We civilians have something to thank the war for.

There are now nine spinal units which provide the specialised treatment to our spinally injured patients. Fifty years on, the staff of the units, along with the Spinal Injuries Association, which is a user support group—and here I have to declare a non-financial interest as its president—are concerned that spinal injury has not been included as a unique specialty in the European list of specialties. It has been merged under the title "Rehabilitation". More than 50 specialties are listed, so why not spinal injuries? I ask the Minister, who I believe we all trust and admire, to look into that and to write to me. This has to do with the training of medical staff and also the GMC. If the Department of Health will commission an audit of spinal injuries treated in spinal units it will find that this specialised treatment is in the long run cost-effective and essential if complicated problems which become very expensive—for instance, pressure sores and depression—are to be avoided.

The Spinal Injuries Association has many horror stories of some of its members' experiences when treated in general hospitals without expert staff and the necessary equipment. The Spinal Injuries Association can supply the Minister with case histories. Recently, one high lesion tetraplegic had to be admitted as an emergency to the Edgware Hospital with a urinary problem. His girlfriend was asked to come and evacuate his bowels as the staff did not know how to do it—or they did not want to do it!

There is concern that if general practitioners become total fundholders severely disabled people of many different specialties may have severe difficulties. Will the Minister please give assurances that these most vulnerable patients will be protected and their needs understood? With trust hospitals, ECRs, fundholding GPs and lack of money in the National Health Service, will the Minister assure the House that such patients will not become the unwanted, uncared for members of society?

There are many specialties which need to go to special units which can give the correct treatment and the necessary psychological support; for instance, cancer patients. They should not be sent to general surgeons. They need the support of experienced expert teams which can give them the best care and treatment.

I wish to conclude by congratulating Stephen Dorrell on his recent achievement with the Treasury. The National Health Service has so many people to support. Only last week an occupational therapist from the wheelchair service said to me, "I have too many people who need equipment. We do not have the money to provide what is needed". I ask the House why the second day lottery funds cannot go towards such provision.

5.38 p.m.

Lord Stallard

My Lords, it is always a pleasure to follow the noble Baroness, Lady Masham, in any debate on national health affairs. I have listened with great interest to what has been said today and I too must declare an interest. During the 50 years of the NHS, and previously, I have been involved with the health service in one way or another. I am still involved in that in your Lordships' House I am chairman of the group on ageing issues. It has dealt with many of the problems that have been aired today.

I also listened with interest and appreciation to several contributions from Members on the Government Benches. Like my noble friend Lord Bruce of Donington, knowing the whole history of parliamentary debates, I share the joy that there must be in Heaven at some of those conversions. I hope that they continue.

I hope that those noble Lords will share with me too some real concern about the situation outlined in the Evening Standard yesterday. I quote from just the beginning. The article states: London hospital managers have already admitted that this winter they will face their worst crisis for a decade. But the story gets worse. An Evening Standard survey of all 16 health authorities in the capital shows that the vast majority are in financial trouble and next year they will have to make cuts totalling £88 million. The sick citizens of London face far more than one winter of discontent: in at least two areas managers predict crippling deficits into the next century". I hope that the noble Baroness who is to reply to the debate, who I know has the respect and admiration of noble Lords on all sides of the Chamber, will be able to comment on that report in the Evening Standard.

In my few minutes I wish to deal with a couple of specific issues. I have never served as an academic, although I have the greatest respect and admiration for those who have. I have the greatest respect and admiration, too, for staff at all levels who served our great National Health Service, and, as we all know, still do.

I wish to raise a couple of issues which continue to arise whenever we debate National Health Service issues. The first is in relation to the statement that more patients than ever are being treated. That worries me because I visit hospitals all the time throughout the London area and I know the situation on the ground. I know too that many of those new patients are in fact the same patients. I know one example of a lady patient who was transferred eleven times. She went from one hospital to the next, to another and back to the first one. She is registered as a new patient at every stage of her treatment. She was not 11 patients; she was one patient being treated in 11 different places for her complaint. How many other cases are there like that?

Only a couple of weeks ago a man whom I had known for many years was taken into the accident and emergency department with a suspected heart attack. Fortunately, it was not a heart attack but after about six hours—that is about the average waiting time to see a doctor in the accident and emergency departments in London—he was referred back to his own GP. He went back to his own GP, who advised him to seek another appointment at the hospital in a different department so that he could be treated for what the doctor thought was his problem. He has already become two patients in that hospital's records.

If that is the norm—that one patient becomes two patients—we can halve the number of patients being treated rather than doubling it. Therefore, I query the statement that more patients are being treated and it grieves me to think that perhaps the figures are being exaggerated slightly.

Secondly, I wish to discuss the question of age discrimination. The Hillingdon example frightened the life out of most of us, certainly most people of my age. We found out that we were virtually untreatable and certainly not admissible to some aspects of the health service. That must have worried an awful lot of people. Age Concern, along with a number of other organisations, has been campaigning for many years in relation to the problems of the elderly and age discrimination. Noble Lords may remember the late and respected Lady Phillips who piloted a Bill through your Lordships' House which dealt with the question of age discrimination at all levels, but unfortunately it was thrown out in the other place.

That argument continues but it has now moved to hospitals, where we understand that there is age discrimination. Following a recent conference set up by Age Concern it was reported that many hospitals are discriminating against elderly patients. For example, many elderly women are not being called back for breast cancer scans when they reach the age of 65. Some of them assume that because they have reached that age and have not been asked to go for a scan they have nothing more to worry about and that they cannot contract breast cancer. But the facts are different and they show that more women in fact contract the disease after the age of 65. Therefore, that is a worry.

Several women have been told by their GPs that they could not have National Health Service screening. One woman was referred to a private consultant who charged her £100 for screening to which she was entitled free of charge. I understand that practice nurses have said that for several years they have been telling older women that they could not have screening because of their age. That is happening. Those facts emerged at that conference and they are extremely worrying for us all.

Other facts which emerged from the same conference are that until the 1980s, being an older person was widely believed to be a contra-indication for renal dialysis and transplantation. But that has now changed. Although there is still a significant under-treatment of people in that area, twice as many people under the age of 50 are on dialysis as those over the age of 50, although the incidence of kidney failure rises with age.

The final and extremely important point which I wish to raise is in relation to the introduction of 17.5 per cent. VAT on incontinence equipment. That is causing grave hardship and a lot of worry for many elderly patients because it is the elderly population who are mainly affected. All the time it is the aged people who are most vulnerable when there are cuts and increases. I was at a very interesting meeting yesterday evening when that question was raised by the speaker, who said that there was great worry and a lot of fear among people that that increase would prevent some people from acquiring the necessary equipment for their incontinence problems. That is extremely worrying and I should like to hear what the noble Baroness has to say about that. Is it true? I have umpteen examples of people who are directly involved. I could go on for the next 80 minutes, let alone eight, but I finish there and hope for some positive replies from the Minister.

5.46 p.m.

Baroness Flather

My Lords, first, I must declare an interest by telling your Lordships that I am a member of the Hillingdon Trust Board. That hospital was mentioned scathingly and written off by two Members opposite. I shall say more about that later. If their statements can be based on such ignorance about this matter, I wonder what they have based their other statements on.

My perspective also comes from being a board member. As your Lordships would imagine, I am not capable of taking a wide-sweeping view of the National Health Service but I can talk about my experiences both as a user and as a board member.

I have been in this country for a long time and I started to use the health service seriously when my two little boys were diagnosed as having astigmatisms. I had to take them to a specialist hospital to have their eyes checked every three or four months. I have waited for up to seven hours in the hospital for those two little boys to be seen. That was in the good old days of the late 1950s, early 1960s and onwards.

I have also used the National Health Service myself for two operations. I felt that everybody in those hospitals would have been more pleased had I not been there cluttering up the hospital, making a nuisance of myself and messing up the beds. The general impression that one used to be given was that patients messed up the general look of the hospital; they made it untidy and they should not have spoken unless they were spoken to.

I have recently been in hospital for another operation, this summer in fact. I found that there was a very different attitude among the staff. Everybody has vilified the market place, the internal market. But when you know that the hospital next-door is also offering the same operation, you try to do a bit better. That is achieved by giving better service to patients. Patients have now become important. I see that every day. Indeed, waiting times for appointments have been greatly reduced. The way patients are treated is totally different. One is no longer patronised and doctors explain what will happen.

Of course, it might well be said, "It's all right for you because you are a Member of the House of Lords and they would know that". Yes, they would know that, and in my hospital they would know that I was a member of the board. But it is not just that: I have seen other people being treated in the same way. I was in a ward with four people. One of the patients was a very elderly woman who had fallen down the stairs and been brought in as an emergency. She was most confused. The way the staff treated her was a marvel. I do not believe that her own family would have looked after her better. It is a question of speaking as you find. I am not making a party political point; I am not trying to say that the National Health Service is perfect. I believe that it is probably impossible for the NHS to be perfect. But it is incumbent upon all of us to try to improve and to continue to improve it.

I should like to say something about the internal market. Words like "commercialised" and "privatised" have been used, but it is neither of the two. It is a kind of social market. The purpose that it should serve—it is already apparent that it is beginning to do so—is to provide better standards. Once there is competition, people will try to see whether they are able to provide better standards of service. That is the purpose of the internal market. Its purpose is not to encourage people to compete with each other and confront one another and not to work together. I believe that the service is now maturing. All the different components of the market are beginning to realise that it will work only if they all play their part in each situation.

If social services do not fulfil their part of the task—and I shall return to that point in relation to the closure of the A&E department and the admission of the over-75s—the system is bound to break down. Of course, if we had more money we might be able to get some more beds, but we would not be able to secure beds on the spot. Indeed, it would still take time to get those beds into operation, with staff to run them. Therefore, as has been mentioned in other connections, if the whole cycle does not work you have a clogging at one end of the system.

What other way is there to maintain standards than by making comparisons one with another? In the past we did not have such a way of checking up on standards, and I believe that they dropped considerably in many hospitals. These days it is apparent when hospitals fail to maintain standards.

It has been asked why people use private healthcare. I am a user of private health services. I use such services when I want immediate attention. We can never expect that from the National Health Service. I do not have an insurance policy but I will go for private care if I have to. I will use it if I want a luxury room with my own telephone and bathroom. I do not think that the NHS should or ever will provide that kind of service. It is a matter for me if I want it. If I want to stay in a five-star hotel I will do so. It has nothing to do with anyone else, or, indeed, with the quality of the health service.

