HL Deb 04 February 1998 vol 585 cc645-716

3.7 p.m.

Lord Hunt of Kings Heath rose to call attention to the celebration in 1998 of the 50th anniversary of the National Health Service and to acknowledge the contribution it has made to the health of the nation; and to move for Papers.

The noble Lord said: My Lords, I begin by declaring an interest as someone who has worked in and on behalf of the National Health Service for 25 years. I am also an adviser to the NHS Executive on the 50th anniversary of the NHS. I am deeply privileged to be able to move this Motion on what must be regarded as one of the most notable endeavours upon which this country has ever embarked: our National Health Service. I believe that that is reflected by the distinguished and long list of noble Lords who will take part in the debate this afternoon.

I particularly welcome the decision of the noble Baroness, Lady Knight of Collingtree, to make her maiden speech today. I have first-hand experience of her affection for and knowledge of the National Health Service. I await her contribution with keen interest.

On 5th July 1948 the NHS came into being. In introducing the NHS to the nation Aneurin Bevan promised that it would lift the shadow of fear of the financial consequences of illness from millions of people. He promised that it would relieve suffering, provide a higher standard of practice from the medical profession and make a great contribution to the wellbeing of the people of this country. How well the NHS has fulfilled the expectations of its founder. Despite the doubts, of which there were many, and a great deal of opposition and obstruction, the NHS has proved to be one of the outstanding creations of this country this century. Yet its inheritance in 1948 was hardly of the best, with little extra money to begin with and no extra nurses or doctors. It had an unplanned and patchy system of hospital provision. There was no comprehensive building programme for new hospitals. Often GP services were demoralised. Local authorities struggled to provide services outside hospitals and in the community.

Yet look at what has been achieved from that rocky inheritance. We see the modernisation of general practice to the extent that it must be regarded as the finest primary care system in the world. We have seen many new hospitals built and the planning and co-ordination of services from primary care to secondary care to tertiary care which is the envy of many health care systems. We have had outstanding success in meeting the challenge of advancing technology and new drugs. We have upgraded our treatment, raised productivity, and yet hardly increased our spending as a proportion of national output. We have retained the loyalty and commitment of our workforce. How many other organisations in this country would like to have the commitment that we have received from our staff?

Volunteers in their thousands have contributed to the NHS. We have received the support of the British people. Above all, we have shown that a publicly financed and publicly provided NHS can stand comparison with any healthcare system in the world.

There is much to celebrate. I have been privileged to be a member of a national steering committee, chaired by Professor Michael Schofield, which has put together the activities that will take place over the next few months to celebrate the 50th anniversary of the NHS. It has been remarkable that organisations which may traditionally have fought with one another over the NHS have all sat together: the BMA, UNISON, the RCN, the Royal colleges, and managers. It has been a wonderful experience of seeing people pull together. It is a living example of the uniqueness of the NHS family when it works together.

Hundreds of activities will take place throughout the country. At local level there will be open days, exhibitions and debates. They will be underpinned by national events. A postage stamp is to be published. There will be an ideal health exhibition, many debates, and photographic exhibitions of life in the health service going back to 1948, culminating in a service of celebration in Westminster Abbey on 3rd July.

It is always tempting to look back and to celebrate the achievements of the NHS, but I believe that we should use the 50th anniversary to look forward, and to discuss how the NHS can retain the vitality, relevance and ability to provide a comprehensive health service for the nation for a further 50 years.

No one should underestimate the challenge that we face. In that we are not alone. All healthcare systems in the developed world—in Europe, America or Asia—to a lesser or greater extent face the challenge described by Sir Cyril Chantler as the three paradoxes of medicine: the first is that as medicine becomes more successful in diagnosing, understanding and treating disease, so the capacity to do all three appears increasingly inadequate. The second paradox is that as countries become richer their ability to afford good quality care for all their citizens appears to diminish. The third paradox is that, as people live longer, the burden of illness and disability often appears to increase.

So far the NHS has responded well, and better than most, to those challenges, but there is no room for complacency. The NHS has to tackle a number of key issues. Despite its overall cost-effectiveness, there is an enormous variation in performance between different hospitals, different parts of the country and different doctors. We must iron out those variations and pull the poorest performers nearer to the level of the best.

Quality assurance programmes have been patchy. In some hospitals, where all the doctors are enthusiastic supporters of clinical audit, people have got together to drive up standards and improve patient care. In some hospitals only a few doctors are prepared to put their energies into that. That is a great failing which needs to be addressed. Many doctors are still disengaged from the management of their organisation and the overall leadership that needs to be given.

Staff morale has to be tackled. We owe much to our staff. We cannot ignore the stresses and strains many of them face as the number of patients we treat increases day by day. year by year. We have not been as helpful to and supportive of our staff faced with such stressful situations. Finally there is the great challenge of the modernisation of the health service. The health service is littered with proposals for modernisation which have fallen because of its failure to obtain support from its local community. Unless it has support from the local community, it is difficult to modernise and bring up to date the health service as we would wish.

What is so striking—and I am convinced that this will be history's verdict—is that the 1991 reforms attempted, but failed, to meet those challenges. What is equally striking is the high cost of those changes, which culminated in millions of pounds of debt, which the new government inherited. The notion of competition between hospitals, between doctors and between nurses puts at risk the teamwork approach which has always been a major strength of the health service. The bureaucracy, the billing, the paper chase of millions of invoices put at risk the motivation of professionals in the health service. The unfairness of fundholding puts at risk the equitable basis from which the NHS has always derived so much strength. The macho management and secrecy culture put at risk the public service ethos which has meant so much to the health service since 1948.

We are now entering a new chapter; a new White Paper; and a new reorganisation. It is one with a crucial difference. Unlike so many previous reorganisations, this one has within it the seeds of fundamental change. First, it removes competition, bureaucracy, and unfairness, and restores a co-operative ethos. Important in itself, but more than that, with the White Paper and the forthcoming Green Paper on public health, we have a serious, cohesive and sustainable agenda for many years to come.

The key elements in that agenda are, first, national leadership. The health service is not a loose collection of 500 trusts and 100 health authorities. It needs to be treated as one national service, with national strategic leadership from the centre. That must be parallelled by the same decisive leadership at local level. That is where the health improvement programmes, to be set by health authorities, embracing public health measures and improvements to healthcare service, are so important. They are to be underpinned by a duty of partnership among everyone within that local healthcare system.

The White Paper sets the foundation for much greater professional leadership from doctors and nurses in the organisations for which they work. What is important is that that leadership is to be provided within a much stronger concept of accountability. Primary care is to be given the lead role, again, fairly, and with due accountability to Parliament and the public. This new system will help to improve the quality of our health service. The development of national agencies such as the National Institute for Clinical Excellence or the Commission for Health Improvement, the concept of clinical governance within individual trusts, and the personal accountability of a chief executive of each trust to ensure that proper clinical governance is carried out are important improvements to the way in which we will drive up quality in our health service.

Above all, the White Paper lays the foundation for giving much greater support to our staff through training, development and better occupational health, in the stressful situations in which they often find themselves. That is not easy. The agenda is tough. There are issues relating to the willingness of doctors and nurses to accept the leadership role that they are being given; issues involving managerial capacity to handle such momentous changes; and issues about the pace of change. This is not a reorganisation for two years; it is a reorganisation for 10 years.

I sense in the NHS both optimism and acknowledgement that this is the right direction in which to go. Above all, I believe that it is the best possible answer to those who say that the NHS is unsustainable in the long term and argue that the impact of demography—the elderly population—new techniques and scientific advances are producing a wide gap between what the NHS would like to do and what it can afford to do. That way lies defeat. Its only end point is a retreat from providing a comprehensive service to providing a safety net service for the poor and needy. That must not happen; nor will it happen.

Life is not easy in the National Health Service; there are many pressures, difficult choices to he made and difficult priorities to be set. But what is new? We have faced those issues since 1948 and we have come through. I suggest that the history of the NHS is a signal for optimism about the future. Instead of fearing and retreating from the onward march of science and technology, let us welcome and embrace it. As Aneurin Bevan said, the service must always be changing, growing and improving.

There is an exciting, almost unlimited potential for the service in the future. Let us now plan the direction, development and resources to offer a world class service to the people of this country. In 1948, the NHS was born to banish fear and to provide a comprehensive service to our nation. It has done that and 50 years on our nation still wants its National Health Service. Let us now embrace change, new medicines and scientific advances. Let us embark with enthusiasm on providing better services and better results from treatment. Above all, let us remain true to the ideals of Aneurin Bevan and to all those who have supported, served and participated in our National Health Service. I beg to move for Papers.

3.22 p.m.

Baroness Knight of Collingtree:

My Lords, for 31 years before coming to this House I served in another place. During that time, I took around Parliament countless groups from schools, churches, societies and even the cast of "The Archers". When we reached this Chamber, I told every group that this was the most beautiful legislative Chamber in the world. I believe that it is. I have visited many parliaments and nowhere have I seen such colour, grandeur, dignity and craftsmanship as we have around us. Perhaps, just sometimes, we should acknowledge how truly fortunate we are to work in such a place.

History surrounds us as well as beauty. The 16 barons and two archbishops who forced King John to sign Magna Carta are always looking down on us from their niches. William Joyce, the most notorious traitor of the last war, faced judgment at that Bar. The Woolsack, which has been part of our constitution since 1350, received a direct hit from a German air-raid in 1941. A bomb crashed through the roof, whistled straight down through the floor and came to rest in the dusty cellars beneath. Thank God it never went off! But as it passed through the Woolsack, its fin sliced through the cover like a hot knife through butter. Horror of horrors, all was revealed! It was not full of wool at all—it was full of good old Victorian horsehair. For years we had a horsehair sack instead of a wool sack. I do not know why.

Augustus Pugin would have known. He was busy directing the rebuilding of the Palace after the 1834 fire and being paid a mere £200 a year for all the drawings and designs of every bit of carved wood around us, from the Throne to the Bar and beyond—a mere £200 a year, although he did say that his train fare from Ramsgate must be paid on top of that.

Today we are also looking back—to 1948 and the foundation of our National Health Service. With all the grumbles and complaints which the press so love to report, its benefits are manifold and miraculous. Tributes are due not only to those who work in the service, but to the way which successive governments have nurtured it, bringing in changes where they were needed.

Quite soon after the service began, it became clear that the original promise—that every single part of it would be free—could not be sustained. It must have taken courage for the Labour Government of the day to bring in charges. Many other necessary changes have been made over the years. For instance, in order to check waste, which was widespread, we had to know what things cost. No one knew what anything in the health service cost—from a bed to a biopsy—until a radical accounting system was brought in a few years ago.

Inevitably, considering the size of the health service and its age, mistakes have been made. Among the worst are schemes which downgrade patients to mere statistics. Mixed wards are dreadful mistakes. They should never be allowed, except in intensive care units. I once visited an old lady in hospital and found her in tears. But it was not her illness that hurt. She said, "The doctors and nurses here are young enough to be my grandchildren, but they all call me Mary". It really upset her. It is wrong for staff automatically to address adult patients by their Christian names because it takes away their dignity. And often in a hospital bed dignity is all they have left. Most problems in the health service concern cost, but that one does not.

Fifty years ago the architects of the health service claimed that the cost would go steadily down as the health of our people improved. They never dreamed what wonderful new operations, treatments or drugs would be invented; nor the insatiable demand for them; nor the cost of them. Let us acknowledge that no government of whatever political colour will ever be able to make enough money available to ensure that every patient will instantly receive the treatment he wants at the hospital of his choosing by the doctor he prefers. But all governments will always try. All governments will do their utmost not just to preserve the health service but to keep on improving, with the help of our brilliant doctors and researchers, Britain's care for Britain's sick.

3.29 p.m.

Lord Alderdice:

My Lords, I thank the noble Lord, Lord Hunt, for promoting the debate and giving us the opportunity to celebrate and discuss the National Health Service on its 50th anniversary. It is an honour for me, on behalf of your Lordships' House, to congratulate the noble Baroness, Lady Knight, on her maiden speech. She has served her party, she has served Parliament, she has served our country and, more widely, she has served people in a most distinguished way. As I heard her speak of the elegance and beauty of your Lordships' Chamber, I could not help but think what an adornment not only she but her contribution already are to your Lordships' House. We look forward to further enrichment in the coming years.

There is no doubt that we can, as a nation, look back at 50 years of the NHS with a great sense of achievement. We often find ourselves saying—I was going to say with muted pride but perhaps it is not so muted sometimes—what a wonderful service we have in the National Health Service and what a tremendous contribution is made by those who work in it. Indeed, we are right to be proud of it and right to be proud of our country on having sustained it over the past 50 years.

I suppose that when we all come to the time of a 50th birthday—I am probably one of the relatively few who has not quite attained that distinction in this House—it is also a time for review and for thinking about how to deal with the rest of the years that one has. As we look at the NHS, while we can say with great pride what an excellent business it is, we must acknowledge also that there are serious problems.

I was struck by the comments made by the author of the Turnberg Report which looked at the health service in London: We found a health service under pressure. Services across the whole spectrum of care, from those in the community and primary care to those in the hospitals, were sorely stretched. Although the impact of these pressures were most keenly felt in the care of elderly people and those with mental illness, others were not immune from failures to meet an acceptable standard of service. Furthermore, there is evidence to suggest that the pressures are increasing. Despite all this, health care workers are doing the best they can and we found examples of good practice. even in circumstances of severe pressure". We all know those words to be a true reflection of the situation. But is it not because resources have not been put into the service? Of course, those of us involved with healthcare could want and could use more resources. It is not because we do not have quality staff who are committed. It is not because we do not have a community which is concerned for it. Therefore, it is appropriate to try to ask ourselves why it may be that at this juncture, when we have a health service which is the envy of many and which is admired by our own community, it is in such difficulties and why many people begin to wonder whether it is sustainable in its present form. We must address those questions.

It seems to me that there are a whole range of difficulties but perhaps I may outline a couple of very broad principles. For much of its time the health service was conducted under an old socialist principle. I do not say that in a political way but in terms of principle and understanding. It was a caring way which said, "We are disturbed that there are those who are vulnerable, unwell, handicapped, or very young, and who cannot care for themselves and who have difficulties and we want to ensure that they are all cared for. Therefore, we shall reassure our people that whatever happens they need not worry about money or whether care will be available. We shall make sure that whatever is necessary is provided. It may take us a year or two, a decade or two, or even longer, but we shall make sure that whatever is necessary is provided by the community as a whole."

That was very commendable. But the difficulties were two-fold. First, there was no end to the demand. As time went on, as medicine progressed, and as people's expectations rose, more and more requests came forward. The demand was not satisfied but rather expanded by increased provision. Curiously, within that, no one ever felt particularly that what was needed was being provided. People acknowledged that the staff were doing their best but felt that more was needed. People were not saying, "I have a part to play in my care. I am responsible for my health."

A pathologist spoke to me recently of his despair. A cervical smear came through on a patient who had developed cervical cancer. The pathologist looked back through the records and discovered that the patient had had a cervical smear carried out on two occasions. On both occasions, two or three years apart, it had been demonstrated that there were changes of a dangerous sort occurring. "But", the note went on, "the patient is not keen to come for a review appointment." If the pathologist had made a mistake and had not noticed that situation and the patient had subsequently died of cancer, there would have been national outrage. A committee of inquiry would have been instituted immediately. Sadly, the problem was that the patient did not feel responsible for her own care. That is a problem which exists and we must pay attention to it.

On the other hand, there are those who say that the service is not sustainable; that it costs too much; and that the financial question must be introduced. The problem is not that finance is not a significant consideration because of course it is. That is the reality. The problem is that finance was introduced as the motivation and not a consideration. The market was introduced as the mechanism for making decisions about the distribution of healthcare. The money was not an issue for the person receiving the care. Patients still do not know how much their care costs. They still do not look at that as an issue for them; it is a matter for doctors and nurses. Even more it is a matter for managers, accountants and, perish the thought and worst of all, the inevitable management consultants who are brought in who can always find something to do, something on which to advise. Frequently, it is another review carried out by another set of management consultants.

The problem is that the community as a whole does not see what is happening in terms of responsibility. I have often felt that rather than producing accurate bills which could then be used for contracts we would have achieved much more in our health service if we had produced less precise bills but handed them to all patients as they left hospital with a big stamp saying, "Your bill has been paid by the community as a whole." In that way we would all know that we were sharing in the responsibility of dealing with our care.

Money is a consideration. It should never have been introduced as a motivation. People do not go into healthcare to make money. They need to make money to live and they deserve a reasonable lifestyle. But the health service did not come from businessmen setting up healthcare. It came from people with a vocation— from the Churches, charitable bodies and others. It came from people committed to the care of others.

What does that mean in terms of how we might further develop that care? We must consider the ethical dilemmas which face us in a major way because we can now do things which are disturbing for us to think about. We must make decisions in relation to where we should put our resources, which areas of care should receive more resources and which areas of care must be left to be dealt with in another way. We must consider the general question of how much money we should put into healthcare. We should not pretend to the community that there is a bottomless pit of resource; that every problem can be resolved; and that if anyone falls ill or dies, it is someone's fault.

Nor, on the other hand, should we suggest that if you happen to fall ill and you are vulnerable or poor it is your problem and you should earn more or find someone else to contribute. Rather, as a community we should work together on those decisions; struggling with the ethical tensions, deciding how much money to put in. That is why my right honourable friend in another place talked about that dreadful phrase "hypothecation of taxes." We must take responsibility for our future and our healthcare, our health service, the welfare of the community and all the rather precious individuals within it.

3.39 p.m.

The Lord Bishop of Birmingham:

My Lords, I must begin by, first, thanking the noble Lord, Lord Hunt of Kings Heath, for introducing this very timely debate. I am sure that we can think of no one better qualified than he to have done so. Secondly, together with the noble Lord, Lord Alderdice, I must congratulate the noble Baroness, Lady Knight of Collingtree, on her maiden speech in this House. It is a particular pleasure for me to find myself doing so, not simply as the third speaker from Birmingham, as it happens, but because I in fact live in the constituency which she represented with such distinction for so many years. It has been marvellous to have her as a friend. Thirdly, I must declare something of an interest not only as a patient but also my late wife worked for the National Health Service for 30 years and both my daughters now work for the NHS, one on the managing side and one as a doctor.

The National Health Service is a standing refutation of the notion that governments can do no positive good. It is a product of ideals translated into policy and practice. It also shows that there are some things which, for the sake of the common good, can be done only by governments. They cannot be left to private or voluntary initiative alone. As we have already heard, the NHS is indeed an amazing institution—an institution so secure in the affections of the people of this country that no politician, even when he or she has apparently been chipping away at the foundations, has ever dared to suggest that he or she was doing anything other than strengthening it.

It is striking that people's deep affection in general for the NHS remains apparently untouched by their particular experiences of things going wrong. In the present culture of blame and complaint, it is worth remembering that, while some bad experiences are a direct consequence of individuals not doing their job properly, far more often they are symptoms of a system which is under great strain.

Of course, the possibility of clinical or managerial bad practice can never be entirely eliminated. It is one of those issues which has to be addressed again and again. Indeed, as we have already heard from the noble Lord, Lord Hunt, it is the same with one of the basic issues which prompted the establishment of the NHS: how are we to provide for equality of access to the best possible provision of healthcare for all? Fifty years ago the inequalities were shameful, and 50 years later the problem is still with us. It has to be addressed again and again.

If one looks back over the past 20, if not the past 50, years of the NHS, one is struck by the phenomenon of almost continuous change and reorganisation. That has partly been caused by changes in political and managerial fashion; partly by advances in medical practice; and partly by pressing questions about the availability of resources. There have been ups and downs but undoubtedly there have been improvements. I shall mention only one—the developing culture of accountability. It is right that practitioners should not only be professionally accountable but that they should also be accountable for the consequences of their decisions in terms of their use and material resources.

There is no point in looking back without also looking forward. So what about current proposals? The recent White Paper is, I believe, to be welcomed, not least because it represents development rather than revolution. In thinking about its proposals, I hope that the Government will be able to reassure us on three particular points.