Finally, and because I am running out of time, as indeed have other speakers, I turn to Hillingdon Hospital. The social services did not provide the placements for the elderly who were in the hospital and due to be discharged. The Mount Vernon Hospital closed its A&E department and, through a mistaken belief that that hospital was not welcoming elderly patients, they started to come to Hillingdon Hospital from the northern part of the borough quite unexpectedly. Therefore, we had an unduly large intake of patients without having the facility to move them out. What can happen in such a situation? The only consequence is that there are no more beds. We are not going to put our elderly patients on trolleys because, as the noble Baroness, Lady Masham, knows only too well, it is very dangerous.

Hillingdon Hospital had its A&E unit (and admissions for the over-75s) closed for a very short time. However, movement has now started again. Unfortunately, without doing that, we were unable to get action from the other authorities which should have been "doing their own thing" in that connection.

5.55 p.m.

Lord Howell

My Lords, it is a privilege to take part in this anniversary debate. I thank my noble friend both for her excellent speech and for providing us with the opportunity to speak in such a debate. I take part today as someone who has been involved in health administration from as far back as 1946 when I was elected to Birmingham City Council. I have been a patient on repeated occasions and, indeed, will be next week. My passion about healthcare knows no bounds. I was delighted to see how it brought about the re-election of President Clinton last night. Indeed, it is likely to bring about the election of Mr. Tony Blair next year.

The principle of market forces has become the new theology of the health service, dividing doctors and nurses and, now I learn, setting hospital against hospital. In Birmingham we have four main general hospitals—the Queen Elizabeth and Selly Oak in the south; Heartlands in the east, Good Hope in the north; and the City in the west.

It seems that the chairman of the trust responsible for the Queen Elizabeth and Selly Oak—the University Trust—together with the chairman of the Heartlands, proposed that their two hospitals should be developed at the expense of the other two hospitals—Good Hope and the City. They represented this to the chairman of the West Midlands Area Health Authority without consulting the other two hospitals, the general practitioners or anyone representing the patients. No wonder the chairmen of the Good Hope and City hospitals reacted with anger and mobilised themselves into opposition. They realised that such a proposal would have denied them the resources to develop their own hospitals, especially as regards access to private investment funds.

Birmingham needs four hospitals. Each is already overstretched, both for funds and in workload. It appears that as a result of their protests the chairmen of the City and the Good Hope hospitals have produced a response from the West Midlands area chairman. He has set up a rationalisation exercise to see which hospital should do what in Birmingham. That is no way to conduct a vital public service. The general practitioners must have a major say as to where they send patients and the services they need close to the homes of their patients. And patients must have a big say, which they do not often have at present, about the health service because it is a service for them. If the review to which I referred does not provide for that it will be doomed. I hope that the Minister will ensure that consultation is a reality.

All over the country hospitals and general practitioners are in the red. Competition based upon financial desperation can only be damaging. The Secretary of State told Parliament a week ago that Birmingham will have an expected deficit in March next year of some £8,400,000. The so-called agreement achieved yesterday between Messrs. Clarke and Dorrell will not solve the problems, because what Mr. Dorrell received yesterday is for next year and not this year. And it is this year where the problems exist. Can the Minister tell us today how she expects Birmingham to cope with the deficit this year? The public have a right to know, and we have a duty to obtain that information and assess its consequences.

Now we have a new, totally unjust, and, I would say, immoral penalty being imposed upon Birmingham and its neighbours. It is called the market forces factor which allocates funds for growth next year. Under the formula Essex will receive £24 million for growth, Birmingham £2 million and Sandwell £0.6 million. That is a disgrace. Birmingham and Sandwell serve areas of the greatest need in the country, as was recognised in the previous formula worked out by York University, which the Government have now allowed to be thrown overboard. That assessed all the relevant needs of the cities: poverty, bad housing, incidence of disease and social make-up of the population. All that has been disregarded. The cynical might say that Essex man wins again. I believe it is a straight political fix and political chicanery of the highest order. We must be given an explanation of why we have moved from a formula that was reasonably fair and was produced by York University at the request of the Government to the formula I have just mentioned.

As far as I am aware, no one in the debate has paid tribute to general practitioners. I wish to do so because the general practitioner service is the bedrock on which the whole of the health service is built. There is concern among GPs that the proposals in the White Paper on choice and opportunities will endanger the health service at general practice level. I can see some sense in GPs doing some work in hospitals. However, there is no sense in encouraging hospital trusts to employ their own GPs, so controlling money which at present flows into the GP service and possibly ensuring priority for the patients of trust GPs over the patients of community GPs. That is what will happen in a market situation. It will produce unfair competition. That causes great concern among general practitioners. I hope that the Minister will address the point. GPs are the only independent advocates on behalf of patients in the entire health service. That is especially true as regards patients who are underprivileged and those with social problems. The independent role of GPs is paramount and Parliament has a duty to protect it.

I have a final point to make and that is the great problem of offloading onto general practitioners patients who are discharged from hospital far too early, who are ill and who ought not to be discharged. That is causing immense concern and distress. I have heard of many cases of patients having to be readmitted to hospital within a few days, becoming a double statistic—

Lord Bruce of Donington

They are counted as new patients.

Lord Howell

As my noble friend says they are counted as new patients. Why is this done? It is done to transfer the cost of those patients from the hospital onto GP fundholders. That is a serious matter.

People have told me that at one time it was difficult to receive a service unless one could pay to have a private service. What is now happening in parts of the city of Birmingham and elsewhere is that it is not possible to obtain a service unless one's general practitioner is in funds. If he is not in funds, one receives second-rate treatment. That cannot be justified. I hope that the protection of the public, which is what this debate is all about—it is as important to recognise that fact as to be nostalgic over the past 50 years, which we all enjoy doing—will be the prime point that the Minister will address in her reply.

6.4 p.m.

Viscount Waverley

My Lords, I apologise for my croak. The approach to the National Health Service is indicative of the political divide, with solutions and future direction a contentious issue—all the more so with the forthcoming election. There are some who say that the health service will not survive another Conservative term of office. That has to be a matter of interpretation. It is more correct to say—if one must—that the health service is being subjected to a creeping strangulation. It is important, however, to understand the reasons why that is so before making a definitive judgment.

I believe the time has come for decisive action and for fundamental questions to be answered. Do we retain the health service, or keep only properly funded aspects of it? Do we determine that it cannot be afforded and implement a two-tier means-tested system and insurance based service? What core services should be provided by government? In other words, what are to be the objectives of our future health service and how are they to be achieved? Let me say here and now that I believe that it is fundamental to our society that those genuinely less well off should expect a free and speedy service.

Mrs. Thatcher as Prime Minister—who did not have time on her side in the late 1980s—needed to react to the health crisis by implementing a damage control exercise. What her advisers did not do—I regret—is consult sufficiently. Time may not have permitted that, but with hindsight change was implemented too quickly without the consensus of the medical profession. This Government, with expedient use of time, have the opportunity to be the architect of a rejuvenated, modernised service by addressing the real issues, by being sympathetic to the concerns of the people of this nation, and to all who are directly involved. Certainly tough decisions will have to be made, but they must be made by consensus. I call on the Minister to instigate an immediate consultative process to address those fundamental questions. The process could be completed within one year, with essential pilot programmes leading to full implementation within five.

The Minister should also attempt to allay the fears of those who believe the health service will crank to a halt in the meanwhile—that was a point made by the noble Lord, Lord Howell—by giving an assurance of an injection of money if required. The question of accumulating debt must be addressed in the upcoming Budget. I suspect the Minister will find wholehearted support around the country for an in-depth appraisal, provided it was seen that something positive was being done. For my part, I find merit in a national chain structure of high-tech district hospitals with a comprehensive web of community care centres. District general hospitals would handle all emergencies and major elective surgery while some community care hospitals would be expanded and others built from scratch. Can we hear more from the Minister about the role of PFI funding in such a scheme? Is there a role for drug companies to plough some profits back into the service? I shall not enter the realm of general practitioners as that would be bound up in my desire to see an all-encompassing consultative process. However, I see a need for better patient understanding of which aspect of the service to call upon in any circumstance.

In conclusion, I believe that simply throwing money at the service is not the answer. A carefully considered appraisal and restructuring will, when all is in place, meet the ideals of my father, who as a hardworking consultant physician at the Royal Berkshire Hospital, used to say to me that if one wanted the best medical opinion and attention one should use the National Health Service. We have the basis for the finest health service in the world, with standards the envy of all. That is surely a unique base on which to build.

6.10 p.m.

Lord Ewing of Kirkford

My Lords, perhaps I may cite Aneurin Bevan. At the time of illness, wealth should be no advantage and poverty no disadvantage. Perhaps I may follow that by citing Herbert Morrison: the health of the people is the highest priority. One of Aneurin Bevan's great achievements in introducing the health service in this country was to get Herbert Morrison on his side. Anyone who reads the history of that time will clearly understand that that was no easy task. But it was on those twin pillars that the National Health Service was introduced and built by a courageous, visionary, post-war Labour Government. I am grateful to my noble friend Lady Jay for giving me the opportunity today to place on record my gratitude and tribute to that post-war Labour Government for the courage and vision that they showed in very difficult times. They were not easy times; they were very difficult. I live with the abiding memory of my late father going around miners' houses in my native Kirkford, from where I take my title, collecting tuppence from each household in order to give to the general practitioner to ensure that the health of the families was cared for in times of sickness.

One of the problems in this country is that too many people forget what it was like before we had a National Health Service—tuberculosis, poliomyelitis, diphtheria, scarlet fever and rickets in children were rampant diseases. They were tackled by that post-war Labour Government through a massive programme of immunisation. I was delighted that the noble Lord, Lord Butterfield, and the noble Baroness, Lady Brigstocke, mentioned the need for proper preventive healthcare programmes. There is no profit in prevention but—by God!—there is a lot of benefit; and we must never lose sight of that.

Even in his absence, I wish to support the right reverend Prelate the Bishop of Exeter in his plea for proper recognition and support for the hospital chaplaincy service. The valuable support given by the hospital chaplaincy sector to patients and their relatives in times of sickness is not generally appreciated.

I wish to deal with three specific issues. On my first point I concentrate on Scotland, but I have no doubt that the same applies to England and Wales. I refer to the relationship between health boards and trusts. I declare my interest as chairman of the Fife healthcare NHS trust. Contrary to common belief, the trusts have absolutely no power. As soon as one gives the power to purchase and, conversely, the power not to purchase, to a health board or any other organisation, that is where the power lies. The trust can supply only that which the health board is prepared to purchase from that trust. We need greater transparency. The health boards should be under a statutory obligation to publish what they purchase, from whom they purchase it, and what they pay for it. We go into these contract negotiations totally blind about what is going on inside the purchasing organisation—the health boards or the area health authorities. I plead with my noble friend Lady Jay—she will have responsibility for this matter in 20 weeks' time—to open up the whole question of negotiations and to give us greater transparency.

I turn to care in the community. If we have succeeded in doing a disservice to the National Health Service, it is as regards the care in the community concept. We have succeeded in giving the clear impression that the hospital is not part of the community. The concept is, "Get the patients out of hospital and into the community". I repeat to my noble friend: that programme must be slowed down. The net result is the blocking of hundreds of beds simply because the social work authorities do not have the resources to get the patients into nursing homes. The Government claim the credit for increasing the disregards to £16,000. But they did not give an extra penny piece to the local authorities to take care of the increase in the disregards from £8,000 to £16,000; and that is where the crisis exists in the National Health Service.

I hear the private sector say, "But we can care for these people much more cheaply than the health service". Of course they can because in the health service, in the hospitals, we treat the patient's condition; in the private nursing homes they manage the patient's condition. The two are entirely different. That is not a criticism but a statement of fact. The care in the community programme has to be slowed down.

My closing remarks relate to the value of nurses. The debate in this country is not about whether we can afford to pay the nurses. It is about who can charge the lowest standard rate of income tax. What a sterile debate. My noble friend should take one matter on board. My trust offers the nurses a total of 2.8 per cent. That is not because that is all we think they are worth. It is because that is all we can afford. The gap between what we can afford and what a nurse is worth grows wider year on year.

When the Government have a difficult case to defend they send the nicest Minister they have to defend it. I do not address my comments to the noble Baroness, Lady Cumberlege, because, as I say, in 20 weeks' time my noble friend will be occupying the seat where the noble Baroness now sits. Therefore my closing comments are to my noble friend. Whatever she does, she must begin to close that gap between what we can afford to pay to the nursing, caring profession and what they are worth. Let my noble friend have this on her desk; have it on the wall; stamp it on the mind of every civil servant who crosses her carpet: the health of the people is the greatest priority. We shall achieve that only by raising the morale of the caring professions.

6.17 p.m.

Lord Astor of Hever

My Lords, I, too, am grateful to the noble Baroness, Lady Jay, for the opportunity to speak on the National Health Service on its 50th anniversary. It is also my 50th anniversary. It is one thing that I have in common with the noble Lord, Lord Monkswell. On these Benches, we are very proud that for two-thirds of its existence the NHS has been under Conservative governments.

The noble Baroness seems to enjoy prophesying the imminent fall of the NHS. This scaremongering is nothing new. Labour always shamelessly proclaims that the end of the NHS is nigh. One needs only to read its manifestos for the past six general elections. Indeed, Harriet Harman said last year, I firmly believe that a 5th Tory term would spell the end of the NHS". But the NHS has prospered under Tory governments and stagnated under Labour. Moreover, the public are now beginning to distrust the Labour Party on health issues, which is one reason why I am confident, unlike the last speaker, that the noble Baroness and her party will still be on the Opposition Benches next year.

Many health workers resent them talking down NHS achievements in order to help Labour into government. During election campaigns, the Labour Party concentrates on the few examples where NHS treatment has gone wrong, never referring to the other millions of treatments that are completed successfully every year. Last week, the Independent—not a Conservative newspaper—highlighted Labour's complacent attitude to health, which, it said, has focused on scoring points in Opposition rather than constructing a viable alternative. But it is not the complacency that concerns me. It is the cost of what the Labour Party has told us it will do. I give just two examples.

The first is Labour's minimum wage legislation. Mr. Bickerstaffe laid particular stress on the importance of that commitment when he met Mr. Blair in September. In 1992 Mr. Cook costed that pledge alone at £500 million, but we have not been told the cost this time. To fund that, Labour would either have to increase health spending or pick and choose which hospital services would be cut. Not a penny of the minimum wage legislation would buy more patient care. It is another example of Labour putting its old friends the unions first.

Secondly, I read in Labour's document Renewing the NHS, that the party would abolish competitive tendering—which ensures value for money—in the placing of contracts by the NHS.

Conservative reforms have freed hospitals from funding overmanned and inefficient state-run services. They are now free to choose the provider of their choice and to make substantial savings in running costs, yielding extra resources for patient care. The BMA points out that, "the NHS provides better value for money than any comparable health care system in the world". Labour's policy would give hospitals no choice of service providers and would increase their running costs. The thought that a unionised state monopoly—for instance, in hospital laundry services—would save money is pure Peter Pan politics. Once again Labour is putting the interests of its old friends the unions above those of patients.

Government spending on the NHS this year increased by £1.3 billion over the previous year. That is equivalent in real terms to some £500 million over and above inflation. This record of constant investment, combined with the Government's determination to put in place efficient and effective management structures, has transformed the NHS.

At the party conference in Bournemouth last month, the Prime Minister committed the Conservative Party to increasing NHS expenditure in real terms, year on year, throughout the next Parliament. Labour, in contrast, has promised the NHS only £100 million next year—a drop in the ocean, given that the NHS costs more than £42 billion a year. The noble Baroness, Lady Jay, used the word "threadbare", which is rather appropriate in this context. The £100 million is, in real terms, a cut of more than £800 million, before taking into account the cost of the minimum wage.

I read in the Labour Party's 1992 election manifesto these words: This election will decide the future of the NHS. Indeed, it will decide whether or not we continue to have a NHS of the kind that the British people want". Four years on, this Government, rather than the Labour Party, successfully oversee a National Health Service that the British people want and, as a nation, are able to afford.

6.24 p.m.

Lord Rea

My Lords, I am tempted to respond to the remarks of the noble Lord, Lord Astor. However, I have so much to say and only eight minutes in which to do so that I shall have to leave that to other speakers. A 50th anniversary should allow us to take a few steps back from day-to-day problems and permit us a broader view.

Although the percentage of GDP spent on the National Health Service has apparently increased from 5½ per cent. in 1991 to 6.9 per cent.—I need to check those figures, but they are the ones I was given—much of that increase, welcome though it has been, has gone on administering the internal market and the contracting process, as mentioned by a number of speakers. I suggest that in recent years the Government have been relatively generous towards the National Health Service because they could not allow their enormous unpiloted experiment to be seen to fail.

National Health Service costs rise at a higher rate than inflation because of the age structure of the population and advances in medical technology. There are other reasons, such as the increasing expectations of a society whose health knowledge is improving. As societies become more advanced and a smaller proportion of the workforce is needed to produce the goods we need, a higher proportion of the workforce and national income should become available to be diverted to beneficial, more labour-intensive activities such as health and social care, education or improvement of the environment. All that depends on a prosperous productive sector to provide the resources and a proper taxation system to obtain the money from that productive sector. There will be good years and bad years for the economy. All developed countries grow over time. As national incomes rise there is a tendency for the proportion of that income that is spent on health services to rise also, taking a larger slice of the larger cake.

However, the additional money is not always well spent. The most obvious example is in the United States, where, despite 14 per cent. of its much larger GDP being spent on health, a large part of the population receives a very poor service. Some other developed countries have full cover for their population but have higher costs than are necessary, partly because doctors are paid for each item of service. That system is difficult to control when the doctors themselves decide how many items a patient needs. We should be very grateful to Aneurin Bevan for his foresight in avoiding that expensive way of paying the medical profession.

Our National Health Service, as the noble Lord, Lord Astor, said, is the most economical in the developed world, considering the range of care it provides. That still applies—just—despite the expensive mistake of the past few years. It is always necessary to question whether expenditure on health services is being properly directed, provides value for money and serves all sections of the population according to their needs. The use of those words should remind us that the National Health Service is still based (believe it or not, after all these years of Tory rule) on socialist principles.

As a doctor, I am naturally more interested in health than in health services. They are very different matters. It was recently estimated that medical care has been responsible for only about 20 per cent. of the great improvement in the health of the population that has occurred in the past half century; it contributed hardly anything to the much greater health improvement of the previous century before any effective remedies were available. The main improvements in health then, as now, were due to a decrease in poverty, increasing living standards, and public health measures which reached the majority of the population. The major public health problem today is the disparity in health status between the two ends of the socio-economic spectrum—the health divide. Even the Government, who tried to silence the findings of the Black Report in 1980, now agree that health inequalities exist. Although the causes of the increasing health divide lie outside the National Health Service—in people's living and working conditions—the National Health Service has to pick up the pieces. It is established that the socially disadvantaged have higher consultation rates in primary care than the privileged and need more medication. That also applies to hospital use, because of their greater burden of serious illness, although there is some evidence that for equivalent conditions those of high social class are more likely to receive an operation, say, a coronary bypass or hip replacement.

The standard of primary care in relatively deprived areas is known to be worse, as are many other services. But a first welcome step has been taken towards ameliorating that through an additional payment, made since 1990, to the 5 per cent. of general practitioners who have patients living in so-called deprived electoral wards. However, in a paper which, with others, I shall be publishing in the British Medical Journal early in the new year, we shall be able to show that those payments only cover about half the additional costs that such patients incur. The majority of general practitioners with some deprived patients on their list get nothing extra owing to the extreme cut-off point on the scale used by the Department of Health to measure deprivation.

It would he useful if any of the changes in primary healthcare which may result from the Government's proposed legislation could be used to expand services for the less privileged, especially in the inner cities. As well as more general practitioners, they need the help of nurses: district nurses, practice nurses, nurse practitioners and community psychiatric nurses, as well as counsellors for the many social problems of inner cities, including homelessness and alcohol and drug abuse and associated crime and violence.

The noble Baroness will doubtless say that such improvements are in progress; she may well point to examples of good practice. I can only say that much more urgent action is needed to cope with the consequences of the fractured society created by the policies of the present Government.

6.31 p.m.