First, there can be no doubt about the rightness of the emphasis on primary care. But can we be assured that that will be adequately resourced? I have in mind not only financial resource, but also medical, nursing and other personnel. In my own city of Birmingham we are faced not with a rise but with a cataclysmic decline in the number of general practitioners in the next few years. How is that trend to be reversed? Further, if there is to be no substantial overall increase in funding, how will developments in primary care be adequately resourced without taking resources away from other parts of the system? We need some openness on that point.

Secondly, can the private finance initiative really deliver what is asked of it? Birmingham certainly needs the rebuilding of one, if not two, of its major hospitals. Can this really be done through the PFI without putting intolerable burdens on the delivery of the services which those hospitals would be expected to provide?

Thirdly, there is the question of how to handle change. I hope that lessons will be learned from the experience of recent years. I know, both from personal contacts and still more from what chaplains have told me, about the terrible pressures which are being placed on managerial and nursing staff who have had to continue to deliver care to vulnerable people while themselves being made to feel personally insecure. That was not good for patients, nor was it good for professional morale or recruitment. I hope, therefore, that questions of staff morale in a time of change will not be forgotten. In saying that, I deliberately mention managers as well as clinical staff, because I believe that managers are too easily underrated or even denigrated. If the system is to run well, we need the best possible managers and they, like everyone else, deserve appreciation when it is due.

It is worth asking why change is so hard to manage in the NHS. Why does the prospect of change provoke such high levels of anxiety? Why is rational discussion so quickly overlaid with disproportionate feeling? I believe that health is an area in which all of us feel naturally insecure; an area in which we crave assurance and certainty. We need to know that the doctor will be there when we need him or her. We need to be assured that the hospital is there when we need it. Those who are responsible for change need to reflect, among other things, on the symbolic function of a hospital in a community. People need to know that it is there, rather like a cathedral or a parish church. If a hospital is felt to be threatened, it feels as if a whole community is under threat.

All of that means that proposals for change must be handled with very great care. Reasoned argument is not enough. In this area of life, people are not simply reasonable. They need assurance as much as they need argument. Those who are responsible for proposed reform must take the people with them—which is not the same as succumbing to the meretricious rhetoric of, "Let the people decide". What is at issue today is whether our successors in 50 years' time will be as grateful to this generation as we are to those who established the NHS 50 years ago.

3.47 p.m.

Lord Winston:

My Lords, the whole House will be in debt to my noble friend Lord Hunt for introducing today's important debate. It is a great pleasure and, indeed, a privilege for me to join in this tribute to the remarkable work of the health service over the past 50 years. Although I believe that the little red book tells us that it is not customary for mention to be made of a maiden speech in every following speech, I should like to be the first from these Benches to pay tribute to my noble friend Lady Knight. She and I have had some differences of opinion about certain areas of healthcare in the past. However, it has been a great pleasure to listen to my noble friend's maiden speech today. I am sure that there will be other times when I shall have the pleasure of arguing with her, but not on this occasion.

Instead of dealing in macro, as previous speakers have done, I should like to concentrate on two issues which are slightly more in micro and which were raised by the White Paper. In fact, the whole issue of the health service is such a large one and the White Paper is such an excellent document that it is difficult to know where one should focus. I hope that my noble friend the Minister will forgive me if I seem to raise some spectres in my short contribution to the debate.

There are two issues which will be of great concern. They were raised partly by the White Paper and partly—inevitably—by the conduct of the health service as a whole. First, the remarkable management of the health service proposed in the White Paper is not, I believe, possible without a radical change in our thinking as regards information technology. It seems to me that the key to implementing much in the White Paper will depend on taking a fresh look at the way we handle information in the health service. There are essentially three different kinds of information which come to mind. The first is information to the average doctor. The White Paper makes mention of the NHS Net, which is an excellent idea. The Government have made a commitment to invest in that which I welcome. However, I am quite certain that that on its own will not be sufficient.

Secondly, information to patients is a different area entirely. One of the good aspects of the health service which has endured under successive governments has been the remarkable way it has become much more in tune and focused to patients' need for information. That is still happening. I should have declared an interest at the beginning of my speech as I am an academic medic working in the health service and in the university sector. We, as doctors, have become much more attuned to explaining matters to patients, but there is still much more work to be done. Information technology is one way of achieving that. I do not believe for a moment that a computer print-out or a printed document will ever replace—God forbid!—face-to-face contact between doctor and nurse and doctor and patient, but the documents help to implement the exchange of information.

The third issue is one which is dear to my heart. It is a completely different and more expensive aspect of information technology; namely, the communication of digitised information. We have a remarkable opportunity here. It is now possible to communicate vast amounts of information down a telephone line. Over the next few years we shall see not ISDM, which will be completely out of date, but the ability to transfer eight, perhaps 10 megabytes of information rapidly down a telephone line. Provided that one is within a few miles of an optical cable, it will be possible to show operations in real time; to show endoscopic photographs; to show X-rays, and to report on X-rays in Wales when one is in London; to look at an ECG monitor in real time and to look at ultrasound photographs. I believe that will revolutionise the way that we communicate and exchange information in the health service. However, the provision at present is woefully inadequate.

I perform laparoscopies regularly. Those operations depend purely on a visual inspection down a telescope. At the moment in 90 per cent. of cases doctors do not even have a still camera which will record a simple photograph. We must rethink how we record this kind of information. It is possible and the method of doing it is not particularly expensive, but the whole system clearly needs to be reviewed and a proper systems analysis carried out. It is clear that data collection in hospitals is woefully inadequate. I work in a hospital which was one of the first to have a computer terminal in a clinic from which we could obtain results, but that is still an incredibly slow and inadequate system. There needs to be a re-evaluation of how best to do this.

Another example of inadequate provision was highlighted this morning during discussion in a Select Committee. I hope it is not inappropriate to discuss the results of our investigation into microbial resistance. There is a potentially serious problem here with bacteria that are becoming increasingly resistant to antibiotics. We do not know the scale of the problem because we do not have the information technology in place to work it out. Organisations such as the Public Health Laboratory Service are underfinanced and cannot install the kind of information technology that we need at the present time. The Government will need to consider how we can achieve this investment in the health service. It seems to me that this is a golden opportunity for PFI in that we could sell our ability to read digitised information to other countries. There are remarkable opportunities here for the development of the health service.

I wish to discuss briefly academic medicine in the time that remains to me. There has been a magnificent relationship between the NHS and the universities. Indeed the university sector has provided a major part of healthcare in this country and it has been responsible for some remarkable developments, not all of which, unfortunately, have been capitalised in this country. I refer to CAT scanning and ultrasound. Is it not sad that all those machines are made in America, Japan and Germany? I refer also to renal dialysis and heart lung machines. I refer to my own field of in vitro fertilisation which the health service initiated. The list is endless.

However, there are serious threats to academic medicine. Threats are posed by the fabric of our buildings and the underfunding of universities. The research assessment exercise has meant that often certain departments which must provide a service cannot undertake competitive research and maintain a four or five rating in terms of the exercise. Therefore universities are finding it difficult to support those departments. We need to look at that issue.

The NHS has depended on centres of excellence. The White Paper has omitted to focus on how those centres of excellence will interface with the national centres for clinical excellence. We have a series of national centres for clinical excellence which carry out remarkable work. The internal market resulted in a loss of autonomy of patients to visit the best centre. Some years after the introduction of the internal market I still receive letters from 50 patients a week who write from all over the UK explaining that they cannot receive the relevant treatment locally in Bradford or Aberdeen and asking me whether I can treat them at Hammersmith under the National Health Service. They do not understand that I cannot do that. The internal market has resulted in a loss of best practice for patients and a loss of critical mass of practice so that we cannot carry out the best research trials because we no longer carry out large competitive trials which used to enable us to compete with any country in the world. At one time when I visited the United States I could show people large studies which the Americans could not undertake because they were so private practice oriented. There has also been a loss of adequate training to pass on these developments to other major centres.

This White Paper focuses on primary care, as it should do, but we must not forget that many of the basic elements in the development of healthcare have concerned such issues as endocrinology, immunology and now molecular biology, cellular biology, neurosciences and other such issues. These studies will make important contributions to the way we continue to improve the health of the nation.

3.58 p.m.

Baroness Young of Old Scone:

My Lords, I add my thanks to my noble friend Lord Hunt of Kings Heath for his excellent introduction to this important debate. I have a particular thrill in wishing the National Health Service a happy 50th birthday as this year I am also 50 years old. I am three days younger than the National Health Service. Unfortunately my mother miscalculated and booked into a private hospital for my birth. Therefore I was cheated of my NHS birth, but I have been a proud customer ever since and have worked for 20 years in National Health Service management.

Therefore the National Health Service and I are both middle aged, but what a middle age! She is a decidedly active 50 year-old and still has tremendous "oomph", but she has that touch of wisdom gained from her years and she is much loved by those for whom she has worked hard and tirelessly for 50 years. On the odd occasion she has a bad day. Middle-aged women sometimes have bad hair days, whereas the NHS has bad bed days!

I shall discuss some of the old chestnuts that have beset the health service over the years and discuss what hope we have for the future. First, is the health service a service for health, or is it only a sickness service? When I used to manage health districts I became rather confused as to how I judged whether I was performing a good job. Was it a good thing to treat more people, or did that show that the population I was trying to serve was becoming sicker? We should of course be trying to achieve a healthier population and an improved health status. However, after 50 years we are still dependent not necessarily on what the NHS can achieve by way of healthcare, but on completely different issues.

The reforms of the NHS signalled in the White Paper cannot just continue to improve the effectiveness and efficiency of healthcare, but they must tackle, or at least work in tandem with, three other issues. The first issue is that of lifestyle. I worked in St Thomas's health district and drew up its first strategy for healthcare. Yesterday's announcement on the pattern of health services in London appeared to endorse that study that had been drawn up 15 years earlier. Everything has its day. But the professor of general practice in those days was asked to write a "forward look" for the people of Lambeth. He began with the epic statement that the health status of the people of Lambeth will never improve until they cease to abuse themselves with sex, nicotine and alcohol. So we have some way to go towards improving lifestyles through a variety of processes, not least education. However, we have also to tackle issues of poverty, unemployment, homelessness and social exclusion because those are the major determinants of the health of the population.

A third set of parallel issues is now beginning to impact more clearly on healthcare. They are environmental issues, air pollution and childhood asthmas, air pollution and cancer, water pollution, the need for environmentally safe food, and the need for sustainable ecosystems. We have to seek environmental improvement if we wish to see good health status as well. I welcome the forthcoming Green Paper on public health. I hope that it will tackle all three of those strands.

The second chestnut is that the NHS is always short of money. It is always short of money. I feel rather like the chap who fell asleep on a hillside and woke up 110 years later. Every time I dip my toe into the health service again, having been away from it for eight years, I still hear about beds, cash, nursing crises, and A & E departments full of patients on trolleys. Since the early 1980s we have heard that that was the ultimate crisis which would propel the National Health Service into cataclysm.

The real question is this. The health service is short of money, but how short? Over the past 50 years, by chance in this country we have stumbled across a unique system of managing healthcare that is cost containing. It is, and has been for many years, the envy of other countries which fail to stumble upon the system, in particular the United States of America where the health system costs twice as much yet still leaves 30 million people uncovered by healthcare.

We have benefited from that happy stumbling upon a system that controlled costs. But as a result of successive financial squeezes we are now running a system which has small financial tolerances. There is little room for error in the system. Even small mistakes in the way that patients are dealt with, or services provided, can provoke disasters. I do not talk of major disasters but the disasters that noble Lords or their relatives experience as individuals. Those experiences are truly disastrous for the individual. I cite, for example, patients spending 24 hours on a trolley in an A & E department; an operation that one has dreaded for months and has wound oneself up to go through being cancelled three times; long waits for cancer checks when one does not know whether one is positive or negative; and no place of asylum for an acute psychiatric patient in extreme breakdown. Those are personal disasters for the people involved.

I do not wish to focus on those to the exclusion of everything else because 95 per cent. of people who go through the health system have a good experience. They are well treated technically and personally. But we cannot ignore the 5 per cent. who are not so well treated. At present the root of the problem is the fact that we still spend 30 per cent. below the OECD average on healthcare. We spend a lower sum partly because the system has been naturally cost containing in the past; and that is good. But comparatively small sums of additional funding could make a disproportionately huge difference to that 5 per cent. to whom the health service does not provide a good service.

The White Paper flags up £1 billion which can be redirected from the transaction costs of the internal market to improved healthcare. I welcome that. We need to take great care in managing that money across the system into healthcare; and it will take some time. The White Paper also indicates the possibility of improvements in clinical effectiveness and better direction of funds on clinical grounds. Again I applaud the measures in the White Paper for that. However, at the end of the day we come down to this question: will £1 billion extra into care, and efficiency and effectiveness savings be enough? Having made those changes, if that small number of patients still have a very poor service, we must seriously examine our consciences to see whether as a nation we wish to continue to be the poor relatives of the OECD countries in terms of investment in healthcare.

I have one last point to deal with as an ex-NHS manager otherwise I shall no longer be invited to dinner parties! I refer to the question of NHS bureaucracy and the fleets of administrators that it has always been claimed are wandering around the health system. When I began managing health systems in 1971, I ran a 500 acute bed teaching hospital in Glasgow. Two and a half administrators ran it. We did not run it; it ran us. We managed the odd support service. We did a few things to keep the doctors happy. But, generally speaking, the system managed itself. I did not think that that was good. We were only able to get away with that at that stage because we were seeing increases in funding on a year-on-year basis. We were buying ourselves out of trouble most of the time. I worry that the NHS White Paper will fall into the ready trap of management bashing. There are costs to be saved, in particular from the high cost of running the internal market. But the health system is large, important and complex. It is close to the real needs of individual human beings. It needs to be managed effectively if it is to make the changes flagged up in the White Paper, and continue to develop increased quality and effectiveness.

I conclude by saying that I think that the NHS is pretty frisky at 50. She is a precious national friend, and with a bit of that NHS commodity, tender loving care, both she and I will look forward to another 50 glorious years provided that as a nation we can resolve the issue of how much we want to spend.

4.6 p.m.

Lord Jenkin of Roding:

My Lords, as I listened to the noble Baroness, Lady Young, speaking, I realised that the National Health Service is quite young. I enjoyed very much what she said. I, too, thank the noble Lord, Lord Hunt of Kings Heath, for the opportunity to have the debate.

I have a somewhat unique perspective. Almost 25 years ago I began to shadow the Department of Health, helped by my noble friend Lady Knight of Collingtree, who was a splendid member of my team. I much enjoyed the noble Baroness's maiden speech and congratulate her on it.

I subsequently became Secretary of State. For two and a half years I was responsible for the National Health Service. More recently I have chaired an NHS trust, from which job I retired at the end of November, so I think that technically I do not need to declare an interest. However, having had that double perspective over nearly half the lifetime of the health service, it is worth sharing a few thoughts on the subject with noble Lords.

In the early days it used to be said, "For goodness sake, can't we take the NHS out of politics?" We do not hear that said today. Today's generation of managers and doctors is a great deal more realistic and less starry eyed. That came home to me yesterday when I chaired a seminar run by the University of Manchester health unit for chief executives of trusts. It had asked me to describe how the political and professional interface works. How does it work? How does one have on the one side Ministers and Parliament, and on the other departmental officials and the managerial, professional and clinical staff? To prepare myself, and to remind myself how the system worked, I went back to the department and asked to see some of the old files which were brought into being in 1979 when I became Secretary of State. I found them fascinating. I remembered some of the contents, but most had gone from my memory. Perhaps it is not wholly irrelevant in the context of this debate to share my findings with the House.

We inherited a totally "top-down" service, structured in such a way that not only did the money flow down but so did an enormous amount of instruction. It was a command and control system. However much people wanted to see decisions made locally, the managerial and professional hierarchies that existed then had the inexorable effect of sucking decisions away from the place where patients were looked after up into the higher levels of the service—from the units, through 200 district health authorities, 90 area health authorities, 12 regional health authorities, and so on, up to the DHSS. That "suction-pump" effect was brought home to me clearly as we studied the service when in opposition. We pledged ourselves to try to return more decision-making to the levels where patients are looked after. We saw it as an essential part of the improvement of the service.

The files showed that a day or two after the election I handed to my department a substantial folder of documents with a clear statement of our policies and priorities, a list of public pledges and a big bundle of policy reports on which my honourable friends and others had worked in opposition. In turn, I was handed the usual position statements by the department. They were not quite so thick as my bundle, but probably a great deal better written. The problem over the next two or three months was to marry those two inputs into policy. I found particularly interesting the summary of the policy that I asked the department to introduce. In the light of subsequent history, it bears repetition.

Accountability to Parliament was to remain at the heart of the system. We rejected the recommendation in the Royal Commission report that the service should be a corporation, rather like a nationalised industry. We intended to abolish the area health authorities; the districts were to become, largely autonomous bodies, carrying so far as possible total responsibility for using all the resources at their disposal to provide the most appropriate service required by their local communities". I wanted to see the region as "a co-ordinating tier" carrying out strategic planning, collecting information, allocating finance and being responsible for regional specialties. I saw no reason for regional health authorities. But, I have to say, it took me and my successors a good many years to get rid of them.

In management, I wanted to maintain consensus at district level, but with much stronger management at local level, the local manager with the chairman of the medical committee and the senior nurse occupying the key managerial roles at local level. Functional management should be accountable to general management. That was not the case when we took over; there were functional hierarchies. I was once told by a member of the Association of Hospital Porters that there should be a "regional hospital portering officer." That is true. I told him that that was not an election pledge we were prepared to give. I wanted to see the highest salaries paid to those who were doing the most responsible jobs at local level. I get very cross when the newspapers and the Labour research group castigate senior health service managers who are doing an enormously difficult job because they are paid a sum which they believe is too great but which is still very small compared with payment for comparable jobs in the private sector. I wanted consultant contracts held at district level. Again, that took some time, but we achieved it. I wanted to save money on management. That is the sort of refrain that runs all through the documents.

But all of that had to be accompanied by a much more effective system of monitoring for quality—the noble Lord, Lord Hunt, referred to "quality assurance"—to ensure proper standards of care. And of course I insisted that the Secretary of State would still set national standards and priorities—because, as a number of speakers have said, this was a national service. The rest is history. Virtually all of that has happened. It took some time. I did not achieve it all during my two and a half years. But all of it has come about.

So when I became a trust chairman in 1991 I had a worm's eye view. There we were, running a very devolved service with a high degree of local autonomy, able to take major decisions off our own bat using the resources that we had at our disposal and able in many ways to run a much more effective service.

But, as the right reverend Prelate remarked the change was very difficult for professionals in the health service. Huge cultural changes were needed, and it took time. But we did see clinicians become responsible for major management decisions. In my trust almost all the service directors were clinicians by the time I left and were taking responsibility for their contracts.

Much has been said about the internal market, to my mind a great deal of it exaggerated. It was never more than a managed market. In our part of north-east London we were sharing all the information with our health authorities and GP fundholders. We were withholding nothing. We were collaborating, and long before Mr. Dobson's White Paper. Part of the problem is that too much is claimed in that White Paper.

I wish to draw attention to two developments of enormous importance. The first, which is comparatively recent, is the emphasis on outcomes. I welcome that. The noble Lord, Lord Hunt, talked about clinical audit and clinical effectiveness. All that is hugely important. It is again now being accepted by clinicians as a matter to which they have to pay attention. I refer to the Cochrane collaboration and so on. The other is public expectation. The public in our part of London have just raised half a million pounds for an upgraded special care baby unit. Public attention and criticism there may be; but public support for the NHS is certainly evident.

4.17 p.m.

Baroness Pitkeathley:

My Lords, I, too, thank my noble friend Lord Hunt for providing the opportunity for this important debate. I add my congratulations to the noble Baroness, Lady Knight. I had the honour to be introduced with her into your Lordships' House. I am sure that we shall work together here as we did in the past, when she was so supportive to carers in Birmingham.