Lord Colwyn

My Lords, while thanking the noble Baroness, Lady Jay, for giving me the opportunity to speak about an important national and public service, I should also pay tribute to the care and treatment provided by that service over the past 50 years. I must apologise to the noble Baroness and other speakers for my late arrival. I have been busy in my dental surgery. It is always a pleasure to follow the noble Lord, Lord Rea. I cannot remember whether he continues to be a general practitioner. To be able to speak at 6.30 p.m. is quite convenient for those of us who are busy in our surgeries.

I do not know whether the noble Baroness made any reference to the general dental service. I have a copy of the brief from the British Dental Association which I know was sent to her and to many noble Lords taking part in the debate. I feel confident that my noble friend will be able to deal with the usual points about underfunding and inadequate fees which I am sure must already have been mentioned.

It is probably true to say that hardly a single day goes by without some reference to health. But are we as politicians, or the news reporters, really talking about health or something quite different? As we are all aware, the state of the health service has been a subject of major political debate for many years. That debate has concentrated not on health but on the nature of funding, the provision of services, the appropriateness of cuts and the conflicting claims of private and socialised medicine. It seems to me to have ignored any serious discussion of the more fundamental issues—above all, the question of whether changes in the financial structure of the medical services will result in any real improvements for the health of the population as a whole.

The assumption that greater availability of medical services, more doctors and health-related personnel, the construction of more hospitals and clinics and the development of a wider range of drugs and surgical techniques, will inevitably lead to improvements in health, to increased longevity or to the eradication of disease, is ill-founded yet widespread. It is an assumption which has been challenged repeatedly for more than a generation by an articulate, well qualified body of researchers yet almost totally ignored by policy makers and the public.

Longstanding failure on the part of governments and public bodies to control the almost uninhibited growth of medical technology or to rationalise the style and content of treatments on offer has resulted in problems that are now too blatant and potentially destructive to be swept under the carpet for another generation.

The noble Baroness calls for the need to maintain the public service values of the NHS. Those values are evident every day. The NHS treats more patients than ever before. There are better survival rates, lower peri-and neonatal mortality rates, shorter stays in hospital and generally an improved standard of health for the population.

The Motion also implies that more money should be made available. But more money is not fundamental to the public service values of the NHS. That depends on people and can rarely be bought.

Health services tend to be demand led. We know that demand is high and continues to increase. We need to pay attention to how to meet the demand and meet the greater expectation of the health service. The NHS provides support for those who no longer have family or alternative networks of care: elderly people living alone and people experiencing the crisis of mental breakdown. Those patients do not always require hospital treatment but are admitted because of their need for 24-hour care for short periods. The service cares for a population that lives longer, has greater diversity, is more mobile and is exposed to greater stresses. Of the relatively few patients who need hospital care, many now benefit from improvements in diagnostic and day care services and do not require admission to a hospital bed. Better care in hospital also results in shorter stays.

The recent White Paper, Choice and Opportunity, emphasises a commitment to better integration between different kinds of NHS care and suggests that a possible way forward is for specialist in-patient services to be supported by more community hospitals where local GPs can also access facilities to treat their patients. I agree with the noble Viscount, Lord Waverley. Those community hospitals will provide a complementary service for people with the district general hospital providing full accident and emergency services and all the back-up support needed to treat those patients with life-threatening serious conditions who need specialist care. Last year my right honourable friend the Secretary of State announced changes along such lines for north and south-east London. A good example is the arrangements in the Wellhouse Trust in north London where acute in-patient services are provided at the New Barnet Hospital and community hospital services are at the Edgware Hospital.

Those in need of urgent help should receive priority treatment but people do not always arrive at the A&E department in an ambulance. Studies have shown that a large proportion do not require admission and could be treated by their GP at a minor injuries unit. Hospitals are often more convenient. That is particularly true of large cities with mobile populations and a daily influx of commuters. Recently there has been a rise in emergency admissions to hospitals and debate about the causes of the unpredictable peaks and troughs in demand. There are probably complex reasons for that and no simple answer, but a pointer in the right direction must be a closer examination of how we provide and manage our hospital beds to cope with seasonal and other pressures.

The noble Baroness calls for government action. But this is not something for government alone or for the hospitals planning to meet those demands. Other organisations and the public have a part to play. That means providing appropriate alternatives such as sub-acute assessment units to avoid bottlenecks in A&E departments—which are often used for the wrong reasons—backed by adequate social care support for discharge from hospital and improved advice and information to the public.

Health is about caring for people. How much I regret that it is a party political issue. After 50 years of the health service, the improvements in healthcare have not arrived by accident. Nor is it an emergency.

6.39 p.m.

Lord Hayter

My Lords, in our rather curious way in this House we are celebrating the 50th anniversary of the health service. Next year I shall celebrate the 100th anniversary of the King's Fund. The link between the two is that the fund has recently brought out a little booklet called Rationing Agenda in the National Health Service. It ties up conveniently with what the noble Lord, Lord Colwyn, has just been talking about. It is not just rationing of money, it is rationing of people, rationing of places in which people are cared for. The truth is that neither the Government nor the Opposition will admit that there is such a thing as rationing. They call it "resource allocation procedures" or "priority settings". But when one thinks about the matter, there is indeed rational rationing.

Many noble Lords will remember Lord Porrit, who had many friends in the House. When he was Governor General of New Zealand he gave me some words of wisdom which have stuck in my mind: there is no country in the world which can afford the health service that it wants. That is absolutely true. So we come back to the question of rationing. If there has to be a limit, let us see what we can do with it.

I suppose that rationing in this country can be divided into three categories: central government; local government; and individuals. It seems to me that the motto in each case is "Pass the buck downwards". We read in the papers today that the Secretary of State has had a bit of a triumph for his budget. He has obtained a little more than we had expected. He has fought the Government on the issue of priorities between defence, education, health and—dare I mention the word?—tax.

The money has been obtained; how will it be used? That is the essential matter to which we should address ourselves.

Let me move down a little further into the local budgets. When I was a young man there were words which one could not use in private conversation, certainly not in this House, and about which the noble Lord, Lord Winston, will know: in vitro fertilisation, and some other words that even now I do not dare repeat because I am so old fashioned. But the point is that, in 1993, when 114 purchasing plans were examined, six health authorities absolutely refused to allow in vitro fertilisation. Therefore, if you happened to be in the right place you had it and if you happened to be in the wrong place you did not have it. That seems to be absolute nonsense.

I turn to the category of individuals and to the point made about GPs by the noble Lord, Lord Colwyn. Basically, health services are or should be free whereas social services are means tested. Therefore there is the curious contrast between the two and the doctor has to make up his mind on whether he will tackle the patient or shove the case still further down the line.

In the booklet that can be obtained from the King's Fund, there are a variety of questions. I cannot mention them all but I shall give some examples. First, should we admit that the word rationing makes sense? Secondly, what are the objectives of the National Health Service? I was shocked to read that question. One of the definitions offered by my noble friend Lady McFarlane today makes a good start, although I am not sure whether or not it is up to date today. Thirdly, who should have the responsibility for rationing decisions?

I can start off with a negative answer: not the press; not television; not the pharmaceutical industry (which is very generous in many ways to elements in the National Health Service but it is in business and therefore quite rightly should be looking after it); not—a name that I shall put down although it is not in the booklet—the Church (there are special interests which can confuse the issue even more); and certainly not the judiciary, which is only to be turned to in the last resort if one cannot make up one's mind elsewhere.

So what do we suggest? The words "budgetary control" came to me when I was a young man in business. I asked an uncle of mine what it meant and he said, "It means that you tell the money where to go instead of watching where it went." That is a very good motto to bear in mind.

My last point concerns education. One cannot blame the doctors for not being good at managing themselves and their trusts if they have not been taught how to do it. A long time ago the King's Fund sent a matron of the London Hospital to the Henley Administrative Staff College. It was an absolute eye-opener. She was the first woman to go there. The college had no idea of her responsibilities and she had no idea of some of the techniques that were being taught.

There are many hard choices ahead and there are limited resources. Successful project management must be the point of education for us all. I commend the booklet to your Lordships. If noble Lords cannot obtain a copy for themselves and apply to me, I shall try to obtain it for them.

6.45 p.m.

Lord Haskel

My Lords, during the 1980s Professor Enthoven's theory of the internal market became the fashionable answer in the private sector to the problems of large organisations. It said that competition within the organisation would produce the best goods and services. So, that theory of a fairly obscure professor of management was plucked out of California to become the answer to the problems of the National Health Service. It is not difficult to see why the Government fell into that trap. They virtually created it themselves.

In the mid-1980s the Government were busily running down the status and dedication of the public service and at the same time praising the wonders of business, individuality and the market. After all, business managers were seen to be successfully cutting costs. So what could be more natural than adapting business's methods to a public service which was chronically short of funds.

Industry became a little sceptical when contradictions began to appear regarding people's individuality. Workers had to focus on quality yet at the same time speed up to cut costs. They had to have long-term vision, yet be ready to change direction at a moment's notice. Most firms moved on but the Government decided to implement that relatively untried theory. My noble friend Lord Winston told us how untried it was. At vast expense consultants were brought in, and my noble friend Lady Jay told us the cost. Civil servants became business managers. Many noble Lords have spoken of the large numbers of new managers who were appointed and encouraged to manage in the worst kind of bureaucratic manner. Citizens became customers and the public sector was landed with the latest management theory of the private sector. There is a wonderful account of that in a new book published last week called The Witch Doctors. Perhaps I may reassure noble Lords that the "Doctors" in the title are management consultants and not medical doctors.

Of course, the inevitable happened. Industry found that shopping around the market might produce cheapness but it did not produce excellence. It also turned out to be less expensive to concentrate on selected suppliers with whom to co-operate in order to produce world-class results. The private sector is more fleet of foot; that realisation triggered mergers and long-term commitments fairly quickly. But, quite naturally, things happen more slowly in the public sector. In the NHS the Government persisted with its internal market philosophy, which was rapidly going out of fashion.

The noble Baroness, Lady Flather, told us that the internal market has been modified. However, the internal market and fundholding GPs have not produced the centres of excellence and the multidisciplinary hospitals that modern medicine needs. Indeed, as other noble Lords told us, it is proving to be a barrier. With an outdated philosophy, competing fundholders are not best served by competing hospitals. The internal market still left the old hospitals expensive to run. To have new hospitals—reconfiguration—meant closing the old hospitals to make way for the new specialist units. That meant that health authorities needed to make long-term commitments to those hospitals instead of shopping around, as they were required to do in the market system, however it was modified.

The whole ethos of the National Health Service now is competition between trusts. Trusts are judged on their ability to provide the services. Yet there is little doubt that mergers would provide a better service. But they are reluctant to act as this requires local health authorities to co-operate and plan. This is a complete change from the market ethos. Mergers to produce single, acute trust hospitals are not compatible with competition, and the pressure for the limited resources within the NHS means that full competition cannot work. It is too expensive, as industry found out. The Government have to decide where competition stops and co-operation starts.

The NHS internal market does not deal with the contradictions of its customers being citizens and voters. As customers, they want quality and service. As citizens, the public legitimately are attached to their local services and are reluctant to see them disappear. They have their local preferences and attachments, and vested interests.

Many noble Lords have spoken of the lack of money in the NHS. So, trying to use the private sector's financial principles in the NHS throws up contradictions. To close wards and reduce services because patients have been processed more quickly, and the available cash used up, demonstrates this. In the private sector this increased efficiency would be rewarded by higher profit. In the NHS it means that the gains made in the past few years in speeding patient care will be lost. As a result we have drift. We were promised lots of new projects via the private finance initiative and, in spite of the remarks of the noble Viscount, Lord Bridgeman, nothing major has happened.

However, business and government can learn from each other. Many lessons have been learnt by the NHS from private sector management theory: breaking up giant organisations into manageable units, measuring performance, accountability and becoming more customer conscious. But these business and financial perspectives are near the bottom of the list of criteria valued in modern business today. Inspiring a shared vision and developing organisational talent are near the top because it is those talents which enable managers to improve performance and implement change.

Many noble Lords have told us that these values exist in the public service. Perhaps the focus needs changing, but they are there. Before the internal market there was a shared vision in the NHS which would be greatly admired by modern business. It is sheer vandalism to destroy it.

The Minister is going to have to take difficult decisions; more difficult than dealing with excessive and bureaucratic management. The NHS is landed with yesterday's theories from the private sector. There is nothing more dangerous than yesterday's view of the future. My suggestion to the Minister is to stop trying to apply transient private sector management theories to the NHS. Let the NHS develop its own, incorporating the public service values of service and dedication, remembering that the NHS is also a social and political community, and using the best of private sector efficiency which has stood the test of time. Allow health to be the indicator of success instead of accountancy.

That is why the Minister should support the Motion of my noble friend Lady Jay to maintain the public service values of the NHS and why we should both thank her for moving the Motion.

6.53 p.m.

Baroness Berners

My Lords, I begin, as others have done, by thanking the noble Baroness, Lady Jay of Paddington, for initiating this debate so that all sides can bring out the problems as they see them and confirm the excellence that has been achieved during the first 50 years of the National Health Service, as so well expressed by the noble Baroness, Lady Seccombe. Indeed, I very much support the sentiments of the noble Baroness, Lady Brigstocke.

There is so much in place right now to maintain the public service values of the NHS due to the recognition of this Government of that need, as mentioned in the speech of the right reverend Prelate. Under the Conservatives, the National Health Service has responded fully to the advances in medical knowledge by facilitating the demands of the ever-increasing discoveries and inventions of this compassionate service, as is evident in the drop in infant mortality from 13.2 to 6.1 per thousand live births between 1978 and 1995, to a longer, more useful and often more comfortable life expectancy.

Taxpayers' money is being continually readjusted so that it is used more efficiently and effectively as greater and greater demands are made on it to provide for the staffing of all the many facets of maintaining and improving the health of the nation. This Government are maintaining the value of the service by increasing the spending, so that we are still confident that we shall be attended to quickly and expertly in an emergency—and for free.

I think we sometimes forget how that is being managed. It is due to wise and efficient Conservative policies over the past 17 years. We have a much better chance of being treated more quickly for less immediate conditions, with a far shorter waiting time than 10 years ago. I know that some of my more elderly friends and relations are amazed at and very grateful for all the expert personnel who swing into action and put together a very helpful and supporting plan that will solve some of their problems—either to enhance their independence or arrange for care when it is not possible to continue on their own.

Thanks to the Conservatives, today's National Health Service is managed locally by people who understand local needs and how to meet them. So it is quite evident that the Government's concern is that the patient should come first. They have provided far more information for patients than ever before—about how they can be helped and who will advise them on the available services in their area—and they have provided information to patients in hospital, as was so well expressed by the noble Baroness, Lady Flather. The developments and improvements continue through the release of funds at the local level for the health service, so that there can be more up-to-date, economical and efficient use of capital investment to build new units in more appropriate places to serve the patient better by streamlining the services in the area.

The East Gloucestershire Health Authority has been able to provide a new unit for the acutely mentally ill and another new unit for geriatric assessments. Both of those, fortunately, are close to where we live. This past month a new maternity hospital has been opened adjacent to several new wards in the Cheltenham General Hospital. The new orthopaedic ward opened its doors to patients on the waiting list recently—of which my husband is one—so that we could see how much will be done for us and where some of the taxpayers' money goes. Those parts that keep us walking about without pain can cost a bomb! Of course they are expensive; it has taken years of research by skilled medical and industrial scientists to come up with the goods—as mentioned by the noble Lord, Lord Butterfield—matched by the skills of the surgeons and clinicians. Much of the taxpayers' money goes to the funding of these important activities.

Is it not the principle of the division of the cake that, where some receive more, others inevitably will receive less? This balancing act goes on down from the national to the local level, where the hunk, slice, sliver or crumb must be fairly distributed or rationed, as the noble Lord, Lord Hayter, said. If all departments are running at full strength with normal work, when an emergency arises some of that work must be left for a while so that the emergency can be dealt with. I think noble Lords will agree that it is not a sound economical practice to have areas of accommodation and personnel lying unused to deal with an emergency that may never happen—certainly not in a small set-up. The staff of the National Health Service are of such quality that they will have done all that is possible; they will know where commodities can be put on hold, and will know what will be demanded of them in order to cope efficiently when the emergency arises. The East Gloucestershire Health Service cannot be the only one in the country that has managed to budget, with the funding available, to have adequate forward plans for emergencies, winter or otherwise, as well as run an excellent service.

7 p.m.

Lord Desai

My Lords, as the last speaker in this debate from the Back Benches, I am aware that quite a few things have already been said. I shall concentrate on the question of rationing, as mentioned by the noble Lord, Lord Hayter, and the internal market, mentioned by my noble friend Lord Haskel.

We can start with the proposition that the National Health Service, by and large, is a very good and efficient service. It is a credit to all parties on all sides and especially to the people who work in the service. I do not believe that anyone doubts that. No one doubts also that there was rationing in the National Health Service from when it first started.

The issues that arise nowadays are the following. Despite £43 billion being spent, there is a feeling abroad—not just on this side of the House, but it also appears in the newspapers, including the Evening Standard, where there have been many headlines—that at the margin increasingly people are not happy with the way the NHS is performing. The question is why that is the case. I wish to suggest an answer.

Before the reforms of the National Health Service and the introduction of the internal market, people who needed the health service felt that they could get it. They had access to it either through their GP or through the hospital. Yes, there were problems, but, by and large, people did not feel that there was discrimination, one against the other, depending on where you lived or your GP. There were queues and there was rationing.

There was also the strange phenomenon that the United Kingdom had, through the NHS, the most cost-efficient health service of any developed country. We were spending a smaller proportion of our GDP on health and that was a good thing. The amount of money spent on something is not a good indicator of quality, but the outcome is. In terms of the health service, we were getting a good service.

It was false propaganda during the 1980s which stated that the NHS was in crisis and that it was costing too much money—about 5 per cent. of GDP. People also said that there were inefficiencies and that the demand for healthcare was unlimited. It is a fallacy to say that the demand for healthcare is unlimited. It is not unlimited because nobody actually fancies going to a GP. It is an unpleasant thing to do and it costs time. You go only when you have to.

The internal market signally failed to deliver. First, the devolution of funds to some GPs—not all of them, yet—made people who belonged to a fundholding practice feel that they were better off. Indeed, they were better off than people who belonged to a non-fundholding practice. I do not believe that that was a delusion. The mistake arose from the fact that when fundholding was introduced, placing patients here or there became not a matter of the health needs of the patient but of the need for efficiency and the profit-making quality of a fundholding GP. Until then people belonged with the practice and they got whatever they wanted. But once there was a cost consideration, GPs were encouraged to market their services. If there was a genuine market in health, as there is in hamburgers, one would not mind. But you cannot have a genuine market in health because people do not pay up front; they have to be provided with whatever they want.

In the allocations among hospitals we did not have a market, but what I would call, and have called before, Stalinist pricing. If one has Stalinist pricing there are more or less fixed prices for, say, hip replacements, but differential costs because the accountants have imposed rules on hospitals. Inner-city hospitals have to meet the cost of the land on which the hospital stands. Nobody is about to buy it. The accountants will tell you that opportunity costs are very important—a great deal of money is spent on these Coopers & Lybrand reports. If one is in the City of London and, for example, at St. Bartholomew's, that land is very valuable. You have to factor that land into the costs. If that happens you can see why in inner cities there is a crisis in the health service. Inner-city hospitals have become uneconomic and they cannot attract patients. Therefore, they have to be shut down or the number of beds reduced.

That is wrong costing. An inner-city McDonald's—or an inner-city Claridge's, I should say—can easily charge a higher price for hamburgers, but St. Bartholomew's cannot charge. So it is false pricing. There is not a proper market but a bureaucratic one. Once you set up a market like that, costs have to be written down specifically. These are transaction costs in the form of managers and accountants who have to write down all this bilge.

Roughly speaking, up to 5 per cent. of the budget is transaction costs, not in terms solely of the managers, since the time spent by the health professionals in filling out forms has also to be taken into account. But up to 5 per cent. or more of the budget is concerned with transaction costs. It is a total waste of money.

I am sure that when people thought of the internal market they thought that it was such a nice word because it suggested that it would be efficient. What was already an efficient service, and one which had to ration in a way which citizens found satisfactory, has now been messed about with. In not understanding the principles of the market we have a polluted and distorted market in which people have been segregated and made to feel unhappy. The inner-city hospitals are in crisis and that is costing a great deal of money.

I say to the Government that they should go back to school. We shall tell them how the market works and then there will be a proper market. Perhaps we need a better, collective socialist market than the one we have right now.

7.8 p.m.