I want to begin with two very personal reflections, which I hope will illustrate how important the NHS has been to me. The first concerns a story told me by my grandmother when I was a small child. She was widowed in the First World War, left with two small children and very little money. The eldest of her children, my mother, went down with whooping cough, a killer in those days, which quickly spread to her brother. Terrified for their health, my grandmother called in the local doctor. The children were getting worse and she was extremely relieved when she saw the doctor coming up the path. He stopped at the front door step, peered in at the children and said, "I hope you have my fee". My grandmother answered that she would not have it until two days later when her small widow's allowance was due. The doctor turned and walked away. That story was very influential in my life because of the outrage I felt then, and still feel, that healthcare should be dependent on the ability to pay, that sick children should not have a right to healthcare.

The NHS, whose anniversary we celebrate this year, changed all that and at a much later stage saved my life. Diagnosed with cancer 12 years ago, I was seen by my GP on Tuesday, by a consultant on Friday morning, operated on on Friday evening and, thanks to that swift diagnosis and speedy treatment, made a full recovery, as noble Lords see, and certainly intend to live to a ripe and very healthy old age. There are 60-odd years between my stories—years which saw increasing concerns about the need for public health care available to all and free at the point of delivery; years which have seen, too, enormous changes, both in the need for care and in the way care is delivered. I believe that one of the greatest is the change that has been seen in the different way in which patients themselves are regarded, and that is the first theme I wish to address.

Welcome though the health service was in 1948, no one could pretend that it put patients' wishes and feelings at the heart of its processes. Patients were "done unto", expected to be docile and grateful, and even thought to be a nuisance. When I worked in the NHS in the 1970s the old joke about hospitals being fine if it were not for the patients was only too true. Patient power is still not as prevalent as we might wish, witness the extraordinary warning against patient involvement in a recent editorial in the General Practitioner: The public's grasp of complex health service issues can be tenuous and explaining the issues will absorb both the time and resources of primary care groups. Those GPs who are involved in this process can ill afford the time, when they are faced with the more pressing issue of commissioning care". Far from not affording the time, I think most people would agree that there is no more pressing issue than involving patients in their own healthcare. However, in spite of such occasional statements, thanks to the efforts of many patient organisations and consumer groups and to the pioneering work of some health professionals, I am sure it is true to say that patient-centred care is becoming more integrated into health processes with every passing year.

When I was a social worker it was customary to refer to those who sought help from our services as applicants; then they became clients, then users, and now they are sometimes called consumers or even customers. But you do not turn applicants into consumers simply by changing the name by which you refer to them; you have to change your systems. I believe that the policies introduced by the White Paper on the NHS show how we can do that.

There is a stated commitment to involving users and carers which I very much welcome, but many of the specific proposals also offer opportunities for such involvement. A new duty of partnership is to be introduced, for example; we must ensure that that includes partnership with users and carers.

The commitment to opening up NHS trusts and ending secrecy may be an opportunity for users and carers to be nominated to trust boards, to attend meetings, to receive minutes and so on.

Primary care groups will have to demonstrate involvement with users and carers. My own experience of involving carers in primary care provision shows that a small input to supporting carers can have large spin-offs in improved health for carers and those for whom they care.

I also welcome the fact that health authorities will have to carry out annual surveys of patients and carers. This will give us a fantastic opportunity to collect data on patients and carers throughout the United Kingdom and to ensure that their needs are more fully recognised.

Opportunities certainly will exist. However, systems will not be changed overnight and attitudes will be even harder to change. We must acknowledge that professionals trained in one way find it hard to react in another. If you have been trained to assume that knowledge about illnesses and conditions is in some way the property of the professional, it is hard to learn how to share that with patients and their families. But assuming that patients and families know more than they do can similarly be a problem. A carer who was looking after her recently discharged husband who was recovering from a stroke was terrified when he had a small seizure in the middle of the night. When she took it up with the consultant, he said, "Oh yes, that's very common; it's nothing to worry about". Not unnaturally, the carer thinks that, if it is so common, it is a pity that no one bothered to mention it before. As one patient said: "When you question some health service personnel you get the feeling that they think you are questioning their knowledge, whereas you only want to know what is best".

We must also remember the imbalance of power which so often exists between professionals, patients and families. Because the professionals have a monopoly of the jargon, and often of the information too, and because the patient's image of professionals may make him or her reluctant to challenge or even question them, it is perhaps not surprising that the power in the relationship is so unevenly distributed.

I emphasise that keeping the power in their own hands may not be intentional on the part of the professionals. They may genuinely believe that people are better off not knowing about their illnesses. Often they are genuinely trying to enable the patient to participate equally. Training of NHS professionals must include knowledge of the importance of involving patients at the earliest possible opportunity.

The second theme I wish to address is co-operation between health and social services. Co-ordination or even communication with other services was not exactly a theme of the early health service either. Everyone who has worked in social services will give you their own horror story. In the 1970s I wrote a book about hospital discharge planning which showed that there was not any such planning. Although communication has improved, everyone working in health or social services or at that interface can similarly give you their own "discharge from hospital without warning" horror story.

The boundary between health and social services has long been recognised as problematic. But we should remember that consumers neither know nor care who provides a service; they want a service which is reliable and understandable. The boundaries are even more problematic when they involve a shift from free healthcare under the National Health Service to care provided by social services, which nowadays is inevitably means tested.

All authorities produce evidence of strategic agreements on hospital discharge, but that by no means guarantees that they operate that way in practice. Sadly, developments in recent years have made the situation worse, not better. The way in which the introduction of new community care policies coincided with the rush to the market in the NHS, with its emphasis on through-put and rapid turnover, meant that a most unhealthy competition grew up between health and social services as to where responsibility lay.

Good working relations between health and social services are possible, but they depend on trust. Pooled budgets will help, but it often comes down to relationships. Joint working can also be improved by ensuring that good practice is widely disseminated. I welcome the proposals for this in the White Paper. I hope that the terms of reference for the national institute of clinical excellence and the national performance framework will be developed in close consultation with patient representative groups.

If co-operation between health and social services is to operate really effectively, we must understand that preventative services for patients and their carers often do operate at the margins of health and social care and disputes are therefore very tempting. Everybody knows stories about only medical baths being provided and no social baths being allowed. There are many other stories like that. What other services are provided at the margin? What about rehabilitative care, which we used to call convalescence? What about back-care support for carers so that they do not injure themselves and can therefore maintain their own health? What about chiropody services which enable frail older people to keep mobile and therefore prevent their admission to hospital? To engage in disputes about where responsibility for such services lies is to ignore the important bigger picture—not which agency pays, which budget it appears on, but what is the long-term outcome for the patients and their families.

I conclude by citing the experience of a carer which will form part of an important report on carers' experience of the NHS to be published by Carers National Association in June. She speaks of the 18 years of caring for her severely disabled son and lately for her husband following his stroke. She says: We've had both good and terrible experiences within the NHS—excellence of care provided in the early stages, through a handful of dedicated neurology and paediatric specialists, and through a team of complementary practitioners. We've got a lot to thank the NHS for and especially for those people within it who've been prepared to 'go the extra mile' and work in partnership with us. In the end, that's what's enabled us to cover this long, long haul. They were very good with my son and husband, and my son's favourite activity is being ill enough to spend a week or so with the NHS—for years, his bouts of pneumonia etc., were my only form of respite care! Thank you, NHS—I hope you are looked after as much as you deserve". I am sure we all hope so too.

4.28 p.m.

Baroness Gould of Potternewton:

My Lords, I too offer my thanks to my noble friend Lord Hunt for initiating this important debate on such an historic occasion. I wish to concentrate my few remarks on the health of women. There is no question that -over the past 50 years enormous achievements have been made in identifying, preventing and treating women's health needs. It is not possible to present a history of the advances made, as I should have liked to have done, mainly because it has taken time for there to be a recognition of the variations in the health cycles of men and women, except, of course, in relation to maternity care. But these variations are an important factor in the provision of services and the attitude of health providers.

In the short time available I wish to look at four areas and their requirements for the future: breast cancer, cervical cancer, osteoporosis and domestic violence. Enormous changes have taken place over the past 50 years in these areas but there is still a long way to go.

This country has one of the highest incidences of breast cancer in the world. It is the single most common cause of death in women. One in 12 women have a lifetime chance of developing cancer. Every year there are nearly 27,000 new cases, and there are more than 300 deaths a week. The Government's action in releasing £10 million for breast cancer diagnosis for an extra 100,000 patients is welcome; but there are still not enough breast cancer specialist units and breast cancer nurses to provide adequate treatment and aftercare. And of the 90 per cent. of women diagnosed, the cause remains doubtful. Rapid advances have been made in looking at the causes of cancer, but the research will take a long time. Finding better treatments, methods of prevention and certainly a cure will still take many years.

What is without doubt is that the earlier breast cancer is diagnosed, the greater the chance of successful treatment. Early detection is therefore crucial and screening remains the best means of detection—screening which, I firmly believe, should be available to all women irrespective of age. I am now in the category and age group where I no longer receive automatic screening. The cut-off date of 65 for automatic screening raises the false assumption that somehow the risk is diminished. Yet it is maintained that half of all women with breast cancer are over the age of 65. Women need reassurance that they are not at risk. And there is evidence to show that the lack of prompting means that there is a lower take-up among older women. I appreciate that the Minister recently indicated that there is to be no instant change to that policy. But I ask whether there is any prospect of future change.

I do not wish to dwell on recent incidents because, in spite of the appalling mistakes made, cervical cancer screening is essential for early detection. The cervical screening programme offers a good proven test. It has steadily decreased the number of registrations for cancer of the cervix and there has been a 7 per cent. fall in the mortality rate. My noble friend was so correct in her appeal to women to continue to attend screening for both breast and cervical cancer. Nevertheless, women throughout the country must now have reservations about the reliability of the system. Their confidence will be restored only when they see the success of the changes being made to improve the service and the elimination of the current unacceptable variations of provision in different parts of the country. Health professionals will need to communicate sensitively and be aware of the intense anxiety screening may sometimes generate.

To look briefly at the problem of osteoporosis, the financial burden is escalating towards £1,000 million each year—a figure that will continue to rise with the ageing of the population. The NHS is faced with having to provide the treatment for one in three women who will be affected by osteoporosis. Around half of all women over 65 will be sufferers and one in four women over 70 will have an osteoporosis-related fracture. Hip fractures make up 90 per cent. of the cost of osteoporosis care.

That does not have to be the case. Osteoporosis is preventable and treatable, but successful treatment depends on successful diagnosis. All too often a fracture is the first indication of the condition. Screening, not generally recommended, should be offered to those women at risk—where there has been early menopause or a family history of the condition. Again, currently fewer than 20 per cent. of health authorities have a strategy for dealing with osteoporosis and, in spite of the degree of suffering and disability, only one in 10 patients are receiving adequate treatment.

Osteoporosis used to be seen as an inescapable factor in the ageing process but now there is a growing public awareness that it is a preventable disease, thus raising expectations of early and better access to prevention. One hopes that a higher degree of co-operation and partnership between primary and secondary care, as outlined in the White Paper, will be a step towards meeting those expectations. That will not only relieve the suffering of many but will save the NHS millions of pounds.

Lastly, I come to the subject of domestic violence—not usually talked about in a health debate, but it is a public health issue; it is a women's issue and a crime issue. The vast majority of domestic violence sufferers are women. It accounts for 25 per cent. of all reported crime. But it is also clearly a health issue. The first port of call for many of those women is either their GP or an A&E department. As well as their physical injuries, domestic violence victims are more likely to have poor general health, depressions, addictions and difficult pregnancies and to attempt suicide. That raises considerable implications for the health service, not least that of cost.

Apart from raising public awareness of the extent of the problem, we must ensure that health and social care professionals are trained to recognise and deal with the problems such violence creates. But alongside that there is the need for a co-ordinated national strategy, extending across medical and social agencies, professionals and voluntary groups. It would be helpful if my noble friend in her reply could update the House on government action being taken.

If time had permitted I would have examined many other key areas of health that affect women, including HIV/AIDS in pregnant women, heart disease, contraceptive provision, the problems of black and Asian women and also the problems of mixed wards—a question so eloquently dealt with by the noble Baroness, Lady Knight.

The NHS must ensure that gender sensitive health services are provided for all. It must identify and meet the specific needs of women from minority cultures. It must continue to ensure that provision and uptake are maintained and, importantly, that there is adequate training for healthcare professionals so that they can respond to women's physical and mental needs.

As the Government recognise, health is not only about health services, but also about lifestyle—as referred to by my noble friend Lady Young of Old Scone—poverty, environment, unemployment, bad housing and social isolation. Improving health is a matter for interdepartmental co-operation by government and liaison at local level between local authorities, community groups and industry. Only if we understand that can we truly hope to have a society which promotes services which are equitable and gender sensitive and which promote the health and physical, mental and social well-being of all, as was envisaged by those health pioneers 50 years ago.

4.37 p.m.

Baroness Gardner of Parkes:

My Lords, I open with the traditional thanks to the noble Lord, Lord Hunt, for introducing this debate.

The 1948 introduction of the National Health Service was a brave step and there was a great need to improve the health of the nation. Much has been achieved and treatments routine today were not even dreamt of 50 years ago. I was one of many Australian dentists who came to Britain to meet the need for enough dentists to provide national health treatment for patients. My arrival in London was in 1955 and by that time charges for national health treatment already applied. A full set of false teeth cost the patient 30 shillings.

In the 1950s and 1960s we extracted hundreds of teeth every week in our surgery. Patients used to say, "I might as well have them out now as they've got to come out sooner or later". The condition of many teeth then made that a fairly realistic statement. In the north of England a full set of dentures was a common 21st birthday or wedding gift. Those were the days when the surveys showed that most people bought one new toothbrush every year—when they were going on holiday. At that time they would buy a new toothbrush and a new pair of knickers. They were not concerned about dental treatment, but did not want the toothbrush to look bad in the bathroom when they were away.

Today's London dentist rarely takes out a tooth. Teeth are now for life. Dentistry has been one of the major success stories of the National Health Service. The new Swedish gel treatment for caries—tooth decay—claims to remove the need for any drilling at all and fissure sealants have been in use here for years. But in spite of all those remarkable advances, I have a real concern about the future of dentistry. Why is it that so many patients are unable to find a national health dentist? Why are this Government, the members of whom, in opposition, supported my amendment, passed in this House and reversed in the other, to retain free dental examinations, doing nothing now?

Above all, it is the children's teeth that we must care for. Today's children represent the future and we must not allow dental health to regress. There are many children in areas of deprivation who receive no dental care at all and who would not dream of going to see a dentist. These are the children we must reach with our treatment now. Their only real hope of general dental improvement is the introduction of fluoride to the drinking water.

I have been checking the situation in some of the regions. The West Midlands has the best d.m.f.t.— decayed, missing, filled, teeth—in the UK for the under fives. The north west has the worst! Birmingham introduced fluoride to the water system in 1964. I note that we have had two outstanding speakers from Birmingham today—the noble Baroness, Lady Knight, and the right reverend Prelate—and I am not sure whether the noble Lord, Lord Hunt, has a Birmingham connection. I know that if the noble Baroness, Lady Fisher, were here she would strongly support what I have to say. Birmingham supports water fluoridation and has seen the great benefit to the community.

As I fought a parliamentary election in Blackburn in 1970, and saw the reference in the Observer last Sunday to the fluoride debate there, I had inquiries made in that area. The manager of the community dental services estimates that as many as 100 children a week have teeth extracted under gas anaesthesia, something which I thought was a thing of the past. Many of these children have all their deciduous teeth removed. It is outrageous that children's teeth are allowed to deteriorate to this extent when fluoridation of the water supply could do so much to avoid the pain of tooth loss, the damage to the spacing of the permanent teeth and, very importantly, the psychological damage for those children going to school for the first time in a toothless, gummy condition.

Those who oppose fluoridation do so on an emotional basis. Fluoridated water has long been in use in Australia. It commenced in Tasmania in 1953 and in Canberra in 1964. Canberra is the seat of government for the Federal Parliament and the early introduction of fluoride to the water supply shows that the Australian politicians had great faith in it. It has been justified dentally and no adverse health effects have occurred over what is now a long period. I ask the Government to introduce fluoridation of water supplies throughout Britain at the earliest possible date.

There is time to comment briefly from my much wider experience in the NHS. I have served at most levels on local committees and hospital boards. I was chairman of the Royal Free NHS Trust for over three years, until November last year. That was a most satisfying experience, at the sharp end of the NHS, and I was very privileged to have that position. This very afternoon the newly rebuilt out-patients department is being opened by His Royal Highness the Duke of York at the Royal National Throat, Nose and Ear Hospital in Gray's Inn Road, which has now become integrated into the Royal Free.

Morale in the health service is very important. As a dentist, and again now in the nurses' case, I have seen the pay review body's recommendations either ignored or phased in by successive governments. I deplore that. It is very hard for dedicated National Health Service staff to see private sector pay rushing ahead of their own.

As joint chairman of the All-Party Osteoporosis Group, I must mention the importance of the growing awareness of osteoporosis. Indeed, I do not need to say anything more because I was so impressed by what the noble Baroness, Lady Gould, said on this subject. Last week, at a meeting we had here in the House, researchers came to speak about it. They made the point that the noble Lord, Lord Winston, made. One speaker from University College made the point that it is difficult for researchers on one site to know what is being done, although they know work is being done, at Bart's. It would be desirable to have information technology or databases to let people know exactly what was happening at the other site.

We spend an unbelievable amount of time on compiling statistics. We should try to find out how many of them are really useful and try to assess which ones are valuable and which are not.

The Corporation of London has asked me to say that it welcomes the news that some services will continue on the Bart's site. I am pleased to be able to say that my dental practice was in that area for 35 years. In that time there were dramatic health improvements for local residents. The City Corporation's view is that: Adequate provision for emergency treatment is manifestly important … the upgrading of the current minor injuries clinic provided at the Smithfield site must be considered as part of the implementation process". In its letter the corporation points out that the City has a very small resident population and a large day-time population, a situation which is quite different from other parts of London. I know that from my own practice there.

There is so much to say about the NHS and little time to say it. I should like to comment on two linked major problems at the present time. The first is the ever-rising costs of the new and exciting drugs and treatments being developed and introduced. The second is expectations. Other noble Lords have made this point too. Treatments almost magic in the results they achieve are available today. Everyone hears about them and wants them and expects to have them. No government can provide unlimited resources. Current and future expectations will be almost impossible to satisfy. The present Government will need to assess health priorities carefully and ensure that whatever budget is available is spent wisely and fairly and without waste.

4.47 p.m.

Baroness Jeger:

My Lords, this is the first time that I have felt happy to be so old. When one is talking about the National Health Service one needs to look through a telescope and remember what healthcare was like before the NHS was set up. We have the right year for our 50th anniversary but we do not have the date quite right. The appointed day was 5th July 1948. So I hope we shall have another party, even if we do not have another debate, on 5th July 1998.

The noble Lord, Lord Jenkin, referred to keeping politics out of the NHS. I am so ancient that I can tell him that the NHS was born in politics. I know that my noble friend Lord Bruce of Donington—another old chap like me—will remember the battles that took place to get that legislation through. What could have been more political than the Third Reading debate in the other place—216 in favour and 113 against? I am glad that things have become more sensible but we should not forget—we are allowed to reminisce a little on anniversary days—that it was a long and difficult fight. Five Labour MPs in that parliament were doctors—my husband was one. They were expelled from the BMA on the ground that they had voted for socialised medicine. They had refused to put up notices in their waiting rooms urging patients to express their disapproval of the proposals which were before the House.

My husband was very much in the background, but he was very close to Aneurin Bevan. Sometimes Nye would come to us in the evening and say, "I have had five royal colleges on to me today and the society of this and the committee of that". He would then ask us, "Come on, tell us what your day has been like at the coal face?". The "coal face" was a very poor part of Shoreditch with very modest premises. It was very near the London Hospital where my husband had trained. He deliberately chose to use what training and gifts he had to work in what was a very deprived area. Therefore, when one looks back I hope that we put some marks on the credit side.

One of the things that impressed me most was the number of patients who came to see us and to whom he had to say, "Why did you not come before? Why did you not bring the baby months ago?". People would say that because they had not got any money they hoped that the illness would get better. As the noble Baroness said earlier, that was a fact of life in those areas.

I wish briefly to put on record some of the factors on the credit side that should go into any sensible person's ledger. I think of the reduction in the number of illnesses that used to be fatal. For instance, there was polio. There were many infectious diseases for which the National Health Service provided the necessary injections. The numbers of those illnesses have been drastically reduced. I know that one must give some credit to the engineers who built the sewers for the fall in the number of infectious diseases. That was all part of the raising of standards.

One of the changes that I see is that patients are now coming earlier because of better education and understanding of their prospects. In addition, they do not get a bill at the end of the consultation. It is those patients who come to the doctor earlier, but I regret that the National Health Service is coming in later. One of the disasters of the present situation is the waiting lists.

They are one of the most expensive elements in the NHS. With my limited experience, I do not know of any operation or treatment which becomes cheaper the longer the patient has to wait for it.

We hear of people needing surgery being told to wait 18 months or even two years. I do not know how much money that saves, but I do know that on the other side of the ledger is the cost of such patients being unable to work. They need social security services, which are not always widely available in some areas. They seek housing benefit, statutory sick pay and help for bringing up their children. Older people now need much more support at home. I wish that we could bring these two bits of arithmetic together and find out whether there is any real saving in postponement with long waiting lists. I want to know what these waiting lists cost. So many of them are unnecessary because the facilities are available.

When I first came to the other place there were 13 hospitals in my constituency of Holborn and St. Pancras. I am very glad that my old colleague on St. Pancras council is now the Secretary of State for Health. He has given such a good start to our revision of the situation for London hospitals. I am very glad that we are discussing hospitals in London. The trouble is, however, that the Tomlinson report thought that London hospitals were exclusively for Londoners. Nothing could be further from the truth. I often used to visit those hospitals. I did not find many of my constituents there so I certainly was not going to the hospitals canvassing for votes.

There were the teaching hospitals such as Great Ormond Street, the University College Hospital and the Hospital for Nervous Diseases, as it used to be called, in Queen's Square. It was like an international party. Not only were there patients from all over the country, but from all over the world. There were not only patients, but students and nurses from all over the world were training so that they could go back to their own countries and take their gifts and accomplishments where they were most needed.

I never took much notice of the Tomlinson report because it got it all wrong as regards the proportion of the population to hospital beds. That committee had the nerve to write that the Royal Marsden hospital was "isolated and vulnerable". There are some Members of your Lordships' House who have reason to have better opinions of the Royal Marsden hospital. How did the word "vulnerable" come into the report? I decided that that hospital was only "vulnerable" to money-pinching governments who thought that it cost too much—as if anything could cost too much in that direction.

I was very glad that the Prime Minister and Frank Dobson visited the Chelsea & Westminster hospital on 18th December. The Prime Minister was told by the head of surgery about his anxieties. The orthopaedic department had been told that it worked too hard and too well. It was doing 10 expensive operations a week. It was asked to reduce that number to three. The surgeon said, "What would you feel like if you had to tell patients who had been waiting for weeks and weeks that they had to wait more than a year?". In fact, a letter

went out from that hospital telling patients that there was no hope of receiving surgery in 1998 and that it was not possible to give them a date for the following year.

What is saved by a half-empty theatre? Consultants are paid full-time. There are marvellous theatre nurses and sisters. They were told to cut down on the work. It is not a question of wanting productivity in the health service. That has happened at several hospitals which I know only too well. The staff are paid so there is no saving there. The patient goes home. The GP has to get in touch and perhaps the district nurse or the community nurse, or whatever they are called, and the home help are called in.

Baroness Gardner of Parkes:

My Lords, perhaps I may remind the noble Baroness that when the figure 10 appears on the clock, we have finished our time.

Baroness Jeger:

My Lords, I was just finishing. I want the arithmetic sorted out. It is absolutely criminal. We know how to help people. For example, we know that a day cataract operation can save someone from going blind, but we tell old people of 80 years of age that they will have to wait two years for the operation.

4.59 p.m.

Baroness Masham of Ilton:

My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for giving the House this opportunity of paying tribute to 50 years of the National Health Service. I congratulate the noble Lord on his excellent speech. The debate gives me the opportunity to say how delighted many people throughout the country will be at the wonderful news about St. Bartholomew's Hospital—875 years of healthcare should make it a unique historic listed monument which should have a preservation order put on it for ever. It was given to the people of London for their health needs and has always had an outstanding reputation.

The Minister knows my enthusiasm for specialist centres of excellence. I hope that in time St. Bartholomew's will inspire brilliant doctors and scientists to find much-needed advances in cancer cures. I am thinking today of a loved wife of one of our estate staff in Yorkshire, who is the young mother of three children, the youngest being five years-old. She has fought cancer for three years and has been admitted to the local hospital, may be for the last time. I was very pleased to hear the happier story from the noble Baroness, Lady Pitkeathley. Cancer is claiming too many lives. I am thankful that the Government are trying to put that dreaded condition high on the health agenda.

May I ask the Minister whether the HIV/AIDS unit will remain at Bart's? A vaccine for AIDS is becoming a global priority and if there is to be cancer research at Bart's, it seems that the research for an AIDS vaccine could be developed in such a centre. May I also ask whether there is to be a five-day casualty centre for the City of London? So many people come into the City to work. What will happen when someone puts an arm through a glass door or has chest pains?

A few days ago at the Chelsea & Westminster Hospital a surgeon told me that many of the operating sessions had been cut by about 15 per cent. That seemed to be causing frustration when the hospital staff are there, but the health authorities cannot afford to buy the operations. Is not that a waste of resources? How are waiting lists to be cut if that sort of thing is happening?

National Health Service facilities up and down the country differ a great deal. Better communication at all levels is needed, most of all with patients and their relatives and with hospitals and the community. There may be fragmentation between different trusts.

Some weeks ago, my husband, whom some of your Lordships will not know is a Member of this House, developed emboli in his lungs while in hospital. An appointment was made for him to go to another hospital 16 miles away to have an isotope investigation. The appointment was for 2 p.m. At 4 p.m. the ambulance had still not come. The ambulance has its own trust. Can your Lordships imagine what it is like to be waiting?

Last Friday I was invited to visit the Glaxo Department of Dermatology in South Cleveland Hospital in Middlesbrough. It is an integrated out-patient and in-patient unit. It is an excellent unit, serving a catchment population of approaching 900,000 people. I was most impressed by the dedicated staff and up-to-date equipment, but I should like to bring to the notice of the Government and your Lordships some of the concerns of that unit, because no doubt they can be echoed throughout the country. There is a need to improve general practitioners' understanding of skin diseases. There are difficulties in persuading purchasers to fund extended roles for nursing staff. Hospital drug budgets are inappropriately low for all skin needs. There is also a need to extend the drug tariff to include 10-metre lengths of Tubifast bandaging for eczema and four-layer bandaging for venous ulcers to allow the shift of patients into the community. There would be a saving of hospital and patients' time if that could be done nearer home. I should be grateful if the Minister could look into that and write to me about it.

During the last War, in the 1940s, Dr. Ludwig Guttman, a neurologist who had come to Oxford from Germany before the War to escape Nazi Germany, was asked to start the first spinal unit at Stoke Mandeville Hospital. Many paraplegics (due to spinal injuries) were expected. Service personnel were treated at the unit with Army nurses and Dr. Guttman. It was in 1948 when the NHS was born that civilian paraplegics were admitted to that unit and it became world famous for its pioneering treatment. Other units throughout the UK and the world were developed from it.

Patient associations help to promote the needs of their members. I founded the Spinal Injuries Association with colleagues 24 years ago. Before the National Health Service, paraplegics had a disastrous time being treated in general hospitals, generally dying of sepsis through pressure sores or urinary tract infections. The Spinal Injuries Association knows that spinal injuries need specialised care in spinal units. Sometimes in emergencies spinal patients go to general hospitals. There have been some serious cases of hospitals not following the recognised procedures; for example, patients who cannot evacuate their own bowels are refused help for that vital act of life. Why cannot the staff ask the patients and, if they are too ill, ring a spinal unit for advice? Also, as the Minister will know because I have written to her, patients have died because they could not be transported to their spinal unit when very ill. If it is to be a patient-led health service, I hope that the Minister will help patients to get the correct treatment in the correct hospital and whatever their condition requires. We do not want to return to the bad old days before the National Health Service.

At the same time as the spinal units were being developed, so were the lifesaving antibiotics. We became reliant on them. Now, with over-use and wrong use, they are becoming resistant to many bacterial infections.

There is nothing more important than good health. I hope that the Government will do all they can to prevent illness and the spread of infections. Health education needs to be promoted at all levels. The National Health Service is an insurance policy for everyone. With the quick turnover of very sick patients in hospitals, the immense pressure on the service should be recognised.

I have served on a community health council, a health region and a family health services authority. I have seen many successes and many problems over the years. With the ever-increasing expectations of society, the National Health Service needs a great deal of ongoing support from both government and all communities throughout the country.

5.9 p.m.

Lord Colwyn:

My Lords, this is another in our series of debates on this subject. I too should like to thank the noble Lord, Lord Hunt of Kings Heath, for initiating the debate this afternoon. In our debate on 6th November 1996 again to call attention to the 50th anniversary of the NHS—which I believe coincided with the 50th anniversary of Royal Assent—the noble Baroness, Lady Jay, promised the House that a new Labour government would restore the NHS to its public service vigour. She said: 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".—[Official Report, 6/11/96; col. 648.1 She said that there would be substantial increases in funding under a Labour administration.

The Times last Monday also announced massive increases in funding. Under the headline "NHS to get £2 billion extra each year" it reported: Tony Blair is planning a permanent increase of between £1.5 billion and £2 billion next summer to coincide with the fiftieth anniversary of its creation". The implication of statements by successive governments has always been that they will ensure that the NHS has sufficient funding. Reference to funding of the NHS is probably mentioned one way or another every single day on radio, on television or in the newspapers. But are we really talking about health or something else? I make no apology for repeating something that I have said in this Chamber on many occasions. Public debates on the NHS rarely concentrate 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. They have consistently ignored discussion of the more fundamental issues, above all the question of whether changes in the financial structure in the medical services will result in improvements in 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 lead to improvements in health, increased longevity or the eradication of disease is ill-founded yet widespread. In its 50 years the NHS has been a wonderful example of an emergency service—a sickness service—but has had very little to do with health. In our debate on poverty and ill health, introduced again by the noble Baroness almost exactly one year ago, I said I thought that the greatest advances in the promotion of health during the 20th century had been due mostly to the installation of efficient plumbing and drainage systems. I am delighted that the noble Baroness, Lady Jeger, in her marvellous contribution this afternoon agreed with that. Sadly, the incidence of chronic illness is still rising. Instead of focusing on health, the NHS has concentrated resources on illness and encouraged a general increase in the use of synthetic pharmaceutical drugs.

When introducing a debate on poverty and the NHS I believe that the noble Baroness agreed with me when she said: But good health is about more than the NHS. It is about how we live. It is about the kind of country we are. It is about what priorities we give to things like proper childcare, to worthwhile employment for school-leavers—and, indeed, for everyone of working age—to decent housing, to the environment and to building cohesive communities".—[Official Report, 12/2/97; col. 246.1 With present attitudes to health it is inconceivable to think that illness should be viewed as a helpful though often severe reminder that perhaps there is something at fault with one's lifestyle or attitude. It is precisely because this possibility has been ignored that so little attention is paid to the whole concept of health promotion. Health promotion is about the maintenance of good physical and mental health. It has very little to do with medicine and disease management and everything to do with the way people live and the social and psychological environments in which they do it. Millions of people in this country suffer unnecessarily simply because they are not being directed towards health promotion, early diagnosis and prevention, and—the noble Baroness will expect me to say this—natural complementary therapies which are safer, more therapeutic and usually less expensive.

I should now like to follow my noble friend Lady Gardner of Parkes and turn to my own profession of dentistry. Here it is a different story, with a dedicated profession spending much more time on preventive advice and, over the past 50 years, being responsible for dramatic improvements in the dental health of the nation. I am sorry that the noble Lord, Lord Hunt, was unable in his introduction to give a preview of his speech on 23rd April of this year when he is due to address the annual conference of the BDA on what will drive public spending on dental services into the future. The entire profession is waiting to hear the answer to this.

Since the fee cuts in 1992 morale has been low and there has been limited investment in new equipment and premises. The previous government tried to address these problems through reform of the general dental services, which was agreed with the profession and announced by the Minister of Health on 12th June 1996. At the same time he announced that he would be proposing amendments to the Dentists Act to allow pilot studies into different roles for dental ancillary workers and a statutory complaints scheme for private patients.

The previous administration also introduced measures to increase the number of NHS practices in Wales as well as in England. In the last days of the previous Parliament the primary care Bill became law, allowing the piloting of schemes to target resources where they are most needed. Over 100 dentists have expressed interest in this scheme and I understand that 25 will be funded to work up firm proposals which should start in October of this year.

The British Dental Association is active in bringing the problems of NHS dentistry to the attention of all political parties. Before the election the present Government promised to work closely with the BDA to identify ways of tackling the problems within the resource constraints that will inevitably exist. I quote from a response to the BDA:

Labour will want to discuss with the dental profession how existing resources can best be used to address the problems of NHS dentistry". Can the noble Baroness confirm that her department is working with representatives of the dental profession to honour these pledges? Can she give any hint of parliamentary time being made available to allow amendment of the Dentists Act?

The BDA's General Dental Services Committee has estimated that by the end of this financial year £51.8 million less may be spent on patients than had been forecast when the reforms were introduced. My profession will be grateful if the noble Baroness can confirm that this amount and the savings which will become available as patients' registration with dentists is reduced from 24 to 15 months will be returned to the general dental services of the NHS.

The dental profession was delighted when the Labour Party recognised that oral health was an extremely important part of general health and promised to, bring dentistry back into the mainstream of the NHS". Yet in the White Paper The New NHS: Modern and Dependable there is virtually no mention of dentistry and only two references in the recent consultation document to a national framework for assessing performance in the NHS. Dentistry is once again being marginalised and the contribution of over 22,000 dentists who provide dental care for the NHS is not being fully recognised in this 50th anniversary year.

So how can the noble Baroness and her right honourable friend celebrate the past and look forward to the next 50 years? I have asked that Ministers should start to work with those who can deliver improvements in dental care. In general health care the Government must redirect some of their new funding away from the sickness element of the NHS and into some of the new initiatives that can now aid early diagnosis and provide treatment before people become ill. The Government must look forward 20 years or longer and use the skills and innovations of British biotechnology and bio-pharmaceutical companies. There is so much science and new knowledge available that can detect health problems before they appear as symptoms. I declare an interest as a director of a bio-pharmaceutical company which specialises in diagnostics and drug delivery. There are now available diagnostic devices and treatments that could make dramatic, effective cuts in the healthcare budget. The noble Baroness, Lady Gould of Potternewton, referred to osteoporosis, which is a perfect example of this.

The previous Government listened but sadly did not have the foresight or courage to understand that relatively small amounts of money spent on the integration of these techniques into the NHS now can save millions of pounds—and hundreds of millions—in the future. I am a passionate supporter of the NHS. The Government told us during the past 18 years what they would do. Let us see them keep their promises. hut also listen to those of us who are trying to help them.

5.19 p.m.

Lord Desai:

My Lords, first, I thank my noble friend Lord Hunt for introducing the debate. I add my congratulations to the noble Baroness, Lady Knight, with whom I worked as chair of the IPU for many years. It is a great pleasure to see her here, and I thank her for an excellent maiden speech.

The noble Lord, Lord Colwyn, said much with which I agree. I shall speak mainly about the future. We are celebrating 50 years of the NHS, but, as he put it, some of the attitudes towards the NHS are still mired in the past. Although there are differences across political parties about the internal market, they should all agree that the British people want to keep the NHS, and that no political party, when in power, will take it away. If we agree that, we can stop a great deal of day-to-day skirmishing, because it wastes a great deal of energy and diverts attention from the important problems affecting the NHS.

There have been three major changes over the past 50 years to which I wish to draw attention for future analysis. First, our society is much more multiracial than it used to be. Our society is much more open and democratic, in the sense that people want to participate in the decisions that affect their lives. Of course we are a much richer society, and we must not forget that.

My noble friend Lady Jeger said that she saw patients from around the world. We have NHS staff from around the world. We must acknowledge the contribution made by doctors and nurses who come from Commonwealth countries. Their proud contribution to the NHS has been important. I was disturbed to read recent reports about racism in the NHS. When my noble friend replies, will she make it clear that the Government and British society will not tolerate racism in the NHS, especially towards its staff?

Multiracism does more than make a contribution, as it were, on the supply side. I argue, again in support of the noble Lord, Lord Colwyn, that notions of health are also culturally dependent. Our Commonwealth citizens bring to us notions of health and medicine which are much richer than those we are used to discussing. By its excellent service the NHS has prevented people from thinking clearly about health. We say to ourselves that we do not have to think about health, because the NHS exists. That is partly why we are more neglectful of our health than we were before.

We should have a debate, not on the NHS, not on cuts, not on queues, but on health. Let us find out what the various communities think about health. Health is not just a simple, mechanical notion of the way the body functions. It is much more holistic than that. There are alternative medical systems available, although not on the NHS—I hope that they will be available on the NHS—and so we should be able to discuss health in a much wider way, and evaluate how, using different cultural practices, we can promote the health of our citizens.

When we are talking about whether the NHS is expensive, we fall back too readily on crude measures: such a percentage of GDP is spent, and so forth. We should realise that the number of years our citizens live is a great achievement. More people are living longer, and that has never been factored into the measurement of the needs or achievements of the NHS.

I once suggested to the UN, which was looking for a measure of wellbeing, that the remaining lifetime of each and all of us would be a good measure of our wellbeing. We should ask ourselves what we really value. We value the years that we have left to live. A good health service gives us all a longer life. That is what the NHS has done. The longer people live, the wealthier the country is. It is not surprising that with a longer lifetime, we spend more money. However I am sure that if a calculation were made carefully, we would discover that we are spending less money on health now per year of extra life than we did before. That is an achievement of which to be proud.

Society is more democratic, and we should have an open discussion about health rationing. There is no need to be embarrassed about it. Rationing used to occur through doctors' decisions. Doctors used to decide how to ration healthcare. Society is now different. Patients want to know more about diagnoses and alternative treatments. They want to have some say in the way things are rationed. Other countries have experimented with open public discussions on rationing. The Oregon experiment is well known in that respect.

If we can take the NHS out of party politics, we can have an open discussion about the strategy of rationing: who should be rationed; and how we should ration. There should be a participative mode of rationing, because people would like to know what is being done to them. If they know, they will accept it; they will not accept arbitrary decisions, Treasury-driven cuts, administrative decisions, and such things.

We should not just have a debate about notions of health, it is important that we all sit down together and agree the health needs of the people of whom we are taking care. We must also ration healthcare sensibly, and we must have a way of deciding that.

We do not yet have—I may not be fully aware of the research on this matter—information on how our patterns of demand for health services change over a lifetime. The statistics I have read refer more to the US than the UK. They show that the greatest demand for hospital beds happens in the last years of our lives. I do not want to go into all the numbers, because numbers are boring. Our needs for acute care are concentrated on certain phases of our lives. Between childhood and old age our demands for healthcare are random and accidental. They are not systematic. If we knew how the demands changed, we might be able to plan hospitals in relation to them. We now plan hospitals as if all of us might want them all the time. That may not he true. The bed crisis occurs because many people go to hospital and cannot be discharged. There is input but no output. People have to stay there. We should be able to provide specialist hospital care. People between five and 85 need a different kind of healthcare from those of 85 and 90, for example. We should have such data, so that we can combine new data and new concepts with an open discussion. We should then be able to plan a better health service for the next 50 years.

5.29 p.m.

Lord Prys-Davies:

My Lords, I, too, welcome the timely initiative of my noble friend Lord Hunt. I thank him for having set the scene in a comprehensive, well-informed and sensitive speech. It was a speech of high quality, if I may humbly say so. It is clear that the whole House was impressed by some of the points made by the noble Baroness, Lady Knight, in her maiden speech. I hope that my noble friend the Minister will take note of her contribution.