Baroness Robson of Kiddington

My Lords, it is very difficult to follow the commercial break that we have just had. We on these Benches are also very grateful to the noble Baroness, Lady Jay, for introducing this debate. In introducing it she told us something which we all know; namely, that in 1946 there was not a bipartisan policy on what was going to happen with the introduction of the health service. However, she failed to mention that there was a third party in the House in those days as well as now. First, Beveridge was a Liberal and not a Socialist. Secondly, the Liberal Party introduced its plans in 1942 for a policy called Health of the Nation, which was based on the Beveridge Report. That was before 1946, so I believe that we on these Benches take some credit for its introduction.

The Motion invites us to celebrate 50 years of the NHS, which, up to now, has been the envy of the world. I know that personally because I was born in a country, Sweden, which has been generally admired all around the world for its health and social services, which have been magnificent, but the one thing in our NHS that that country has always envied has been our general practitioner service and the fact that every member of our society is registered with a doctor and has somewhere to go for primary healthcare. I believe that that is the basic strength of our health service. The basic principle of healthcare being available to all citizens at the point of need was a grand vision. It was a vision in which we all still believe, one to which we must be still dedicated and one which we must do our utmost to preserve.

Many noble Lords have referred to the benefits of our National Health Service, but the Motion also refers, to the need to maintain the public service values of the NHS and to the case for immediate government action to prevent a breakdown of services this winter". Sadly, I want to concentrate on the problems that face the NHS rather than speak of its benefits. After endless reorganisations over the past 14 years and the threat of a breakdown of services this winter, we must urgently examine what has gone wrong. We could go through the various reorganisations and analyse their impact on the NHS, but that is now in the past. That is history. Perhaps the one thing that we should say is that they were all introduced without adequate tests and pilot schemes being undertaken before their national implementation.

The last reorganisation, the introduction of the provider-purchaser principle, has probably made the greatest impact on the services provided by the NHS. The principle itself is a good one, but its implementation leaves much to be desired. Not enough thought was given to the tremendous increase in the time of both managers and clinicians that would be needed to cost and implement the contracts between providers and purchasers. As many noble Lords have said, that has resulted in an unprecedented increase in the number of managers employed by hospital trusts and boards. I believe that the number has increased by more than 400 per cent. That endangers the money available for patient care.

This year—I am not talking about the present negotiations, but about the financial year in which we are now functioning, 1996–97—the Secretary of State proudly announced that he had negotiated an increased allocation for the NHS of 1 per cent. above inflation. He failed to mention that out of that £500 million at least £178 million was destined to pay off the debts of the previous year. It had to be siphoned off before the new money could go to the health authorities. That has resulted in some trusts which were particularly badly in debt receiving no increase above inflation.

Unfortunately, the same thing is about to happen this year. I am told that, although we are only half-way through the financial year, health authorities have overspent by £134 million. I have discussed this with clinicians, who are adamant that patient care has not received any appreciable increase. They say that health authorities are not taking important strategic decisions because of financial uncertainty and that such decisions are endlessly postponed from year to year. Some of those strategic decisions could be financially sound and might improve the service. It is a tragedy that they cannot be taken.

The largest part of the increased allocation has been spent on increased management costs. I believe that that is mainly because of the short-termism of the yearly contracts between purchasers and providers. Which industrial company could work efficiently on only a year-to-year basis without having any idea of what will happen in the next year? As soon as this year's contracts have been settled—on the whole, it takes managers and clinicians a year to work them out—they have to start working again on the contracts for the next year. That means that clinicians are losing time that they might spend on patient care. I wonder whether the Government might be prepared to try to persuade the Treasury to consider three-year contracts so that much money could be saved, not to mention the valuable time of clinicians, thus allowing them to devote more time to patient care.

The last part of the Motion deals with the danger of the breakdown of services this coming winter. The need for action is urgent. Trusts and boards have, to a large extent, already had to abandon their efforts to reduce waiting lists because of the constant pressure on their accident and emergency departments. There are two main reasons for that. First, in too many hospitals too many beds have been closed—not because they were not needed, but in an effort to save money and to come up with the right accounts at the end of the year. As a result, we have seen people having to wait on trolleys and an increase in the length of time before a patient can be found a bed. Both the National Association of Health Authorities & Trusts and the British Medical Association state that, unless an injection of £200 million to cover the deficit of the present financial year is forthcoming, the outlook for the winter is black. However much money there is next year—and however well negotiated it has been by the Secretary of State—it will not help unless it reaches the health service now.

I have also found out that GP fund-holders are now suffering from a lack of resources. Many of them have no money left for cold surgery—and we are only half-way through the year. They have had to resort to a block on calling in new patients despite the fact that some of those patients may already have been waiting for an unacceptable length of time, many of them in great discomfort and often unable to work as a result. It may be that some of the increase in the number of patients attending A&E departments is because patients use A&E as a last resort. Having failed to be referred to hospital by their GP, they decide to use the A&E department to get help.

What can we do about it? What are the ways forward? Both the BMA and the Royal College of Nursing have advocated the setting up of acute assessment units in hospitals to relieve A&E departments. Heart patients, for instance, could be assessed for hospitalization instead of automatically taking up a hospital bed, even if only for a night or two. Acute assessment units could also be used to make sure that patients who required diagnostic treatment were referred to the appropriate departments and not through accident and emergency. That would relieve the pressures on A&E. But that would not reduce the need for an injection of cash this winter to avoid a breakdown of the service.

At present the Government are engaged in the annual spending round. According to the press, the Secretary of State has had some success in obtaining cash for the NHS, but there are two provisos. First, as I have already said, cash next year will not help the NHS over this winter. It is essential that the NHS receives an immediate injection of £200 million to tide it over this winter. Secondly, when announcing the NHS allocation for next year, account should be taken of the amount of money which, like this year, will immediately go to paying off the debt incurred this year, so that the public is not given a false impression as to the amount of money available to the NHS.

When announced, there will be many calls on the money available, not least from the community services, which have been seriously underfunded since emphasis on care has been moved into the community. Nowhere is this more important than in care given to the mentally ill in our community, where both health authorities and social services are underfunded. The noble Lord, Lord Mottistone, made that particular point. I see in today's papers that Mr. Dorrell has become aware of the problem and is considering the reorganisation of the service yet again—for example, by the appointment of a new health authority to manage community services for the mentally ill. We do not need any more health authorities; we need more money for the health service and the social services to enable them to look after these people. At all costs we must avoid reorganisation and its high management costs but instead concentrate on providing our dedicated staff with the financial backing that they need. I plead with the Government to consider changing the contract principle to a three-yearly contract, to reorganise accident and emergency departments and to be transparently honest in announcing the proposed cash injection.

7.23 p.m.

Baroness Hayman

My Lords, this has been a wide-ranging and fascinating debate. I am sure that the whole House will congratulate my noble friend Lady Jay on her sense of history, timing and geography in initiating it. We continue to debate the National Health Service 50 years after the passage of the Bill whose stages were fought over, as my noble friend Lord Bruce reminded the House, in this very Chamber when the Commons sat here post-war.

I start by declaring an interest as chairman of an NHS trust. I believe that it is important to strike a balance in discussing the National Health Service. One must have admiration for the work that the NHS has done and the work that continues to be done day in and day out by dedicated staff. But that admiration should not inhibit one from speaking out when one believes that problems ought to be addressed. I find inconsistency in the attitude of noble Lords and Baronesses sitting opposite. When, on this side of the House, criticisms are made of government policies towards the NHS, it is said that we are playing party politics. But when praise is heaped on what has happened in the NHS over the past five years, that is an objective analysis and just happens to be the result of government policies. If Aneurin Bevan were able to revisit the Chamber and sit where he was sitting 50 years ago I believe he would be amused and gratified to hear the universal approbation from all sides of the House about his creation. My noble friend Lord Haskel reminded me in the course of the debate of the old saying that success has many parents but failure tends more often to be an orphan. The parentage and support of and for the National Health Service run across this Chamber.

The NHS is a remarkable creation. Professor Peter Hennessy, in his book dealing with Britain post-1945, describes the National Health Service as the nearest that Britain has come to institutionalising altruism. It is a very noble creation. That is why some of us feel passionately that the values of that noble creation—the equity, collaboration and work that the staff do by way of public service, not service for profit—should not be undermined by an ideological approach to the organisation of the service.

My noble friend Lady Jay deserves congratulation not only for her historical sense but her sense of contemporary political timing. Many noble Lords have referred to reports of the Secretary of State for Health going to the wire (as sources close to the Department of Health would have it) for extra funding for the NHS. I echo the sentiments of the noble Baroness, Lady Robson. We wish Mr. Dorrell well in all his attempts. However, one must understand the severity of the financial problems now building up which could eat away at any settlement for next year. One must also understand the importance of an injection of cash this year to address the current problems expounded by many of my noble friends. For example, the noble Lord, Lord Howell, referred to the problems in Birmingham. Without doubt, one is dealing with a severe crisis in the NHS.

I have no desire to instil in patients unnecessary anxiety about the services that are available to them. In the vast majority of cases the NHS continues to provide a high quality of response to patient need. That has been spoken to by noble Lords on all sides of the House. However, I do not believe it right to ignore the views of professionals and others throughout the service about the severity of the difficulties. The BMA says that the NHS faces the most difficult winter since the introduction of the internal market. NAHAT has said that this is the toughest year since 1987–8. It is essential that there is extra investment. The trusts federation—which is hardly a left-wing voice against the Government—has said that this year the NHS is not crying wolf and that resources are needed now because it is £200 million to £300 million short.

When I have raised these issues previously with the Minister, who has a long record of fighting for resources within the NHS, she has tended to look at me wisely and say 'twas ever thus. Noble Lords opposite accuse us on these Benches of making party political capital, of in some way enjoying the problems that exist within the NHS. I have to say to the noble Baroness, Lady Rawlings, that far from not having experience of hospitals my right honourable friend the Leader of the Opposition was visiting Great Ormond Street Hospital with Mr. Chris Smith this morning. My noble friend Lady Jay was at a hospital yesterday. I was at a hospital today.

One of the things that most upsets staff within hospitals is when Ministers go into the mode of Panglossian speech that, "All is for the best in the best of all possible worlds", and there is nothing wrong when their daily experience is of appalling problems, real difficulties and real pressures on A&E described by the noble Baroness, Lady Brigstocke. We have a duty to expose them.