The whole country has every reason to be grateful for Labour's finest and most enduring achievement—the NHS. There were other achievements, but this has been an enduring achievement. It has directly improved the quality of life. Those of my generation in your Lordships' House can testify that it has increased the length of life. Fifty years ago, the NHS brought a fundamental freedom to the vast majority of the British population; the freedom of access to health services.

For me, it was Nurse Grace Owen, a district nurse at the time, who best expressed the feelings of millions of people in 1948 when the NHS hospitals first opened their doors. She said of that occasion: Utopia had arrived. Now all these services would he free. It was a wonderful feeling—. Access to those hospitals was founded on two basic principles: the provision of healthcare for all, free at the point of treatment, which would be funded largely out of public taxation. Fifty years on, the enthusiasm for those principles remains.

Looking back to 1948, there have been many changes in working conditions within the service and there have been many reorganisations. But the essence of the health service still lies in the transactions between doctors, nurses and other health professionals and patients. This essence also remains untouched.

Probably the most profound change in the NHS structure occurred in 1991 after the Prime Minister of the day, the noble Baroness, Lady Thatcher, took personal charge of her government's response to the needs of the NHS. That led to the purchaser-provider split and the creation of the internal market. A new business ethos was introduced which shifted emphasis to value for money and competition. It was argued that what was principally at fault with the NHS could best he solved by competition between competent managers. Giving due credit to the government of day, they believed that that would stimulate greater enterprise and commitment, which in turn would improve services to patients. The general evidence is that that did not happen.

Looking to the future, I suggest that what we should expect of the NHS is: first, that the hospital system is able to deal with urgent cases urgently; secondly, that waiting lists will be shortened; thirdly, that patients will not be discharged from mental hospitals to the outside world unless proper support facilities are available for decent community care; fourthly, that the service provides a high standard of care to all patients, whether in hospitals, surgeries, clinics or their own homes; fifthly, that the devotion of the staff will not be taken for granted or exploited; sixthly, that the Government take steps to reduce the cause of inequalities in health. How likely is all that to come about? Will it be in 10 or 25 years' time?

From time to time, I am obliged to attend the busy outpatient departments of a major district hospital in South Wales and of a leading teaching hospital here in London, St. Bartholomew's. Those hospitals are working at their maximum capacities. I believe that the new Government start with a store of good will in the NHS. There is a feeling that their problems have a prospect of receiving full consideration by the Government. But this also means that health professionals and ancillary staff, as well as the general public, expect great things from the new Government.

It is agreed that the problems facing the NHS cannot be addressed overnight. However, the policy statements issued by the department since last May show that they are being identified and tackled. On 9th May, the Secretary of State confirmed that the internal market would end and that the service would be developed on the basis of co-operation, team work and competence. Since then, the department has announced a series of major initiatives. I wish to welcome six of those initiatives because I have an interest in them

I welcome the independent review of health inequalities by Sir Donald Acheson which was set up last July and is to report this year. Given the personal interest of my noble friend Lady Jay in this area of policy, I am confident that she will use her influence to ensure that its findings will be speedily acted on. In September, an advisory committee on resource allocation was set up to advise how inequalities can be tackled through resource allocation. That could have a profound effect on the allocation not only between districts but also between priorities. I find that there is widespread support for the Royal Commission on the funding of long-term care for elderly people and also for the independent reference group to give independent advice to Ministers about psychiatric hospital closures. I welcome the appointment of an additional 390 junior hospital doctors, from whose ranks will come the consultants and GPs of the future. If the NHS is to work as well as we hope for in the new century, those initiatives are significant steps in the right direction.

I was interested to hear the speech of my noble friend Lord Winston and I hope that my noble friend the Minister will deal with the two issues which he raised. Can my noble friend please explain the remit of the independent reference group which will give independent advice to Ministers about psychiatric hospital closures? I have read that in future the closure proposals will be measured against new criteria. Who will draw up such criteria? Will the voluntary organisations with a special interest in the mentally ill be consulted on their formulation? Ministers will know that public confidence in the policy of running down and eventually closing Britain's long-stay hospitals and substituting care in the community, which has been a policy of every government since the early 1960s, is now increasingly fragile. I therefore hope that this independent reference group will address the issues effectively and realistically.

5.38 p.m.

Lord Butterfield:

My Lords, I wonder whether the noble Lord, Lord Hunt of Kings Heath, will accept the thanks of a man from Stechford for introducing the debate. We are grateful to the noble Lord and there are a few Brummagem folk around who have spoken in support of his ideas.

On the 50th anniversary of the NHS, we were delighted to discover that the Secretary of State had managed to raise an additional £2 billion a year for the service. When I mentioned that to my folk in Cambridge, they said, "Well done Dobson, but keep going". Your Lordships will realise that some people wonder whether £2 billion will be enough to provide everything that is needed. Many needs were outlined by the noble Lord. Lord Prys-Davies.

Looking back, I want your Lordships to know that I first became wedded to the philosophy behind the NHS in 1941, when, as a medical student at Johns Hopkins, Baltimore, I read and proselytised the Beveridge report. I was not particularly popular or politically correct among the Americans. The American medical profession has always resolutely resisted any political intervention in the doctor/patient relationship. We have heard something about the tensions at the beginning of the health service; but as things went on, I even felt compelled to resign from my trade union, the British Medical Association, over its policy of opposing the NHS back in the 1946–47 era.

However, we can all see what a remarkable success the NHS has been, although not in every way. Many points have been raised this afternoon which show that we must continue with our efforts. But overall, it has been a remarkable performance and I have been proud of it, going around the world as a professor giving lectures, because I have realised that we have been able to stimulate the development of health services throughout Europe and in many parts of the world, although not perhaps the USA as we all might have hoped.

We all recognise that the service has faults but on its 50th anniversary, we can be proud of that extremely British, flexible and transparent organisation. That is becoming clearer and clearer. It was not transparent a few years ago but it is becoming increasingly transparent now. Today we have been discussing how patients may look into the whole question of rationing. That is a terrific step forward.

Many of the original flaws of the NHS have been corrected. When I became a medical student, there was a serious maldistribution of medical expertise around the country. It was rather top-heavy in London. But all that has been largely smoothed out and I believe that London has the status and potential to be a world-leading medical centre.

That will be especially true if its support is maintained from its many traditional sources of guidance and help. I mean by that, for example, the historic links with the royal colleges concerning excellence, with the universities concerning research and teaching and with the wonderfully balanced and remarkably unselfish professions which served the NHS.

There is no doubt that since Aneurin Bevan first shocked the medical profession by incorporating all our hospitals—teaching, charity, municipal and so on—into a single service, we have not only seen a much more uniform spread of medical specialties but also, rather more gradually as I see it, the development of a service which puts first patients' health rather than the interests of the professions or institutions.

The NHS is not, we know, a national disease service. In the more recent years of its life, the idea of the health of the people has caught on with the public in a most remarkable way. Health promotion is widely recognised and practised. We have much better health behaviour. It is not perfect but we know about diet and are taking more exercise; for example, people here walk up and down the stairs rather than use the lift. It is interesting that it is unusual now to see people smoking in our dining room. We should reflect on those matters and be grateful that the health promotion drive is getting through. Of course, there has been the acceptance by mothers and children of our vaccination programmes. Breast and cervical cancer screening services have been developed. I am intrigued that there is growing concern about the amount of cancer of the prostate in men which appears to be developing in the country. We should he helping to track that down.

I have been very impressed, as an old grey man who has lived as a doctor throughout the time of the NHS, by the people of the various professions and those who work in the service side of the NHS and in the remarkable charities which take care of the interests of different people—the British Heart Foundation, the British Diabetic Association, the cancer charities and so on. They have all had a beneficial effect on the service not only by raising incredible sums of money from the public for research projects, but also by the way in which they have been watching the health service and its performance in relation to the very people with whom they are mainly concerned.

I have always been interested in diabetes. I have been fascinated by the way in which the British Diabetic Association has been watching the way in which different insulins and different measuring devices for blood sugar have been introduced and so on. We must realise that part of the achievement of the NHS must be attributed to us all—all the people who use it and have worked for it. They have all been keeping an eye on it and making observations which have had a profound effect on its quality.

Before I came here to speak today, my wife, who is an American, said, "Don't make it sound too good because there are still things to do". I wish to make it clear that I realise that. But we can be proud of the first 50 years.

I wish to look briefly at our future prospects. I am delighted that more effort and resources are going into management in the NHS. It has been said, and it is true, that hardly anybody knows what anything costs in the NHS. That is a great tribute to the original philosophy but it has its disadvantages.

I am delighted at the way in which we have built up a research and development department with very good leadership. Moreover, I am astonished and amazed by the remarkable efforts of our pharmaceutical industry and its allied industries in the development of new and safe therapies and drugs. It is not to be forgotten that the NHS has developed research into the activity of medicine so that we can now prescribe on the basis of research evidence rather than hope. We have also produced a remarkable general practice service in the community.

I wish to end quickly with three other remarks. I remember speaking in this House when we were all worrying about fetal research. Since those years when IVF was being introduced, the work which has gone forward in fetal research has been astonishing. There is fast-growing interest in the possibility that diabetes and many other chronic conditions may arise from things which happen to the fetus.

Lastly, I pay two personal tributes. First, 90 year-old Professor Reginald Revans of Manchester did the NHS a great service when he studied action learning in London hospitals. He really showed that if managers share their difficulties and help each other in their diversities, hospital performance statistics improve.

More recently, a former director of mine in the army operational research group, 88 year-old Stanley Hey, of all things a radio astronomer, is leading a personal campaign from Eastbourne, to measure the pressure points in the skin as people lie immobile in bed. He has found ways to relieve them. To my mind, that is more evidence of the way in which people are joining in with the drive and philosophy of the National Health Service.

5.50 p.m.

Baroness Ludford:

My Lords, I, too, warmly welcome the opportunity to discuss the NHS and thank the noble Lord, Lord Hunt, for initiating today's debate. I should also like to congratulate the noble Baroness, Lady Knight of Collingtree, on her interesting maiden speech. Like my noble friend Lord Alderdice, I am one of those who do not match the NHS in reaching its 50th birthday. I am an NHS-reared infant; indeed, I believe that I imbibed my fair share of NHS powdered milk and orange juice.

As has been noted on all sides of the House, the NHS is a unique and highly valued national institution. Perhaps I may say that I am impressed by the proportion of women speakers in today's debate. In fact, I think it is the highest proportion in any debate in my short time in this House. I am also grateful to the noble Lord, Lord Butterfield, for mentioning the role of William Beveridge. The fact that the NHS is one of our finest institutions is something that Liberal Democrats are proud—and, indeed entitled—to share, given the Liberal origins in the person of William Beveridge, who was of course later a Liberal MP.

The value of the NHS rests on it being supported by all parties and by a wide social consensus. However, I understand from a new MORI poll for the BBC released today that nearly one quarter—23 per cent.—of people think that the NHS will not exist in 10 years' time. It is worrying to think that people now hold that view. Perhaps that is linked to the fear of 70 per cent. of that sample of nearly 5,000 people that the NHS is underfunded. As other speakers have observed, the NHS is under strain from funding constraints, staff shortages, low morale, a staggered pay award for nurses, and so on.

The situation as regards dental services has also been commented on today. The problem with that service is that it is gradually being eaten away. Like long-term care—and I am glad that there is now a Royal Commission in that respect—that service has been partially privatised over the past few years, without public debate and without the long lead time allowing people to take out private insurance if it is available, or to make other provision. Indeed, in many places no NHS dentist is available. We also no longer have free eye tests, which I happen to believe is economically counter-productive.

The same poll as I just mentioned also shows that almost two-thirds of people—that is 63 per cent.—said that they would be willing to pay another 2 pence in the pound on income tax for the NHS. Before anyone becomes cynical about such statements compared with what people do at the ballot box, I should also point out that another finding showed that about the same proportion of people believe that there must be budgets and that they should be respected even if rationing has to be observed. Therefore, people are not advocating unlimited spending; indeed, they are perfectly aware that there are constraints and they are saying that they are willing to pay more. It is vital that quality and standards are maintained, not least to enable the middle classes to continue to use and help fund the NHS so that it does not deteriorate into a safety net service for the poor.

I should like to concentrate on the need for NHS decision-making to be open, honest and accountable. We need democracy, not bureaucracy, in the health service. It is unhelpful to deny that rationing takes place. Everyone knows that it does, not least rationing by waiting-list. I am sure that no one begrudged Her Majesty the Queen Mother her immediate hip replacement operation, but many will have been envious. I know of cases, including my own family, where people have despaired of receiving treatment on the NHS because of an 18-month or even a two-year waiting-list. They have had to pay for private treatment when they have not been insured, because they never intended to seek private provision. Indeed, the survey from which I am afraid I shall continue to quote, indicates that nearly one in five people—that is, 18 per cent.—have had to do precisely that; in other words, they have had to pay for private treatment while not being insured. That suggests that they had not anticipated such a thing happening. So there is an NHS lottery at present, which needs to be addressed by open debate through democratic channels. I strongly agree with what the noble Lord, Lord Desai, said in that respect.

Health authorities are not democratically elected at present; they are appointed quangos. But there is at least some public access to their deliberations through consultation and public meetings. Despite what the other advantages might be of local commissioning groups of GPs which the Government now propose, I worry that purchasing decisions will be even less transparent than they are at present. I was interested to hear what the noble Baroness, Lady Pitkeathley, quoted in that respect. Her quote suggested that GPs really cannot be bothered to talk to patients. I found that rather ominous. If GPs are going to make purchasing decisions, how will they debate those requirements with their patients?

We heard yesterday the Government's conclusions on the London health services review, and I made my own feelings rather clear. The experience of the past five years in London is an example of how not to make decisions. Ever since the Tomlinson Report five years ago, it has been a top-down exercise—a mix of medical, Whitehall and party politics. Local people's views have been arrogantly ignored. When 99.5 per cent. of the people in the area said that they wanted to keep Bart's accident and emergency department open, it was closed. There has been no real participation or open debate. Therefore, the public have never owned the result; they have never felt that it belonged to them.

I believe that the noble Lord, Lord Jenkin of Roding, spoke about taking the NHS out of politics. I am sorry, I see that the noble Lord is shaking his head so perhaps I misunderstood him. We need to get it back to community politics and take it away from administrative politics. I think that the public are prepared to consider hard choices if they are truly involved and have the facts; and, indeed, if they feel that they are enjoying respect for their own views as citizens. There has been administrative devolution in the NHS, but we now need political devolution.

When the public are consulted they are much more likely to take account of factors such as public transport and accessibility to hospitals. That is something which is not always considered by managers. They also put some value on the psychological benefits of an attachment to their local hospital. The word "emotional" was mentioned in yesterday's debate, but I believe that there is now an appreciation of the link between mind and body in getting well. If people go into hospital with a positive attitude, they are more likely to get better. We have often actually externalised the costs of longer travelling times to hospitals and pushed those costs on to private individuals, instead of the health service.

The survey from which I have already quoted found that 75 per cent. of people believe that community hospitals should not be closed to pay for larger regional hospitals, mainly because of the travel difficulties. Again, one could be slightly cynical of that figure were it not for the rest of the survey's findings which show that people are ready to pay for their choices. There may be a trade-off between accessibility and cost. I believe that that trade-off should be put to the public to enable the choices to be made openly, transparently and democratically. We also need to look at the artificiality of health authority boundaries of which, I am afraid, Bart's has been a prime casualty. At present, local people are not able strongly to influence the purchasing decisions of health authorities. As was mentioned yesterday in our debate on London, we on these Benches feel strongly that a Greater London authority—a democratic authority—should have responsibility for the strategic planning of health. I suggest that that should also apply to other regions in the future.

I conclude by agreeing with other remarks that have been made about the need, as Beveridge proposed, for a "comprehensive policy of social insurance" to attack the five giants of want, disease, ignorance, squalor and idleness. At present we do not have an integrated approach to public spending to reflect the cross linkages between different budgets, especially between social housing and healthcare, between education and healthcare, and even between social services and healthcare. To get an effective seamless web of provision, we need to merge the providers and the budgets.

Overall, my main point is that I believe the public are perceptive and responsible, not irresponsible. Government need to treat people as responsible citizens on a partnership level and not impose top-down solutions upon them as if they were incapable of understanding the issues.

Lord McColl of Dulwich:

My Lords, before the noble Baroness sits down, I should point out that the Queen Mother broke her hip and the treatment of a hip that has been broken is an emergency treatment. You can either fix it with a pin or you can replace the hip. It was appropriate in her case to have a hip replacement. She was not jumping any queue and there is no question of putting people on a waiting list if they are an emergency.

Baroness Ludford:

My Lords, I hope I made it clear that there was no suggestion of my implying that she jumped a queue. I was making an observation that has been made to me. No one begrudged the Queen Mother her treatment but other people who may he in pain, although they may not have broken hips, are unable to get treatment. I hope that I did not in any way make a disrespectful remark.

6.1 p.m.

Baroness Amos:

My Lords, I thank my noble friend Lord Hunt of Kings Heath for initiating today's important debate. I need to declare a number of interests. I am chair of the Afiya Trust which works to promote equity in health and social care. I am chair of the board of governors of the Royal College of Nursing Institute. I am a senior associate of the King's Fund and a member of its general council. I am also a non-executive director at University College London Hospitals Trust. I was pleased that in his announcement yesterday on the future of health services in London the Secretary of State supported the development of a new university college hospital which would involve the centralisation of services on one site to enable the provision of quality local and specialist services.

I must also declare an interest as a user because I continue to be impressed by the quality, competence and commitment of NHS staff. I focus my remarks today on the contribution of ethnic minority workers to the NHS because they have been an important part of NHS history. I hope that they will be a core part of its future. For me 1998 is a significant year not only because it is the 50th anniversary of the NHS but also because it is 50 years since the arrival of the "Empire Windrush", heralding a period of post-war migration from the Caribbean to Britain. Members of Britain's ethnic minority communities have made a significant contribution to the NHS over the years. There were strenuous efforts to recruit workers from overseas in the 1960s and 1970s.

Studies have shown an over-representation of African Caribbean, Chinese and African women in nursing compared with the distribution of other ethnic groups in the nursing workforce. But their experiences have not always been positive. Some of your Lordships may recall the PSI survey on nursing in a multi-ethnic NHS which was published in 1996 and which considered the experiences of ethnic minority nurses in the NHS. Its findings made bleak reading. They pointed to an over-representation of ethnic minority nurses in specialties such as geriatric care and mental illness. The survey referred to a lack of access to training, development and promotion and the under-representation of ethnic minorities at senior levels and the prevalence of racial abuse and harassment at work. That experience is not limited to ethnic minority nurses; it applies to other ethnic minority workers who have commented on areas of discrimination and disadvantage. That is why the commitment of the Government to deal with racism in the NHS is so important.

The Secretary of State for Health has on many occasions restated his determination that there should be no discrimination in the NHS for patients or for staff and his commitment to a service where employment opportunities are based on the ability to do the job, and staff feel they are valued and respected and to the delivery of fairness and equality at work. Action has already been taken in some areas. The NHS Executive is working with the Commission for Racial Equality to develop a set of racial equality standards in the NHS. An equality award scheme is being developed to promote and reward best practice. Initiatives are being put in place to tackle harassment and abuse. There is a commitment to the extension of ethnic monitoring so that data are available to enable targeting as appropriate. I hope that sustained action in these and other areas will ensure that the NHS will continue to attract staff from ethnic minority communities, many of whom are ambivalent about the commitment and ability of the NHS to meet its equality and diversity objectives.

The objectives in the White Paper on the new NHS should go some way to dealing with the concerns of those in Britain's ethnic minority communities, given the focus on primary care and on collaboration and partnership. Research published last year shows that health inequalities vary between ethnic minority groups and are directly related to socio-economic status, with those in poorer socio-economic groups having poorer health. As primary care is the first point of contact for users of the NHS, improving primary care for black and ethnic minority groups is essential to eliminate inequalities in health. We need to raise public awareness, tackle language and cultural barriers and focus on prevention. The need for more effective health promotion within primary care and community services must be met.

We also need a multi-disciplinary, multi-agency approach. The health action zones which will provide a framework for the NHS, local authorities and other partners to work together to improve services and to provide more integrated care for patients will have a key role to play in ensuring that issues of discrimination and disadvantage are tackled as a central part of their strategy. I welcome the renewed commitment in the White Paper to a National Health Service based on need and the recognition that continuing to improve the National Health Service will depend on maintaining the confidence of staff and patients; the efficient and effective management of resources; and a focus on excellence and quality. It is a challenge that I have every confidence the NHS is equipped to meet.

6.7 p.m.

Lord Davies of Coity:

My Lords, after 50 years of the National Health Service we celebrate and acknowledge its contribution to the health of the nation. That is the topic of our debate. First, I thank my noble friend Lady Jeger for reminding us how the National Health Service was born and the opposition there was to it. Secondly, I thank my noble friend Lord Prys-Davies for reminding us what happened in the 1980s, to which I shall refer later.

Most of us—but not all, I hasten to add—will have recollections of 50 years ago and of the year 1948. However, those recollections will all be different. At 12 years of age I could not claim to understand the deep and profound significance of the creation of the National Health Service. But what I do recall is the direct effect it had on our family because my father had worked in a hospital since 1929. My father was a male nurse in a mental hospital, or at least that was how he was described after the National Health Service was formed. Before that he was known as an asylum attendant. His job was certainly secure but it was not well paid before the National Health Service was formed. I know that because my mother went out to work and we took in what the "posh" call paid guests but we called lodgers to enable my parents to pay the mortgage and to make ends meet.

When the National Health Service was formed, I recall my father having a pay rise and back pay. That was the first time I saw a £5 note which looked like a large sheet of white paper. On the strength of that back pay, we had our first family holiday and came to London.

Those are my recollections of 50 years ago. It was later that I came to appreciate what the National Health Service stood for. The National Health Service was the dream of Aneurin Bevan to ensure that the healthcare and medical treatment of all the people of this nation would be administered and provided on the basis of need and not on ability to pay. It was that dream that Aneurin Bevan put into reality 50 years ago—a reality, I suggest, that must continue to be the undying obligation of all of us if we want to claim to be a civilised society.

I am not saying that everything has been perfect at any time in the National Health Service throughout the past 50 years. I am not saying that everything will be perfect in the next 50 years. But what I claim is that throughout the whole of the past 50 years we should have been aiming for perfection; and at this anniversary, we should certainly be dedicating ourselves to that objective for the next 50 years.

Of course, the National Health Service has produced great achievements for the health of the British people to which we can all testify. But that, as we also know, is not the whole story. Until the 1980s there was a broad consensus on the one nation state, and across party divides there was, perhaps with differing degrees of emphasis, a general acknowledgement of the need to preserve and protect the one-time envy of the world—our National Health Service.

But then came the 1980s, the Thatcher years; and despite the clarion call, "The National Health Service is safe in our hands", we witnessed massive increases in prescription charges, longer waiting lists for treatment and operations, greater encouragement of private medicine, hospital closures, ward closures, shortage of nurses and shortages of doctors. We witnessed patients lying on trolleys in hospital corridors for hours, some dying. We witnessed patients being rushed across the country to find hospitals and surgeons to perform emergency operations, many not arriving in time. That is the evidence of the neglect and indifference displayed by the government in the 1980s to the deterioration of our National Health Service—all, I suggest, because of a head-led obsession with economics and a gross lack of heartfelt compassion. It was price tag medicine instead of medical treatment directly related to need. It was the complete opposite of what Aneurin Bevan set out to achieve.

How well I remember the statement, "If people wish to spend their money on medical care and treatment"— I suggest that that probably applied also to education—"instead of holidays and other luxuries, why shouldn't they?" But the problem was that the people expressing that view came from backgrounds where those who could afford private medicine could also afford holidays, luxuries and often second homes, whereas far too many people who came from my background could not afford the holidays let alone private medicine.

Lord Jenkin of Roding:

My Lords, will the noble Lord give way for a moment? The facts do not support what he says. When I became Secretary of State, the proportion of the national product to the health service was 4.7 per cent. By the end of the 1980s it was 6 per cent.

Baroness Ramsay of Cartvale:

My Lords, really, this is not a debate—it is a debate but it is timed and therefore one does not interrupt.

Lord Davies of Coity:

My Lords, my judgment of the circumstances is obviously different from that of the noble Lord. But the British people have recorded their view about the situation.

Another aspect of mismanagement of which I am conscious because of my father's work in a mental hospital, and which I observed with horror as it accelerated, was the rundown and closure of mental hospitals and the release of mental patients into the community. That process is now, thank goodness, not being continued. But what of the damaging consequences that the closure policy produced? Many of the released patients have committed murder. Ten times as many have committed suicide. And countless numbers are still living rough.

If we are to do better to fulfil Aneurin Bevan's dream in the next century we must face the fact that our record still leaves a lot to be desired. We must show greater compassion towards those less fortunate than ourselves. We must do more than make nice statements to show our appreciation and thanks to those who dedicate themselves to the care of the sick, the injured, the old and the terminally ill. We often hear it said, "Nurses can no longer be expected to be Florence Nightingales". I do not accept that. I believe that nurses are proud to he Florence Nightingales. But they object to having to be Oliver Twists and forced to ask for more. They also object to being forced to be Scrooge's Bob Cratchit—expected to be more concerned with accounting than with caring.

There is no doubt that noble Lords on the Benches opposite have a great deal to answer for as regards the 1980s. There is no doubt that on 1st May 1997 the British people made plain their displeasure at the way the country was being led further and further away from being a compassionate and caring society and more and more towards a calculating one. We now have a Labour Government. And I say this to the Government. Just to applaud the architect Aneurin Bevan and just to draw attention to the past achievements of the National Health Service at this 50th anniversary will not be good enough. The Labour Government must act and not just state intentions. They must act on behalf of those who now need, and who will need, the National Health Service. And they must act on behalf of those who are in the front line, who have dedicated their lives to caring for others, for without them the National Health Service can never succeed. The signs are good. The reality will be better. Action to produce an infinitely improved National Health Service will be the only worthy monument to celebrate the 50th anniversary.

6.18 p.m.

Baroness Emerton:

My Lords, I wish to add my thanks to the noble Lord, Lord Hunt, for his introduction to the debate and his excellent speech. I add my congratulations to the noble Baroness, Lady Knight of Collingtree, on her maiden speech and the expressions of understanding of the care and concern that patients appreciate.

I have to declare an interest. I am chairman of a healthcare trust. I am pleased to say that I have had the privilege of spending 45 years in the NHS as a nurse. I believe that today's NHS is still the envy of the world. As we look to other countries, so they look at the many areas where we have succeeded and still succeed in the aim to promote health and prevent disease and to provide a cure and care. It is a service which faces infinite demands within finite resources.

We have heard today of many changes which have taken place in the NHS over the 50 years due to medical science, technological developments and developments in public health, with improvements in the environment and diet, and prevention through the introduction of immunisation, vaccination and screening programmes.

Many speakers have indulged in a little reminiscence. I beg to reminisce for just two minutes. When I was nursing in 1953 I faced ward after ward of patients suffering from tuberculosis. That disease was practically eradicated, but, sadly, we are seeing its return, particularly among the homeless.

I wish to take up the remarks of the noble Baroness, Lady Pitkeathley, on whooping cough. I worked on a ward where there were 28 babies with severe whooping cough. Anything more terrifying I have yet to witness. Today we are very fortunate that the immunisation programme has almost eradicated whooping cough.

In relation to cataract treatment, I remember as a nurse having to place sandbags on either side of the patient's face, and having to feed patients, who had to lie flat for three weeks. Today, patients are in and out in a day, with a miraculous cure. So we have seen many, many improvements. I could go on reminiscing; however, I believe that reminiscent therapy is for the demented and I am not, I hope, demented.

The NHS is a highly labour-intensive organisation. Sixty per cent. of the budget is spent on staff, and each member of staff plays a very valuable part in both direct and indirect care. They face rising demands and rising stress levels. More worrying is the fact that there is an increase in the verbal and physical abuse of staff. A recent report stated that nursing was a more dangerous profession than being a member of the police. Within the trust of which I am chairman there are 18 security staff and 46 closed circuit television cameras in order to protect and help the staff. Hospitals are no longer a haven of peace. We are faced with verbal and physical abuse. The staff deserve a big thank-you on this occasion of the celebration of 50 years of the NHS.

We look forward to the next 50 years, and we face many challenges. Initiatives set out in the New NHS White Paper point the way forward and it is to be hoped that we shall see a rise in the quality of care. The Green Paper to be published shortly will, I am sure, produce new thinking on improving public health, the emphasis being on a "health" service and not a "sick" service.

Within the overall challenges there has been increasing development in medical science and technology and the treatment of disease. We also heard during the debate of the rise in public awareness of disease and diagnosis and the rise in public expectation. The demographic trend, given the rising numbers of elderly, will also mean considerable pressure for the NHS in the future. In addition, there are rising cost pressures.

I want to concentrate on one or two of the challenges with which we are faced. The first is recruitment and retention of staff. Achieving the right number of right people, in the right place, at the right time, with the right qualification, is very difficult in a competitive market. The recent Campbell Report recommends an increase of 1,000 in the number of medical students. The current level of wastage in nursing is 21 per cent. The training programme for pharmacists has been increased from three to four years. In the year 2,000 there will be very few qualified pharmacists emerging from the training programme. All require education programmes to produce skilled, competent and knowledgeable staff.

The Government are to be congratulated on the current national recruitment campaign for nurses, midwives and health visitors—which needs to be backed up by local initiatives. During the past week, staff from my trust campaigned in a local supermarket and were successful in attracting new entrants, some of whom were wishing to return to nursing. The strong impression was that they wanted the opportunity to talk to nurses and find out what the career opportunities really are in the profession. By backing up the national campaign with local initiatives I believe we can be successful.

The delivery of high-quality care is dependent on high-quality education programmes. Again, much has been achieved in 50 years in the advance of medicine, nursing and professions supplementary to medicine in both pre- and post-qualification education. Moving nursing into further education is an achievement that has taken over 40 years.

Importantly, within the past 18 years the nurses, midwives and advisory health visitors, who deliver 80 per cent. of patient care, have taken a lead in developing a system of professional self-regulation that has produced a standard of practice and education which is the envy of the world. Indeed, the United Kingdom can be proud that it has influenced the development of regulation in other countries, and still continues to do so. Many key figures in nursing, such as the late Dame Catherine Hall, have been instrumental in shaping the UK-wide regulatory system which ensures that the public receive the highest standard of patient care.

Emerging from the Government's new NHS White Paper is an emphasis on enhancing the role of nurses, especially identified in commissioning healthcare as members of the boards of primary care groups. I ask the Minister to ensure that education and development programmes are available to those nurses to enable them to fulfil that role. Will the Government also ensure that development programmes are available for health visitors and school nurses to enable them to contribute fully to the new public health agenda?

The NHS is a complex organisation, meeting the needs of the population often at the most vulnerable time in their life. Fifty years on, the healthcare system can deliver the most highly technical and skilled care; but that must not be at the exclusion of meeting the most basic needs that go to make the patient or client comfortable, the ability to retain his or her dignity and the provision of support for relatives at a time of stress and anxiety.

The NHS plays a vital part in our society today. I know that it will continue to do so given the support of the Government, the dedication of staff and the trust and confidence of the public.

6.28 p.m.

Lord Monkswell:

My Lords, I thank my noble friend Lord Hunt of Kings Heath for introducing this celebratory debate on the 50th anniversary of the National Health Service. I am also pleased that the terms of the debate are drawn to highlight the contribution that the National Health Service has made to the health of the nation. In that context we need to be aware of the health of the nation not merely as the health of individuals. It is that cohesiveness of society which comes from recognising the importance of every individual and treating people fairly. In the context of the National Health Service it means treating people on the basis of clinical need rather than any other basis, such as income, wealth or perceived status in society.

We also need to recognise that in the post-War consensus, so cruelly torn apart by Thatcherism, the National Health Service was only one facet. The others were a commitment to public education, a commitment to decent housing and a commitment to full employment—in other words, the whole panoply of the welfare state from cradle to grave.

Over half the speakers in today's debate are in their late 40s or early 50s. In other words, they are "baby boomers"—those who have lived all their lives under the National Health Service. I am very pleased to have been present to hear my noble friend Lady Jeger making her contribution.

We do not honour enough our fathers and mothers who brought forth the National Health Service. In this celebration it would be remiss not to speak in the most glowing terms of the role played by Nye Bevan, rightly seen as the father of the National Health Service. But in doing so, we must not forget the role played by countless others in the formation of the National Health Service.

We must not forget the misery experienced by so many in the period before the National Health Service was set up who did not receive treatment, or the right treatment, either because they were too poor and could not afford it or were too rich and were therefore easy targets for unscrupulous doctors prepared to engage in unnecessary procedures.

We must not forget, in the fight for the National Health Service, the contribution of doctors, nurses and other health professionals who were ostracised by their colleagues and pilloried by Conservative politicians for the stand which they took.

This debate gives us the opportunity to restate the reasons why the principles underlying the National Health Service that treatment should be based on clinical need, free to the patient and funded from general taxation are so important. First, the National Health Service is cheaper than the alternative because it does away with private insurance, billing, management, marketing and legal costs associated with market-driven systems. Secondly, because it is based on clinical need, there is a greater chance of the right treatment being provided. Other systems lead to poor or under-insured people not receiving treatment or to rich people being over-treated.

It would be remiss not to point out that the National Health Service is currently under severe pressure, which is not surprising after 18 years of sustained Conservative government attack. I hope that from this debate will come a message that we now have a strong Government committed to the rejuvenation of the National Health Service but a warning that the service is very sick because of previous wrong treatment and will take some time to improve.

I am sure that it may take some time to get rid of prescription charges, to bring back free dental treatment and spectacles and to bring back chiropody into the National Health Service. Free feet care, my Lords!

We must challenge over-treatment in the National Health Service. Many elderly people are terrified of being cared for to the extent that they will live too long in a state of complete physical and mental deterioration, locked into their frail bodies. Why should small children who are likely to die be treated by American doctors for their own personal gain? We should question such practices and find solutions to the problems they cause.

I return to my theme of the National Health Service as a major contributor to the health of our nation. Should we not have the courage of our convictions, made strong by our experience of the health service over the 50 years of its existence, and argue with our colleagues in Europe and the United States that they should follow our example and develop free health services? We have a vested interest in Europe. We are now citizens of the European Union and can travel and work freely within it. Why should we not expect the same kind of medical treatment as we receive in this country if we live and work in France, Germany, Italy or Spain? We also have a vested interest in the future of the United States. I hope that during Tony Blair's visit to Bill Clinton he may give the President advice on how to set up a national health service for the United States of America, an achievement which would surely make him one of the greatest presidents the United States has ever had.

We now live in a global village. Surely we have a right to expect the same kind of healthcare as we receive at home anywhere we travel in the globe? Surely we should recognise that every other citizen of the global village should be entitled to the same healthcare treatment as we expect and to which we are entitled? Let us set our sights high. Let us think in terms of a global health service for the 21st century.

6.35 p.m.

Viscount Bridgeman:

My Lords, I add my thanks to the noble Lord, Lord Hunt, for initiating this debate. I must declare an interest as a special trustee of the Hammersmith Hospital, a post created, I believe, by my noble friend Lord Jenkin of Roding. As such, I have the privilege to be a colleague of the noble Lord, Lord Winston.

Speakers from all sides of the House have been broadly supportive of many of the steps which the Government are taking. At the same time, we can look back over the 50 years of the National Health Service and recall some of its achievements. My noble friend Lady Gardner of Parkes, the noble Baroness, Lady Jeger, and the noble Lord, Lord Davies, all spoke about the early days of the National Health Service. It is worth recalling two assumptions made in good faith at the time of its creation but which were not in the event fulfilled.

The first was that the health of the nation would be brought up to an acceptable level and that thereafter the health service would be on a kind of care and maintenance basis. The reality is that, as facilities and treatment improved, so did people's expectations. The second, perfectly understandable, error of judgment was the failure to appreciate the enormous costs of advancing medical and related technology and of pharmaceuticals. The result is a massive problem which has confronted all successive governments of balancing the NHS budget. That point should be borne in mind in view of the remarks made by the noble Lord, Lord Davies, about my party's record over the past 17 years.

I believe that in those 17 years the previous government instituted radical developments which have changed the face of the health service and left in place a valuable legacy on which to go forward today. The first is the institution of market discipline through the Griffiths Report, leading to the introduction of purchaser/provider and the internal market. The internal market has been ruled out by the White Paper, but there must be a warning: relax the discipline and the valuable progress made over costs will be put at risk.

In his admirable speech the noble Lord, Lord Hunt, endorsed the White Paper's proposals with regard to the removal of competition, creating a team spirit at national level. More than one trust manager has said to me how much the team spirit at trust level, from consultant to porter, has increased with the creation of trusts. One has to say that this is due to the sharp tang of competition. Are we to have a team spirit, which is so important for the effectiveness of the service, at national level, trust level or both? We shall see.

Associated with this market discipline is the Patient's Charter. My noble friend Lord Butterfield talked about transparency. The significance of the Patient's Charter is that for the first time there is the assessment for all to see of performance, openly analysed, both in absolute terms and, by means of the much feared league tables, in relative terms too. Patients now have identifiable yardsticks for what their expectations should be. There can be no better way, through this totally transparent monitoring, of getting rid of managerial fat.

Nowhere can its effects be more felt than in the trusts themselves. The current trend of political appointments of non-executive trust directors must be regretted, but I am pleased to note a welcome continuity in the existing executive managements which overall are of a very high level. The reference in the White Paper to making NHS trusts more accountable sits easily with this.

I wish to make two further points. I am pleased to note that the Secretary of State has stated his intention to knock down the "Berlin wall" between the health service and care in the community. The noble Baroness, Lady Pitkeathley, spoke of her considerable experience of that matter. Having formerly been a director of a company providing both agency carers to social services and agency nurses to the National Health Service, I know the problem and I applaud his intentions. But we all wait with interest to see how the Treasury determines which way that wall will fall.

Finally, perhaps I may refer to something which is all that is best in the continuity of the health service through successive administrations. The NHS (Primary Care) Act was a creation last year of the previous government and came into force, I believe, before the general election. That will transform the primary care treatment in the community. I note that the speaker following me is the noble Lord, Lord Rea, and nobody could be better qualified to speak on that subject with its emphasis on relations with GPs in deprived areas. I am pleased to note that Mr. Alan Milburn in another place announced the creation under that Act of the first 94 personal medical service pilot schemes, predominantly in deprived areas. I am sure that from these Benches we wish them every success.

6.41 p.m.

Lord Rea:

My Lords, I am sorry to disappoint the noble Viscount. The tenor of my speech will be in a rather different direction to the one he hoped. However, I congratulate the Government on thinking carefully about the future of primary care, which occupied a large part of the White Paper.

An anniversary calls for a wide focus—a macro approach to use the words of my noble friend Lord Winston. However, I shall concentrate on a single familiar old chestnut; that is, the overall funding of the National Health Service. I shall also briefly discuss a hot potato; that is, the private finance initiative.

We have all said, and agree, that the National Health Service is highly valued by the British people, despite delays, waiting lists, inadequate maintenance of buildings and occasional mistakes—usually occurring because health workers are under such high pressure. A mark of this regard for the National Health Service is shown by the low proportion of private healthcare which the population of this country uses as compared with other countries.

The NHS has managed to keep somewhere near its founding principle of providing comprehensive treatment for all regardless of ability to pay, though it is still far from providing fully equal treatment in relation to need. However, I am delighted that the Government are determined to tackle that issue seriously and I am sorry that the Green Paper on public health was not before us this morning; this could have been looked at in more detail.

As other noble Lords have said, the NHS is extremely economical compared with other health services in the developed world, partly because it is funded from central taxation. That cuts out a raft of administrative expenses and allows a degree of budgetary control, which is the envy of many other countries. Payment of doctors by capitation in primary healthcare or salary in hospital practice rather than by item of service—the bugbear of many other health services—is another important reason why costs have not spiralled as much as they have in other countries.