I was somewhat reassured that this was not a party political issue when I awoke to the "Today" programme yesterday morning to find that it was not just people on this side of the House who were making the point but to hear the dulcet tones of Mr. David Mellor informing the nation that he had taken a delegation of 10 Conservative MPs from south London to tell the Secretary of State how urgent it was to have some money for the NHS this winter.

The concerns of the elderly have been mentioned. It is a group of people about whom we should be worried. My noble friends Lady Turner and Lord Stallard talked about the problems and the anxieties that the awful episode at Hillingdon engendered with the market structures of the NHS, squabbles between rival hospitals, the purchasing authority and the social services unable to achieve a coherent approach—

Baroness Flather

Will the noble Baroness give way?

Baroness Hayman

The debate is timed, and time is short.

Baroness Flather

That is an unjustified attack by the noble Baroness. I recommend that she look into the case properly.

Baroness Hayman

I understand the feelings of the noble Baroness. I know the difficulties—

Baroness Flather

The facts, my Lords.

Baroness Hayman

There are facts here, but some of the facts show that the changes in contracting arrangements between hospitals resulted in a situation where we, as the NHS, did not serve those patients well. Those patients who, 50 years ago, thought that the NHS would give them security in old age had that feeling of security taken away from them.

Noble Lords opposite and Ministers do not understand how public confidence in the NHS has been destroyed by the attempt to commercialise the culture within the NHS. It means that where the best may be being done, people feel that financial considerations and market considerations are not considerations of patient care. The language of the market has itself had a corrupting effect. Talk of purchasing, contracts and of calling patients "customers" has undermined confidence that the decisions that will face any government dealing with the health service are not being taken on the basis of patient need.

The right reverend Prelate the Bishop of Exeter talked about hospital chaplaincy services. I knew that we had gone too far when I met a hospital chaplain the other day who told me that he was terribly busy. I asked whether there had been a particularly harrowing event. He said that there had not; it was just that he was having trouble adding up the figures in his business plan for next year.

One of the other public service values we have lost, and which in some way is threatened in the health service, is that of openness. There is concern that people are unable to speak out. The BMA sent me two examples—two anonymous letters. I have no idea from where they came. One was from a doctor who wrote: I am concerned that if these were to get into the public domain in the present day NHS they would cause problems for me and particularly my trust … despite the serious risks it seemed a duty to inform someone". Another wrote: Please feel free to quote the content—but please not the trust, nor the writer, nor me". It is important that we are open about the issues within the NHS, because they are challenging issues. There are no easy answers. There are big issues that any government will have to tackle. What makes me so sad is that during the past five years the improvements that have been made have not occurred as a result of the introduction of the internal market but often despite its introduction. My noble friends Lord Haskel, Lord Desai and others spoke about the difficulties and damage inflicted upon the planning processes and of the throwing away of some of the tremendous benefits that the NHS brought to us—low administrative costs, the saving of transaction costs, and collaboration rather than competition—which were so important in delivering the service that we had.

I have no desire to talk down the achievements of staff within the NHS or to make patients unnecessarily worried but everyone who works within the NHS—it is clear from the messages that come from the NHS Executive about arranging emergency care this year—knows how severe the situation is. It is fascinating to see what has happened to waiting lists. For five years we have heard, "Waiting lists, waiting lists, waiting lists performance". This year waiting lists are not the dog that did not bark in the night. It is the junior Minister who did not crow at dawn, because we all know that waiting lists will go up this year—

Lord Winston

They are going up.

Baroness Hayman

They are going up, as we struggle to meet pressures on the emergency services.

There is an enormous amount to do, not just in terms of obtaining more resources, rebuilding medical morale, particularly in academic medicine, and in general practice. There is also a recruitment and retention crisis within the nursing profession. We can hope that this Government do something about the short-term funding. In the long term, for the reinvigoration of public confidence in a government who will support, sustain and change the NHS for the future, only a general election can provide the answer.

7.38 p.m.

Baroness Cumberlege

My Lords, I, too, would like to thank the noble Baroness, Lady Jay, for initiating this debate. As a distinguished member of a health authority she, with other members of your Lordships' House who serve on health authority and trust boards, who work or have worked in the NHS, who have given so much in a voluntary capacity, speaks with knowledge and authority; and that is my first point.

The NHS is unique in many ways but what makes it exceptional, outstanding and quite different from other health care systems around the world is the involvement of millions of people. People give willingly to research, to leagues of friends, to special interest groups. They give their blood, their organs, their time, energy and cash. The NHS quite literally belongs to the people and I am always conscious that any government, whatever their political persuasion, are merely stewards—custodians—of this remarkable national institution. But as my noble friend Lord Astor of Hever reminded us, Conservative Governments have been the custodians of the NHS for two-thirds of its 48 year existence. It has been Conservative Governments who have taken it from strength to strength. It has been Conservative Governments who have ensured that the NHS can meet its ambitions. In the 1950s it was Conservatives who established the Pay Review Body and conducted a thorough review of NHS finances.

In the 1960s it was Conservatives who published the first hospital plan for England. In the 1970s it was Conservatives who introduced structural changes in order to plug gaps in the NHS and who created community health councils. In the 1980s it was Conservatives who introduced reforms that have provided a firm foundation for the modern NHS and enabled the majority of GPs to take charge of funds for the care of their own patients. And in the 1990s not only have Conservatives produced the first comprehensive strategy for public health, The Health of the Nation, described by the World Health Organisation as a model for other countries to follow, as my noble friend Lady Brigstocke said; not only have we involved patients through the Patient's Charter, mentioned by my noble friend Lord Bridgeman, setting out their rights and responsibilities, but we have worked with the professions most recently in drawing up the White Paper on primary care. Our new Bill will reflect those views, a direction which I believe will please the noble Viscount, Lord Waverley.

This is a consistent record over many decades of which Conservatives can be proud. It upholds the promise of a Conservative Health Minister, who in 1944 published the White Paper on the NHS declaring that the new National Health Service would be available to all on the basis of need, and also that: they shall get the best medical and other facilities available". I believe that we have more than honoured that promise.

As well as providing the best service for patients, the NHS must also provide rewarding careers for the million committed people who work in it. That is why we established the pay review bodies. For the most part these have ensured that, whatever the pressures on the health service, its professional staff have seen real investment in their careers and incomes. I say "for the most part" because the incomes of doctors and nurses suffered badly in the economic chaos of the late 1970s, when the Labour Party was in power and the IMF dictated this country's fiscal policy.

My father joined the NHS in 1948. Patients came to the house, and in my home we literally had blood on the carpet. The ethic of the NHS was imprinted on me at an early stage. Whether young, old, black, white, rich or poor, people should have access to health care according to clinical need and not ability to pay. As the noble Baroness, Lady Robson, and other noble Lords have said, it is an ethic which is prized and cherished by the British people.

But the maintenance of this ethic depends upon proper funding. That is where rhetoric and reality divide. As my noble friend Lady Seccombe said, the NHS has never had more resources. Whereas my right honourable friend the Prime Minister has renewed his health service guarantee to the British people—that year on year the NHS budget will continue to grow—once again, no such pledge has come from the party opposite.

Indeed, only on Monday of this week, when pressed for an assurance that any incoming Labour Government would increase resources, the Shadow Health Secretary said on the "Today" programme, "That would obviously be my aim". We all have aims, but the NHS deserves more than that. Our commitment to the NHS has been demonstrated for 17 years and the Prime Minister has made it clear that this will continue. This puts in context the criticisms which have been made about the current level of resources.

The noble Baronesses, Lady Robson and Lady Jay, the noble Lords, Lord Monkswell and Lord Prys-Davies, and the noble Viscount, Lord Waverley, have said that the NHS is short of resources. However, I believe that we should see it in the context that I have outlined. The majority of trusts and health authorities are not facing bankruptcy. In a budget of £41 billion, a forecast of less than 1 per cent. overspend halfway through the year is not an insurmountable problem. In fact, any commercial organisation would be proud to achieve a result so close to its target. The NHS has an extremely good record in balancing its books. I am sure that, as in other years and with a little flexibility, it will achieve the desired result because it has a carry-forward facility. Perhaps I may say in parenthesis that I agree with the noble Baroness, Lady Robson, that three-year contracts are sensible and we are encouraging health authorities to follow that advice where appropriate.

I agree also with the noble Lord, Lord Rea, and my noble friend Lord Colwyn that the important criterion is not simply the amount of GDP which a country spends on healthcare but the value which it gets from that expenditure. The reformed NHS is one of the most efficient in the world and we know through OECD and other independent reports that it provides excellent value for money.

The noble Baroness, Lady Jay, gave an undertaking that in the event of a Labour government coming to power they would abolish the internal market. I believe that that call was welcomed by the noble Lord, Lord Monkswell. However, Renewing the NHS, which I understand is still the Labour Party's main health policy statement, states on page 20: We believe there should be a separation in the planning and delivery of healthcare. We want health authorities to commission care but we do not want them to run hospitals on a day-to-day basis". I was not sure whether the noble Lord, Lord Winston, was slightly embarrassed or slightly elated at being quoted by my right honourable friend the Prime Minister in another place—

Lord Winston

My Lords, I was astonished!

Baroness Cumberlege

But I remember the noble Lord saying that the internal market has resulted in many hospitals improving outpatient facilities, improving comfort for patients, improving waiting times in clinics and in some cases improving waiting lists. There is no doubt that that has happened. Of course there was a wider context and I accept that, but I hope that any future Labour government will follow the noble Lord's views.

As was said by my noble friend Lord Astor of Hever, the NHS has improved enormously since the reforms. He is right, for there are countless people who have cause to be pleased that the NHS has been reformed, especially those waiting for treatment. Five years ago 70,000 people had to wait for two years or more for treatment. Today nobody waits two years and the average wait for those not needing emergency care and who are seen at once is four months. The noble Baroness, Lady Hayman, said that we were silent on that issue. We are doing so much better than we were last year but of course I accept the fact that with the winter pressures the waiting times are likely to increase as they do in most winters.