A recent British Medical Association report from its Health Policy and Economic Research Unit, published in October, puts the UK 19th out of the 23 richest countries in the proportion of its GNP spent on health. If we were to come into line with the average expenditure on health in the OECD, our health costs would have to rise by around £7 billion or £8 billion a year. However, a sum as large as that would not be necessary to achieve comparable levels of care because of the higher efficiency of the National Health Service. Even now the standard of clinical care in the National Health Service is as high as anywhere.

But stressful working conditions are taking their toll. The staff of the National Health Service—medical, paramedical and nursing—are all under pressure and many supporting staff are poorly paid, particularly since contracting out was widely applied. A generous increase in funding for the National Health Service of, say, £3 billion to £4 billion annually over and above current funding plans would not be unreasonable as a step towards the OECD average. In the long term there is a good argument for the proportion of national income devoted to healthcare to continue to rise, and not only for the three usual reasons—demography, increasing technology and high expectations. As the productivity of industry improves, the proportion of the population in productive work decreases. That has been on-going for the past 25 years or more, accentuated by globalisation. At the same time the number in service occupations or who are unemployed increases.

Welfare-to-work and the new deal for single mothers are admirable projects, but they constitute "supply side economics" preparing people for work but not creating jobs. The National Health Service is a labour intensive industry—a point made by the noble Baroness, Lady Emerton. There is a limit to improving productivity in the caring business through efficiency savings, though all National Health Service activities must continue to be carefully audited and scrutinised. The new White Paper on assessment, A National Framework for Assessing Performance, is to be welcomed. It was published around two weeks ago. However, I have some detailed criticisms of it about which perhaps I can talk to the noble Baroness quietly at some other time.

To come back to the labour intensive industry outlook, in nearly all healthcare a one-to-one patient to carer relationship is the rule. There is now a pressing need for more hands on deck. There is also a great backlog of maintenance on buildings and a need for many new buildings, so a properly funded National Health Service could indirectly also help to support the construction industry. I realise that that cannot occur while the current spending freeze is in operation, but I am an optimist and feel that the Chancellor of the Exchequer and the Prime Minister may yet undergo at least a partial Keynesian conversion from the monetarist stance to which they seem so wedded at the moment.

An injection of a sizeable sum of additional money into the health service could act as a mini New Deal in Rooseveltian terms. It could create real jobs which would reduce unemployment at the same time as giving the National Health Service a much needed boost. In fact, much of the money would not be lost to the economy since a large slice of it would be recycled, thus creating further employment and also contributing to tax revenue. Already the PSBR is much lower than it was last year, so the funds could be found if the will was there. A spin-off gain would be a reduction in the welfare bill and probably a reduction in crime, much of which is related to unemployment. Crime would fall still further of course if a much more liberal drugs policy were to be followed, but that is another story.

The BMA report that I mentioned details the problems that other methods of funding which have been floated—other than that of direct taxation—would bring, such as various charges or health insurance schemes. I do not have the time to go into the detail of those, though it is an interesting area.

Now we are seeing a new and rather unwelcome method of meeting capital costs for the National Health Service—the private finance initiative. My noble friend knows that I and many others, including the British Medical Association, are highly critical of this process. Its main advantage is that it uses capital from outside the National Health Service budget and does not increase the PSBR. That means that in the short term at least it is an attractive proposition. But private capital always requires a shorter pay-back period and higher interest—up to 15 per cent., I gather—than capital raised by government through the financial markets, with the result that future generations will have to shoulder additional costs. As well as this there are high costs and huge delays involved in drawing up PFI contracts, and in all cases so far the number of beds proposed in PFI financed hospitals is considerably lower than those projected by healthcare planners.

In conclusion, I should like to ask my noble friend the following question, of which I have given her notice. Will she look at an alternative scheme to the PFI which was suggested by Professor Harry Keen and colleagues in a letter to the BMJ on 13th December last year? They propose the issuing of National Health Service bonds to finance capital projects instead of the PFI, which they suggest stands for "Profiting from Illness". These bonds would have government backing, and so would be an attractive investment not only for private individuals but for large investors such as pension funds. They would command a much lower rate of return than PFI schemes—paid by the Treasury through the National Health Service but giving a very much better bargain for the taxpayer—and the management of the hospital would remain entirely in National Health Service hands. The authors say: Objections that NHS bonds would contribute to the PSBR and offend against the Maastricht criteria—are questionable. Borrowing for social investment can be excluded from the ratio of general government debt to GDP and the public acquires a capital asset". That sounds entirely reasonable to me, especially as the PSBR is coming down anyway.

I should be very grateful if my noble friend would give her preliminary comments on this suggestion. It seems such a sensible plan that I hope very much that she can persuade her right honourable friend the Secretary of State to discuss it with the Chancellor of the Exchequer. If Treasury rules cause the taxpayer and the National Health Service to pay more and at the same time cause it to lose control of hospital planning and management, they must surely be bad rules and should be reconsidered—reconsidered, I suggest, as soon as possible—before the National Health Service is saddled with too many PFI millstones around its neck.

6.53 p.m.

Lord Bruce of Donington:

My Lords, it does not seem half a century ago since I was sitting roughly in the position at present occupied by the noble Earl, Lord Howe. I should like to take this opportunity to reiterate my admiration for Aneurin Bevan, who was one of the greatest statesmen of this century and, indeed, as the Prime Minister recently indicated, one of its greatest administrators.

Perhaps I may be forgiven for imagining what he would say in this debate this afternoon if he were reconstituted today and sitting on the Government Benches. He would of course well remember my noble friend Lady Jeger, who was one of his doughty supporters through the days and nights we sat trying to get the National Health Service Act through, despite opposition which went a little further than the conventional duties of an opposition to oppose. I think also that he would have regarded the speech of my noble friend Lord Davies of Coity as being an effective response to what I thought was a speech from the noble Lord, Lord Jenkin of Roding, that fell rather below his normal standard. However, he would have well appreciated the remarks that fell from the lips of the noble Lords, Lord Colwyn and Lord Butterfield. But, above all, he would have liked to congratulate my noble friend Lord Hunt on what I think he would have acknowledged was a masterly presentation of future government plans in connection with the health service. He would also have expressed his complete confidence in my noble friend Lady Jay of Paddington.

The matter would have ended with those pleasantries and he would have been left to examine in his own mind just what had happened to the basic principles upon which the health service was founded. Noble Lords will recall the original principle that the costs of the National Health Service should be borne out of general taxation. Nye gave a very good reason for that. He said that he did not want the poor to be disadvantaged and he did not want the rich to be advantaged. That seemed to be an amiable, delicate and indeed democratic way of providing for the finances. But that has not happened. What has really happened is that there have been some severe constraints on the expenditure of the National Health Service which have involved a breach of the original principle that it should be based on need rather than means.

Progressively, particularly in the early 1980s and onwards, that principle has been chipped away and people requiring the services of the National Health Service have had to pay out of their own pockets for services that originally were encompassed within the service as a whole. A reason has been given for that and there is a danger, unless we challenge it, that it will pass into folklore. We have been told that, for some reason or other, mainly constriction of funds, a ceiling must be set on expenditure on the National Health Service; in other words, it has to be capped. To some extent it has already been capped by the non-provision of services or their indefinite postponement, sometimes for up to two years. The concept is that our finances are in such a position, even after the allegedly 18 prosperous years of Tory rule, that we cannot afford to do anything else but to cap social services expenditure generally and health service provision in particular.

The assumption is that healthcare will need to be rationed, that something has to give and that expenditure will have to be capped. That is a complete load of nonsense. If we make comparisons with other countries, we are easily able to dispense with that assumption. France disposes of some 7 per cent. of her gross domestic product on her health service. The United Kingdom spends 5.6 per cent. of its gross domestic product. Those figures yields £69.1 billion per annum in the case of France and £41.1 billion in the case of the United Kingdom. On a crude basis that means that France spends £28 billion more per annum on her health service than we do on ours. However, there are differences in the gross domestic product levels and slight differences in the populations. If one makes allowances for the differences in gross domestic product it will be found that in France the figure is £51.4 billion per annum as against £41.1 billion in the United Kingdom. On a comparable basis £10 billion more is spent in France.

What accounts for the difference? Surely, it is merely the allocation of funds, because if France can afford total expenditure, which accomplishes so much for the health service, then certainly so should we. The answer is that we have our priorities wrong. There is no reason whatever why expenditure on our health service should not be allowed to rise. There is no need for it to rise to the extent of £10 billion per annum, which is the comparable difference between ourselves and France, but it could be of such a magnitude as to enable the satisfactory operation of the scheme itself. I invite consideration to be given to that. I invite and challenge arguments to the contrary based on the total resources available.

Another thing that I believe Aneurin Bevan would have observed, had he been here—he would have put it in more eloquent terms than I could possibly muster for the occasion—is that the health of the nation and the National Health Service are not merely—I do not use the term "merely" in any derogatory sense—the sole hunting ground or responsibility of the Department of Health itself. It is responsible for the delivery. But the rest of the Government, the departments and Ministers also have their parts to play in order that the policies to be carried out by the Department of Health can be adequately financed.

The Treasury can abandon—at any rate, for the time being, but I hope, permanently—its deflationary policies which result in the creation and maintenance of an unsatisfactory level of unemployment. All those factors, including unemployment, stress at work, fear and insecurity, at present are the lot of millions of our countrymen. They all contribute to extra expenditure on the National Health Service. If the entire Government were to co-operate and attend to those factors which, environmentally or otherwise, affect the demands on the health service, that would lead to a reduction in crime and drug-taking and in people's fears, which give rise to stress diseases of all kinds. All these factors impact on the cost of the health service. Nye would say that the responsibility therefore was for government as a whole.

He would also say that the people are responsible and that there has to be a change of mind among them so that they can be accommodated, by paying attention to duties as well as being looked after themselves. They should co-operate generally in a far more optimistic assessment of life, free from the basic evils of inequality. He would say that that would form the basis of a satisfactory National Health Service. His verdict would be that one has to trust the people. He would say that on today's showing, "Yes, I do trust the people because the people will ultimately force it to happen".

7.4 p.m.

Baroness Robson of Kiddington:

My Lords, I too thank the noble Lord, Lord Hunt, for introducing this debate today. We have listened to 24 speeches, all of which have had important points to make. As a result it is almost impossible to find something that has not already been said. Therefore, I am likely to be slightly repetitious here and there. The number of speakers who have taken part today and the speeches which have been made, cannot leave anyone in any doubt as to the importance all sides of the House believe the National Health Service to have for the future of this country.

It is true that the NHS is probably the best loved and most highly regarded of all public services in the country. It is seen by all the British people as something of which we as a nation can be justly proud. I do not know of any other country that has as comprehensive a health service as we have. I was born in Sweden, which for years had the glory of being pointed out as having the best health and social service, and everything else, in the world. Sweden's service has always been and still is very good, though it is going through the same problems as the health service of this country. But it never had something which is the most important and fundamental part of the health service here—that is, a complete general practitioner service in which every individual can be registered with a doctor. That never existed in Sweden and it was always a lack. However, having watched what has happened in this country, Sweden has, after years, finally begun to establish such a system.

When the National Health Service was established in 1948 Aneurin Bevan achieved personal immortality. It has been referred to particularly by the noble Lord, Lord Bruce of Donington. I enjoyed listening to his ideas on how Aneurin Bevan would have reacted to this debate today. But it must not be forgotten that it was due to that great Liberal, Lord Beveridge, and his report that the basis for establishing the social service was there already. The leading principle of the Beveridge report was that social insurance should be treated as only one part of social progress. Its aim to fully develop and provide income security was an attack on want. But there was more to it than that. There were other evils that had to be attacked. They were disease, ignorance, squalor and idleness.

The development of the NHS was perhaps the most beneficial reform ever enacted in Britain because it relieved people of the terrible worry of not being able to afford to look after their children or their relatives. The White Paper that was published in 1944 stated that everybody, irrespective of means, age, sex or occupation should have equal access to up-to-date medical and allied services. It stated something else which I find very important. It said that the service should be comprehensive, free of charge and that the service should promote good health rather than simply preventing ill health. It was therefore with great interest that I listened to my noble friend Lord Alderdice talking about the responsibilities that we ourselves must accept for part of the health service. We have responsibilities, too. I equally enjoyed listening to the noble Baroness Lady Young of Old Scone, who made very much the same point. Those were the founding principles. Like those everywhere else in the House, we on these Benches accept them as the basis for what we want to achieve.

Some of the matters with which I want to deal have already been covered to a certain extent, but at the moment I am particularly worried by the staff shortages in the NHS and by the lowering of morale. That is partly due to the public sector pay awards that have recently been announced. Although the Government accepted the recommendations of the review, to stagger the pay award, particularly to nurses, by paying only 2 per cent. in the first phase with the rest in December, means that the pay increase will not be the 3.9 per cent. which was promised for the year. I believe that that is wrong in principle. The nurses, who are the backbone of the NHS, deserve better treatment.

It is frightening to read the report from the Royal College of Nursing which states that there is a shortage of 8,000 nurses in the country and that that shortage is growing. What worried me most about the report was that it showed that this year, for the first time ever, there has been a shortfall in the number of applications for nurse education places in England. In 1993–94 there were 18,100 applications for 12,000 places. In 1996–97 there were only 15,400 applications for over 16,100 places. In other words, we are not filling nurse education places although we have increased the capacity of our nursing schools.

There is another problem relating to the recruitment crisis. I refer to the fact that up to about 25 per cent. of NHS nurses will be eligible for retirement by the year 2001. We are not only short in terms of recruitment, but we are losing nurses through retirement. There is also a high drop-out rate.

Why are there such difficulties in recruiting nurses? I believe that it is because the Government have made statements about the importance of the nursing profession to the NHS yet, as a result of the pay award, nurses feel let down by the Government.

Another matter which greatly concerns me is that there is a shortage not only of nurses but also of about 1,600 hospital doctors and about 900 GPs. I said at the beginning of my speech that the GP service in this country is the backbone of the NHS. As we already have a shortage of GPs and we are looking forward to a much more community-based service, in which GPs will be even more important than in the past, we are in trouble. I should like the Government to tell us how they hope to deal with those problems.

Another matter which concerns me particularly on this 50th anniversary of the NHS—other noble Lords have mentioned this—is the inequitable access to treatment across the nation. Access to treatment has always been inequitable. There have been attempts to put that right, but they have not achieved what we had hoped. Now that there is a funding shortage in the NHS, we are having to resort to rationing. There has always been rationing to a certain extent, but it is the fact that the rationing is inequitable across the nation that threatens and undermines the founding principles of the NHS. We believe that only an increase in funding to a GDP level that is more in line with those of other European countries will bring rationing to an end. Many noble Lords have mentioned this point.

Reference has already been made to the BBC's survey into public attitudes to the NHS, which showed that 63 per cent. of people said that they would pay an extra 2p in the pound in income tax if they could be certain that it would go to the NHS. I believe the noble Lord, Lord Bruce of Donington, and others who have said that we can afford to increase the funding to the NHS, but, even if we could not afford that, the nation—the people—want the funding to be increased and they have said that they are prepared to pay for it. We must look forward to greater funding for the NHS.

However, it is not only a question of funding. Not only does the NHS have to be funded, but that funding has to be evenly distributed across the country and across the various services. I am not sure which noble Lord referred to the private finance initiative—

Noble Lords:


Baroness Robson of Kiddington:

My Lords, I am sorry. I shall not be able to refer to the PFI. I am too late. I do not have enough time, but I should like to put forward a proposition before sitting down. To avoid this kicking backwards and forwards between the political parties about the future of the NHS and what should be done, I think that we should set up a standing conference on the future of the NHS. That forum could comprise patients, professionals, practitioners and politicians. It should conduct an ongoing debate on the NHS so that there will be no more drastic changes. The NHS would then develop slowly because it would always be under consideration. We would not hear so many frightening stories about underfunding or about the neglect of NHS staff. It would be an honest attempt to put the NHS beyond a state of permanent crisis. My colleagues in another place have already spoken to patients and professionals and have secured their involvement. What is needed now is the commitment of those in this place. On its 50th anniversary, we could give no better present to the NHS.

7.18 p.m.

Earl Howe:

My Lords, from these Benches I should like to express my gratitude to the noble Lord, Lord Hunt of Kings Heath, for initiating this debate. I am delighted that he has done so and I hope that he will feel, as I certainly do, that the quality of the contributions today from all sides of the House has done justice to the terms and the spirit of his Motion. I add my congratulations to my noble friend Lady Knight of Collingtree on an excellent and sparkling maiden speech.

As is appropriate on an anniversary, today we have had a mixture of celebration, reflection, and looking forward. I should like to follow suit by indulging in a little more of each. I am also pleased that, with only a few exceptions, the debate has been free from the intrusion of party political carping upon a theme which for most noble Lords rises above such considerations. The heartening aspect of those in this House and Members of another place who are close to the National Health Service and care passionately about it is that they are a living rebuttal to the rather cynical observation in one of John Galsworthy's novels that idealism increases in direct proportion to one's distance from the problem.

Looking back over the 50 years of the NHS, we can point to some of the more obvious markers of its success in terms of the nation's health and well-being: the vast improvement in perinatal mortality; the mass immunisation programme introduced after the war, which has continued ever since; the huge improvement in dental health, as my noble friend Lady Gardner has reminded the House; the female cancer screening programmes of more recent years and, perhaps above all, the dedication and professionalism of the men and women of the NHS, who over the years have delivered a standard of care that I believe is second to none in the world.

As my noble friend Lord Colwyn has said, those 50 years have also witnessed in parallel a vast improvement in the nation's standard of living. As we are only too well aware from observation of countries in the third world, better housing and sanitation, better food and nutrition and better air and water quality all make an important contribution to the standard of public health. But none of that diminishes the achievement of the NHS. The achievement is more than simply medical, clinical or political. A while ago the noble Baroness, Lady Hayman, said in a debate that the NHS was the nearest we came to institutionalising altruism in this country. I agree with her. It is that cultural achievement, and the NHS ethic that underpins it, of which we can be particularly proud. Its influence is felt throughout the world wherever there are doctors who have come to the United Kingdom to train or study.

Noble Lords have also referred to the seemingly perpetual tension in the NHS between demand and resources. The NHS has never had more resources than it has today, yet the tension is no less apparent than it was in 1948. The reasons for that have been well rehearsed in this debate, not least by the noble Lord, Lord Hunt. Unless a certain amount of such tension existed there would be little if any incentive to perpetuate that other signal virtue for which the NHS can take credit: its cost effectiveness. That is a quality which no government can afford to downplay.

If we look back as little as seven years to the time when the previous government's reforms were introduced, it is significant for all the present Government's criticisms of those measures that the number of NHS treatments carried out each year has gone up during that period by more than one third. Compared with 20 years ago the figure is 80 per cent. higher. Over the past 10 years the number of patients waiting for over a year for hospital treatment has been cut by over 90 per cent. Eighteen-month waits had almost disappeared by the time of the last election. There are now 55,000 more qualified nurses and midwives than in 1979. The pay of NHS staff is higher than ever. Capital spending has increased by two-thirds in real terms since 1979.

How has all that been achieved? Contrary to what was said by the noble Lord, Lord Davies, the proportion of GDP spent on the NHS during the time when my noble friend Lady Thatcher was Prime Minister rose from 4.7 per cent. in 1978–79 to 6 per cent. in 1992–93. It is now 75 per cent. higher in real terms than it was 20 years ago. However, the improvements I have listed do not reflect simply a much higher health budget but much greater efficiency as well. That process needs to continue if the budgetary cake is to satisfy those who slice it. When I see, as I did yesterday, the Department of Health disguising itself briefly as the Department for Culture, Media and Sport in its decision to keep open Bart's


I am slightly fearful that Ministers are not focusing on the taxpayer and the patient quite as closely as they should.

This brings me to the future. Before Christmas the Government unveiled a major White Paper setting out their plans for the NHS over the longer term. I said at the time of the announcement that the proposals were well intentioned and bold. I stand by those words. There is much in the White Paper to be applauded, not least the recognition that the health service should be primary care-led and the purchaser/provider split should be retained so that purchasers have the freedom to make choices for patients. All that is good. But the package as a whole looks very prescriptive. We must be careful that, in creating large primary care groups—effectively, a compulsory broadening of fund-holding—we also create the necessary drivers for efficiency to ensure maximum value for money. I very much echo the sentiments of my noble friend Lord Bridgeman in this context. I believe there is a danger that the flexibility of the present structures may be lost in these changes, that the process of decision-making may become unwieldy and that accountability will be less clear than it should ideally be.

These matters bear directly upon the quality and quantity of care delivered to the patient, on which the Government have rightly laid strong emphasis. The NHS needs to be well managed. I very much agree with the noble Baroness, Lady Young of Old Scone, that while we are all in favour of ditching unnecessary bureaucracy we must recognise that for many years the NHS was if anything under-managed. There is a balance to be struck, and I wish the Government well in their search for that balance.

As we celebrate at this anniversary and look ahead, the challenges facing the NHS are not hard to discern: waiting lists, long-term care, care of the elderly, more expensive treatments, the need to recruit and retain doctors and nurses and, as the noble Lord, Lord Winston, reminded us, the need to sustain academic medicine. All of these are bound to intensify the pressure on resources. Noble Lords have mentioned a number of others. Much as we may feel like congratulating ourselves on the welcome reduction in mortality from the most serious diseases over the past few years—coronary heart disease, breast cancer, lung cancer and strokes—the prevalence of those conditions does not always bear happy comparison with corresponding figures in other European and OECD countries. The incidence of certain chronic conditions such as diabetes is rising. Clearly, there is work to be done in both treatment and disease prevention if the targets set out in the previous government's White PaperHealth of the Nation are to be achieved. I hope that the present Government subscribe broadly to those targets.

In common with the noble Lord, Lord Hunt. I believe that the NHS has a sound future. It will survive as it always has through its ability to adapt to change and to do so within the budget that Parliament gives it. There is no need to talk in terms of rationing care so long as efficiency is maintained and we are realistic about what the size of the NHS budget should be and how much of it the taxpayer, the patient and private finance should each contribute.

If there is one thread that has run consistently through this debate it is the shared vision of the kind of service that the NHS should provide. I believe that that should give us all encouragement, because no matter what problems face the NHS it indicates that there will always be a will to overcome them. It also shows that the principles underlying the service are not the property of any one political party.

The Government may expect questioning and criticism from this side of the House as their stewardship of the health service continues, but it is also right that the Official Opposition should support Ministers when such support is justified. That selective approach will, I hope, conduce to the greater good of an institution which, perhaps more than any other, is part of the fundamental fabric of our lives.

7.30 p.m.

The Minister of State, Department of Health (Baroness Jay of Paddington):

My Lords, I am pleased to be able to echo the noble Earl's final sentiments. This has been a powerful and wise debate. As always in your Lordships' House, discussion of the NHS has been illuminated by deep personal knowledge and experience which have been reflected in speakers' contributions. No one is more knowledgeable or experienced than my noble friend Lord Hunt of Kings Heath. I am especially grateful to him for his fascinating overview and clear analysis of the past, present and future.

As I said, this has been a wise, intellectually rigorous, and wide-ranging debate, but it has also been, in the best sense, an historically emotional one. We heard personal testimony of how the health service has affected everyone's lives in the past half century. I pay particular tribute to the speeches of my noble friends Lord Bruce of D ington, Lord Prys-Davies and Lady Jeger in that respe. Their memories and observations told us much about he hopes and principles upon which the NHS was built by the post-War Labour government. I confirm that those are the principles upon which those of us who are in government today are determined to build again.

Perhaps I may also congratulate the noble Baroness, Lady Knight of Collingtree, on her maiden speech. Although she was a maiden speaker in this House, she has a long and distinguished record in another place to which I am sure she will add here. I was especially pleased to hear her comments on the dignity of patients. That is a subject to which my colleagues and I give priority. There were many other speeches of equal value. I hope that noble Lords will understand if I cannot, in this time-limited debate, respond to every point. If any noble Lord feels that I have missed an important point, I shall of course be delighted to write to him or to her, or to discuss any matter outside the Chamber.

Although mine is a concluding contribution, I still believe that it is worth while going back to the beginning and the words of Aneurin Bevan when introducing the 1948 Act. The then Minister for Health said: I believe it will lift the shadow from millions of homes. It will keep many people alive who might otherwise be dead. It will produce higher standards for the medical profession. It will be a great contribution towards the wellbeing of the common people of Great Britain".—[Official Report, Commons. 30/4/46; col. 43.] To what extent has that faith of Aneurin Bevan been justified? Life expectancy has improved since 1948 by about eight years for both men and women. The perinatal mortality rate, which has already been mentioned, in 1995 was less than a quarter of that between 1946 and 1950. For the same period, the infant mortality rate dropped by nearly 82 per cent. The death rate for children aged one to four years is now less than 17 per cent. of what it was in 1948.

Although the main cause of death remains what it was in 1948—that is, heart and other circulatory disease—we are much less likely to die of respiratory diseases—for example. tuberculosis. As my noble friend Lord Winston rightly emphasised, many of those changes have been due to the close collaboration of science, academic medicine and the NHS. It is a collaboration which, like my noble friend, I hope will be as vigorous and productive in the next 50 years as it has in the last.

Of course neither the NHS nor the scientific community can take all the credit for the health improvements in the past 50 years. Other social factors, such as improved housing, social security and education, have played a significant part. I am pleased that my noble friend Lord Bruce of Donington laid great stress on the cross-government responsibility for health in that context.

Today we must re-emphasise the social factors involved in health: poverty, unemployment, bad housing, social isolation, pollution, ethnic minority status and gender have, for too long, been regarded as somewhat peripheral to health policy. I am delighted to tell the noble Lord. Lord Colwyn, and other noble Lords who spoke about it, that that is about to change because tomorrow we shall be launching a Green Paper on common health strategy, Our Healthier Nation. The themes of that strategy will be broader, social and economic determinants of health. The strategy will focus upon the stark health inequalities which still divide our citizens, three generations after the introduction of the health service.

We need to expand community responsibility for a broad approach to the choices and priorities involved in reducing health inequalities. I am grateful to the right reverend Prelate, the noble Lord, Lord Alderdice, and my noble friend Lady Young for emphasising that point.

It is obvious that, wherever a broad approach may take us, the NHS will always have a key role, not just in treating ill health but in preventing it. Many speakers today have rightly concentrated upon the White Paper, The New NHS, which represents a milestone for the health service. For too long many people have told us that the NHS is in an inevitable state of decline, unable to cope with the pressures facing it, and that rationing and charging are inevitable. It was interesting that that charge today came most loudly from the Liberal Democrat Benches. The Government reject that view, and so, as I understand it from the noble Earl, do the official Opposition.

The orderly management of decline is not part of our agenda for the NHS or for Britain. Our White Paper is a vote of confidence in the ability of the NHS not just to survive as a universal comprehensive service, funded from general taxation, providing care on the basis of need, but to prosper as well. It is true that if the NHS is to survive in that form in the future it has to change. We do not want change for change's sake. We want to change the NHS for the better. So in the White Paper we have set out an ambitious and far-reaching programme of modernisation.

In his introduction to the White Paper, the Prime Minister said that creating the NHS was the greatest act of modernisation undertaken by the post-War Labour government. It is now our task to modernise it for the 21st century. The task is to build a health service which is modern and dependable. We shall need to get right the funding. We have already put large extra sums into the NHS. We are committed to raising spending in real terms every year.

I am grateful to my noble friend Lord Rea for his imaginative idea of NHS bonds. I understand that the authors of that idea have already met the Secretary of State, and have been invited to have discussions on that subject with officials. I cannot of course foresee the outcome of those discussions, but I can assure my noble friend that there will be more public investment.

With that money will come a responsibility within the service to change: to produce better treatment when patients need it, and to guarantee them excellence. The White Paper gives patients a guarantee of excellence. To achieve that we need to raise standards throughout the health service. Let there be no misunderstanding about that. This Government are as committed to raising standards in the health service as they are in education. To achieve high standards however we need to get the best out of the resources available to us. We want to set and raise standards for efficiency as well as for quality. We believe that the two go together.

There is no denying, as many noble Lords have said, the achievements of the NHS over the past 50 years. It has helped banish the general fear of becoming ill. But today the service needs to become better attuned to the needs of the individual patient. Only recently the Audit Commission reported that almost half of women were not completely happy with the care they received during and after pregnancy. The survey also found significant variations in standards around the country. In other areas, emergency readmissions to hospital are 70 per cent. higher in one area than in another. Unit costs in one hospital may be four times higher than in another.

There is that kind of variation which is both wasteful and unfair. Of course, equally high standards cannot be achieved overnight. No one would believe us if we said that they could. However we believe that patients have the right to see demonstrable improvements every year. That is what the White Paper promises—a 10-year programme of modernisation making the NHS better every year.

I am grateful to the several noble Lords who commended the evolutionary methods that the White Paper proposes. We have to change from the old models because they fail to deliver the goods. The previous government told us that the internal market—competition—would drive up performance. But competition is not the answer for the National Health Service. Nor is the return to the old centralised command and control system of the 1970s. There are one million staff, a large range of professions and a large variety of organisations. I am delighted to agree with the noble Lord, Lord Jenkin of Roding, that we cannot possibly manage the NHS on a day-to-day basis from Whitehall. Experience tells us that improving the NHS means finding the right incentives as well as issuing the right instructions.

There must be local ownership of the process of change. That is why we will keep what has worked in the current system, and we believe that one of those is devolution of responsibility. I respectfully say to the noble Viscount, Lord Bridgeman, that it is local responsibility rather than local competition which we believe will improve the sense of local ownership.

It is already well understood that by giving the NHS trusts control over key decisions they can improve their local services for their patients. However, for too long their sole statutory responsibility has been to balance their books. That financial duty will remain—I wish to reassure noble Lords who believe that the financial strictures will disappear—but, for the first time, in addition NHS trusts will also have a statutory responsibility for quality. Every trust will have to introduce clinical governance arrangements to ensure that quality is at the heart of the organisation and at the heart of each and every one of its clinical teams. We want to see greater devolution of financial responsibility to clinical teams within NHS trusts. We want to see hospital doctors helping to shape change rather than feeling that they are the victims of it. That is why they will have a key role to play in agreeing long-term service level agreements which will focus on quality as well as cost and we hope that they will be working together with family doctors and community nurses.

The GP and the community nurse will be in the driving seat of the new primary care system. After all, they are usually the first port of call for the patients and probably best understand their needs. It is right, then, that the new primary care groups will combine clinical responsibility with financial responsibility. They will be expected to reach agreement for high quality, efficient services. These may, for example, be organised around a particular care group, such as children, or a special disease area, such as heart disease. They will be linked to new national service frameworks. We believe that this is what the clinicians want, what the nurses want, what those people working on the front line want and we are sure that it is what the patients want; that is, a more integrated form of care where the individual patient is no longer passed from pillar to post but where the health and social care system is shaped around the needs of the individual.

The White Paper sets out a system which devolves responsibility for improving the standards clinically and financially to those who are working on the front line. Devolution of responsibility will be matched with accountability for performance. This is obviously crucial because the NHS is a public service—taxpayers have the right to see their cash spent wisely—and it is a national service where patients have the right to expect clear national standards and the consistency of care which so many noble Lords emphasised tonight.

The new NHS will have clear lines of accountability. It will also have a clear framework for judging the performance of every part of the service. The new performance framework, which has been mentioned today, was published for consultation on 21st January. It signals to the public and to all those working in the NHS where and how we want to raise standards. The old efficiency index failed to reflect what is important in the NHS, but we want the new performance framework to deal with what we believe really matters.

We are suggesting six areas which together could give a rounded assessment of performance and the kind of indicators which might deliver that information. The first is in general health improvement. That would cover the overall health status of the population. The second is in fair access. The third is in the effective delivery of care. We might want, for example, to look at whether the right surgery has been provided or how we are managing chronic conditions such as asthma or diabetes. The fourth is efficiency. We need to make absolutely sure that we maximise the use of all our resources. The fifth, which is important and has been mentioned by several speakers, is that we need to judge performance by the experience of patients and carers of the NHS. We want to find out whether patients and carers feel that they are receiving an effective service. The sixth will be health outcomes of NHS care. We are already piloting some clinical indicators to try to judge success. This is the consultation document and we look forward to hearing the views of those who are working in the service. I look forward in particular to a quiet discussion with my noble friend Lord Rea, who has indicated his concerns in this area but does not want to talk about them today.

We believe that those goals are in line with the fundamental principles on which the NHS was created. The methods we are using may properly owe a great deal to modern business management and the advantages we can gain from the use of information technology. However, the values they represent are immutable. As regards information technology, I thank my noble friend Lord Winston for his imaginative vision of the way in which the expansion of information technology within the general area of healthcare could provide such a wonderful contribution to improving services. I hope that we can explore and develop that as we go forward with the modernisation programme.

There is another factor in the new NHS which is essential to raising standards. It involves patients in providing planning services. Their views—after all, our views—should become a key to measuring performance. I am grateful to my noble friend Lady Pitkeathley, for emphasising that and, in particular, for drawing your Lordships' attention to the new national patients' survey which the Government will conduct for the first time later this year.

It is interesting that currently there is no systematic means of assessing patient experience. The new national survey will operate at both health authority and national level and it is likely to involve a substantial number of patients in order to gain an accurate picture. The results will be published locally and nationally in order to allow comparisons between areas and to measure performance over time. Where, in the views of patients, there is conspicuous or continual under-achievement of local health services we expect that to prompt NHS trusts, health authorities and primary care groups to sort out the problem. Failure is not going to be tolerated. For example, the new commission for health improvement will be able to intervene on the direction of the Secretary of State or by invitation from primary care groups, health authorities and National Health Service trusts. In these instances, the commission will be empowered both to investigate and identify the source of the problem.

However, trouble-shooting will be only one aspect of the commission's role and it should intervene only as a last resort. But, potentially, the new body will be a useful tool to help services deal with the extreme cases where both managers and professionals have in the past felt some important levers and support mechanisms were missing. We can all probably think of cases where an independent source such as the commission could have played an important part in helping services to get quickly to the root of the serious clinical problem and to identify ways of resolving it. Most recently, perhaps, were the well publicised problems with cancer screening in breast services and cervical cancer screening which have occurred in different parts of the country this year. I am grateful to my noble friend Lady Gould of Potternewton for emphasising the fact that, in spite of such concerns, the use of such screening services is essential to improving women's health.

I wish to make it clear, however, partly because of the way in which the commission for health improvement has been portrayed in the media, that raising standards through this method is not about sending in heavy hit squads. It is certainly not about a witch-hunt against NHS staff. I am extremely pleased that several speakers today have emphasised the central importance and the need for the staff themselves to be involved in delivering the plans and for their concerns to be taken fully into account, as they will be the people who will deliver the new quality care for patients. After all, for 50 years it has been the staff who do the work. The staff know what can go wrong and how things can be done better. If we want to raise standards we must make sure that there is also a high quality of care and concern for the one million staff who deliver care for patients.

I heard what the noble Baroness, Lady Robson, said in relation to her concerns about the lack of nursing staff and their problems with the nature of the pay award which has been agreed recently. I simply remind her that that was the highest pay award for the past six years and that in that survey, which I agree was disturbing, about the number of nurses leaving the nursing service, pay was not mentioned among the top number of nurses' concerns.

I should like to mention too that we are extremely alarmed by the potential problems which may be caused by a lack of medical staff in particular specialties. That is why this year we have invested £766 million on nursing and PAMs education. That training includes provision for more nurse training places and £10.4 million to support recruitment and retention initiatives. A further £30 million to support those programmes has been announced for 1998–99.

I was grateful to the noble Baroness, Lady Emerton, for placing emphasis on the need for further and specific education for nurses to include them properly in their new role at management level within the primary care groups. I agree with her that that is something which needs to be observed and followed through very carefully.

In general, trusts need to treat staff as valued colleagues who work best if they are respected, listened to and have their real needs addressed. Too often, perhaps, in the past, staff have been seen as a problem, perhaps even as a threat. That is why we feel that that must change and why we recently launched a consultation on developing the first ever human resource strategy on the history of the NHS. The White Paper also underlines the importance of that agenda. I am delighted to assure my noble friends Lord Desai and Lady Amos that racism, to which they both drew attention, is high on that agenda in dealing with particular staff concerns.

I stress also to my noble friend Lady Young that the problems and interests of managers will not be ignored in the new human resources strategy.

The White Paper brings NHS trusts with their staff—their medical, nursing and management staff—into the heart of the local health economy alongside the primary care sector and the health authority. In future, NHS trusts, their clinicians and nursing staff will play an essential role in setting the new health improvement programme which will identify local health needs, healthcare requirements and investment decisions.

Of course, in return for that influence, NHS trusts would incur, as I tried to explain, considerable obligations as regards national accountability. Having helped to set the health improvement programme, they will be bound by it, like everyone else. I am sure that NHS managers would not want it to be otherwise. The importance of those managers in spearheading and concluding a lot of that work is something which we fully understand.

All of that will be spelt out in the new statutory duty of partnership when we legislate for our changes. It will go wider than the new NHS. We want it to include local authorities as well and we shall continue discussions with their representatives about how best to achieve that.

The existing duty in the 1977 Act is too widely drawn to be of much impact. We want to underline the requirement for real operational partnership, to break down those Berlin Walls to which several speakers referred. This spring, we shall be piloting 10 health action zones and they will provide an excellent test bed for better local co-operation of that kind. I should emphasise that we expect that local co-operation to develop, not simply across the statutory agencies but also in collaboration with local voluntary organisations and local private sector business.

Both locally and nationally, we want the NHS to meet the challenges of the 21st century. The White Paper sets out in detail how we shall do that. The new arrangements go with the grain of what is wanted by NHS organisations and their staff. Expectations laid on the service are challenging, requiring good leadership, good management and a positive approach to partnership. The commitment of all concerned will be needed to develop that new role and for everyone to be full participants in local health services. As I said, formal changes in duties will be introduced through legislation. But the new approach to partnership is broader than law-making. We believe that it is already developing and will continue to grow. I am grateful to the noble Baroness, Lady Masham of Ilton, for underlining the sense of local co-operation as the basic tenet of improved care.

It is a matter of great personal pride to me to be a Minister for Health today and to be part of those partnerships for improvement. I was touched when the noble Lord, Lord Bruce of Donington, said that he felt that Aneurin Bevan might have some faith in my performance. I believe that all of us in the new ministerial team charged, as we have been since last May, with improving the country's health recognise the awesome duty we have but also the awesome legacy of the past 50 years.

We believe firmly that by concentrating on what really matters—improving standards for patients and staff alike—we can create a new National Health Service which is both modern and reliable. There is no better time to start than by celebrating the 50th birthday of the health service and at the same time planning positively to take it into the new century.

7.56 p.m.

Lord Hunt of Kings Heath:

My Lords, this has been a most important, wide-ranging and, for me, emotional debate. It has brought home to me just what a privilege it has been to work in the National Health Service for 25 years. Ethos, comradeship and team work, yes, but, above all, it has been to be part of a noble, selfless and community-spirited enterprise.

I am grateful to all noble Lords who have taken part in this excellent debate. In particular, I acknowledge the maiden speech of the noble Baroness, Lady Knight of Collingtree. Her remarks about the need to remove mixed sex wards in many of our hospitals certainly struck a chord with many of your Lordships.

I pay tribute also to my noble friends Lady Jeger, Lord Bruce and Lord Prys-Davies for reminding us vividly of the history and the struggles to get the NHS into being. I thank also the Minister for the comprehensive and excellent way in which she summed up our debate.

I am left with an overwhelming sense of support for the NHS in your Lordships' House, past, present and future. We have identified many pressures and challenges which we must face and they are important issues which deserve our keen attention. But nothing I have heard today leads me to believe that we cannot meet those challenges. Nothing I have heard today leads me to believe that the NHS cannot continue to provide a comprehensive service.

I have little doubt that the future of the NHS is in good hands. Long may that continue. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.