The noble Lord, Lord Haskel, drew a caricature of an NHS riven with competition at the expense of efficiency and care of patients. That is a false picture, as noble Lords who serve on the boards of health authorities and trusts will know. Indeed, some have testified here tonight. Patient care is at the top of the agenda of clinical staff and of professional managers alike. The right reverend Prelate the Bishop of Exeter rejoiced in the increasing number of fully funded hospital chaplains who now work in the NHS. That is the result of the internal market, which gives more certainty and autonomy to trusts. Those trusts have recognised the value of hospital chaplains not only in seeking to look after the spiritual needs of patients and staff but so often as the most perceptive of people. They see the whole organisation and they act effectively as the patients' advocate. I look forward very much to the forthcoming celebrations and development of the chaplaincy, which were referred to by the right reverend Prelate. The noble Baroness, Lady McFarlane, shared with us not only her early perceptions of the NHS but the positive contribution that the internal market has had on values and improved care for patients. I understand her point on equity but through RAWP and son of RAWP resources are now much more fairly spread. However, GPs are of course free agents and we cannot dictate where they work.

The noble Lord, Lord Hayter, in his very perceptive exploration of rationing, rightly pointed out that resources are not limitless. I believe that even the noble Lord, Lord Desai, with his engaging optimism, will agree that deciding priorities has always been necessary in all public healthcare systems. But rationing of core services should be unnecessary while there is scope to improve efficiency and effectiveness. I have heard the noble Lord on other occasions urging us to be more efficient. It is interesting that the Health Select Committee endorsed the department's view that most priority settings should be carried out at a local level within the national framework. The Government provide a framework in their priorities and planning guidance and it is then for local people to decide. We believe that local NHS bodies are best placed to assess health needs and to decide how those needs should be met.

The noble Baroness, Lady Turner of Camden, suggested that the Government have opted out of care for elderly people, and that was an issue raised also by the noble Lord, Lord Stallard. Nothing could be further from the truth. We have confirmed and clarified the responsibilities of the health service for meeting the needs of people with continuing healthcare needs, whether in hospital, the community or other places. We have placed considerable emphasis on the importance of good hospital discharge procedures and the need for effective communication between health and social services staff over arrangements for people needing continuing care.

The noble Lord, Lord Stallard, raised also the issue of breast screening for women over the age of 60. I am extremely pleased to tell him that we are working with Age Concern to inform women that, if they wish to continue to be screened, screening is available to them. I take the point that practice staff are not always aware of that and we are doing all that we can, through Age Concern and others, to make sure that that knowledge is available to them. We are also running three pilot schemes which will operate a call and recall system for women over 60. We look forward to the results of that.

My noble friends Lady Flather, Lady Rawlings, Lady Berners and Lord Mottistone are quite right to highlight the high morale in Teeside, Cheltenham and the Isle of Wight, and, indeed, in other parts of the country. Where improvements have been made, it is right that we should rejoice in them, and we know that there are many. It makes me sad that some people appear miserable when praise is given and achievement is lauded. But I was very glad to hear this evening the noble Baroness, Lady Hayman, rejoicing in achievement, and she will know that Gloucester, Teeside and the Isle of Wight are not isolated examples.

I am grateful to my noble friend Lady Flather for setting in context the issues concerning Hillingdon Hospital. I know that she knows the inside story and perhaps, with respect, I may remind the noble Baroness, Lady Hayman, of H L Mencken's very wise words that for every difficult, complicated question there is an answer which is simple, easily understood and wrong. We know that in the health service, nobody should jump to conclusions without understanding fully all the issues involved. In this case, not only Hillingdon Hospital but also Mount Vernon and others too were concerned.

I was delighted that the noble Lord, Lord Butterfield, who has given so much to the NHS in so many fields as a distinguished academic and clinician, should be sharing his views with us this evening. It seems to me that the noble Lord may have achieved what the Common Cold Research Laboratory has failed to do over its many decades and I for one shall take his advice.

I understand the issues which the noble Lord addressed concerning research staff and the need to maintain pay parity between clinical academics and their NHS counterparts. That was an issue raised also by the noble Lord, Lord Winston. Clinical academics are university staff and their pay is therefore a matter for their employers and the Department for Education and Employment. I understand that negotiations are continuing. I know it has been a very long-running problem which we are extremely anxious to resolve.

The noble Lord, Lord Winston, shared with us his experiences as regards the lack of academics and research workers coming to this country. I believe that the picture is patchy. I was talking to the chairman and director of the MRC the other day on an informal basis and they were telling me that whole clinical teams are now coming over from the United States and other countries to work here, but not always to London. From my personal experience I know that there has been an increase in posts, particularly chairs in academic institutions. Therefore, I can understand that at present there is a paucity of people to fill those.

I return to the noble Lord, Lord Bruce of Donington—a very great man. In the Guardian today I saw a flyer—I think it is called a flyer—which promised us "a verisimilitudinous commemorative speech" from the noble Lord, Lord Bruce of Donington". That is a very grown-up adjective and I had to look it up in the dictionary. The definition was: "A semblance of the truth or reality; something that nearly seems to be true or real, such as a doubtful statement". That was a wrong description, because this afternoon we heard another very powerful speech from the noble Lord, who put forward forcefully his honest view. I shall not seek his redemption but I look forward to the noble Lord's continuing contributions to your Lordships' House. It is important that we should know the history of a lot of our social policy and there is no better place than in your Lordships' House for hearing that first-hand.

The noble Lord, Lord Prys-Davies, asked about the number of nurses. In replying to his comments, I should like to associate myself with the remarks of my noble friend Lord Bridgeman. The number of qualified nurses and midwives has increased by almost 48,000 since 1979 and a 14 per cent. increase in the number of training positions has been announced for this year on top of the increase of 8 per cent. for last year. To some extent, we rely on the pay review body, which looks at the issue of the nursing workforce year on year. Last year's report said that the situation was patchy in some areas but on the whole the review body believes that there are enough nurses.

The noble Lord, Lord Prys-Davies, criticised the NHS reforms. I shall let the record speak for itself. In the five years since the reforms, general and acute activity has grown by 33 per cent. compared with an estimated growth of 10 per cent. in the five years before the reforms. I assure the noble Lord that a number of executive directors of NHS trusts know to their cost that poor performance will not be tolerated.

The noble Baroness, Lady Masham, asked about the future of the Public Health Laboratory Service. I am grateful to her for giving me notice of that question. I can confirm that a review of that service is currently taking place but I assure her that no decisions have yet been made and her comments will be taken fully into account. I note also the suggestions which the noble Baroness made about an audit of treatment for those with spinal injuries. I shall certainly draw those to the attention of those in the NHS Executive responsible for clinical audit.

The noble Lord, Lord Howell, raised the question of GP services, as did the noble Lord, Lord Rea. I suspect that that will be the subject of many hours of very hot debate in your Lordships' House in the months to come as we shall be introducing a Bill. Because of the time, I hope that your Lordships will allow me to address those issues then.

The noble Lord also took up the cudgels for the health service in Birmingham. I assure him that discussions between the parties, including the NHS Executive regional office, have taken place and continue to do so. No decisions have yet been taken and any proposals for significant changes in the health service would be subject to full consultation.

The noble Baronesses, Lady Jay, Lady McFarlane and Lady Robson, drew the attention to the importance of public service values in the running of the NHS. Your Lordships may recall that, building on the work of Sir Adrian Cadbury, in 1994 the Government published codes of conduct and accountability for NHS boards. They state unequivocally that public service values must be at the heart of the National Health Service and I was pleased that certainly in the health authority of the noble Baroness, Lady McFarlane, they are clearly respected and working.

As the noble Lord, Lord Ewing of Kirkford, pointed out, an important feature of public service is accountability to the public itself. The code of openness published last year has extended the principles of open government to the NHS. At the heart of the code is the aim that NHS organisations should give the public the information they seek except for those well-defined occasions when it is against the public interest.

Many of your Lordships addressed the issues of managing winter pressures, including my noble friend Lady Brigstocke and the noble Lord, Lord Stallard. Perhaps I may say briefly, because time is going on, that we have learnt the lessons of last winter. Since that time, planning for winter pressures has been a priority for the NHS. An extensive programme of work has been carried out at local and national level to ensure that the service is as well placed as possible to cope with the anticipated pressure on emergency care this winter.

In a spirit of conciliation and following the example of the noble Lord, Lord Ewing, I should like to conclude my contribution to the debate with a quotation. I use the words of Lord Jowitt, who said: I feel quite certain that there is no subject on which it is more worthwhile to spend our time, our energy, and our resources than on the health of our people. There is no investment we can make which is more likely to repay a thousandfold, and there is no task which will more readily attract men of good will, in whatever quarter of the House they may sit". Your Lordships will notice that there is no mention of women, but we will excuse Lord Jowitt because, as Lord Chancellor, he spoke those words on the Second Reading of the National Health Service Bill on 8th October 1946. I hope that your Lordships will agree with me that those words were indeed prophetic and that those aspirations have been met due to the careful stewardship of successive Conservative governments, the dedication of everyone working within the NHS and the good will and common purpose of the countless millions who support it, not only in the British Isles but throughout the world.

8 p.m.

Baroness Jay of Paddington

My Lords, I should like, first, to thank the Minister for her reply. As always, the noble Baroness has given the House a very detailed and thorough response to what has been an extraordinarily interesting and well-informed debate. It has certainly done justice to the 50th anniversary which we are commemorating this evening. I am very grateful indeed to all noble Lords who have taken part and I am particularly grateful for the practical guidance of my noble friend Lord Butterfield. As someone recovering from flu, laryngitis or a combination of the two, I certainly feel that he has made the most practical contribution to my well-being this afternoon. I thank him for that.

As always when we discuss the National Health Service in your Lordships' House, we have enjoyed the vast experience and authority of many Members who come from all quarters of the country and many different professional backgrounds. It is a very complex subject but, once again, I believe that we have illustrated that there are some profound philosophical differences between some of us.

My noble friend Lady Hayman summed up the views of these Benches in a masterly speech. I do not feel that the Minister fully responded to many of her points, but at this time in the evening I do not intend to reopen them. I am sure that there will be many other opportunities to do so. I look forward especially to discussing further with the Minister the question of the lengthening of waiting lists. If I understood the Prime Minister speaking in another place yesterday correctly, he said that the waiting lists were continuing to shorten.

I should just like to express my special gratitude to my noble friends who have spoken with all their experience and expertise in health practice, in economics, in business and in political life in every part of the country. All of their contributions have been full of well-directed wisdom. It has been a particular privilege to hear my noble friends Lord Stallard and Lord Bruce of Donington, who have fought the good fight for the public service health service for over half a century. Long may they and it continue! I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.