Lords Sitting of 2 February 2000

Preamble
The House met at half-past two of the clock: The LORD CHANCELLOR on the Woolsack.
Prayers—Read by the Lord Bishop of Carlisle.

Scottish Executive: Concordats and Ministerial Committees
Lord Campbell of Croy Lord Campbell of Croy asked Her Majesty's Government:
To what extent the system of concordats and the associated ministerial committees have been used in relation to Scotland.
Baroness Ramsay of Cartvale: My Lords, the Memorandum of Understanding and the four overarching concordats were published on 1st October 1999, setting out the overall framework of working relationships after devolution. Sixteen bilateral concordats covering more detailed working arrangements between the Scottish Executive and UK government departments were published in three tranches during November and December 1999. All those concerned are now working within these frameworks. The arrangements appear to be working well.
Lord Campbell of Croy: My Lords, I am grateful to the noble Baroness for her reply and I did of course see the Government's publication in October. But is a concordat likely to be invoked over tuition fees and the present compromise whereby English students at Scottish universities and Scottish students at English universities will have to pay fees, a matter now being examined by the European Commission as well? Are the proceedings a the concordat system to be made public in the interests of transparency and freedom of information?
Baroness Ramsay of Cartvale: My Lords, the issue of tuition fees is a matter devolved to the Scottish Parliament in so far as it affects Scotland. It is in the nature of devolution that the power and the right to make these decisions goes to the Scottish Parliament and the Scottish Executive. United Kingdom Ministers and Scottish Ministers are in frequent contact on a wide range of matters and keep each other informed of policy developments, as anticipated by the Memorandum of Understanding and the various concordats. Neither the Government nor any of the devolved administrations has felt the need to call a joint ministerial committee for the purpose of resolving a dispute on either this issue or indeed on any other issue, which is why there has not been a meeting of the joint ministerial committee.
Lord Hughes of Woodside: My Lords, can my noble friend tell the House how the concordats and
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committees can actually help the Government to pursue their objectives properly? Can she say how items arrive on the agenda? Can Members in either House write to suggest items for the agenda? When does she expect the joint ministerial committee to meet?
Baroness Ramsay of Cartvale: My Lords, my noble friend has asked a variety of questions. I shall try to deal with as many of them as I can in a brief time. It has not been necessary so far to hold a meeting of the joint ministerial committee in plenary format. The JMC annexe to the Memorandum of Understanding, published in October states that it will meet at least once a year. No date has yet been arranged for that first routine meeting. However, we have already held an initial meeting of a functional JMC on poverty and will follow that up with one on the knowledge economy.
Those two committees reflect the Government's commitment to economic stability and to social justice. We should all welcome the establishment of the JMC on poverty. The Government have committed themselves to eradicating child poverty and this JMC will facilitate co-ordinated thinking and action across a range of devolved and reserved matters. As a result of measures like the working families' tax credit and the New Deal, 60,000 children in Scotland have been lifted out of poverty. That is an encouraging start and the JMC on poverty will enable us to take this much further. My noble friend asked about the agenda. It is open to any Member of either Houses to write to a Minister and suggest that this be looked at.
Lord Mackie of Benshie: My Lords, can the noble Baroness comment on the question of agriculture? That is a devolved matter but negotiations are in the hands of the United Kingdom Government. It is very important indeed that there should be close cooperation and joint efforts to persuade the Chancellor of the Exchequer to take up the money he could get out of Europe if he would pay his whack in this country. At present agriculture needs that money.
Baroness Ramsay of Cartvale: My Lords. as the noble Lord will be aware, there is a concordat with the Ministry of Agriculture, Fisheries and Food. It is up to the UK department and the departments in the devolved administrations to work out a co-ordinated policy for the benefit of the whole of the United Kingdom.
Baroness Young: My Lords, further to the supplementary question of my noble friend Lord Campbell of Croy on student fees, does the noble Baroness agree that the unbelievably confused situation which seems to have arisen as a result of the Government's policy would not have arisen had the policy that was produced in the House of Lords been accepted by the Government?
Baroness Ramsay of Cartvale: My Lords, I do not agree with the noble Baroness. I do not believe that there is confusion. The position is perfectly straightforward; the UK government policy is

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perfectly straightforward; and what is being announced in Scotland is perfectly straightforward. I see no confusion.
Lord Mackay of Ardbrecknish: My Lords, the noble Baroness told the House that there were no ministerial committee meetings on the subject of student fees. Did ministerial "meetings" take place by telephone to discuss this policy—and if not, why not? The result of the two different policies north and south of the Border has resulted in discrimination against Scottish students at English universities and against English students at Scottish universities inside what is still supposed to be one United Kingdom. Was there communication between Whitehall and Edinburgh?
Baroness Ramsay of Cartvale: My Lords, it is the noble Lord who is confused now. Of course there is communication between Whitehall and the devolved administrations. There is constant communication between UK departments and Ministers, or, in the case of the Welsh Assembly, Assembly members. Joint ministerial committee meetings would be called if there was perceived to be a problem that could not be resolved in the normal communication and activities between the two groups of officials. No issue in relation to student fees or any other matter has necessitated that.
Lord Mackay of Ardbrecknish: My Lords, did they communicate by telephone?
Baroness Ramsay of Cartvale: My Lords, the noble Lord insists on asking that question. I am sure that they did. They communicate all the time by every modern form of communication.
Lord Campbell of Croy: My Lords, will the noble Baroness answer my question as to whether the proceedings will be made public, and therefore communicated to the public?
Baroness Ramsay of Cartvale: My Lords, I am not sure which proceedings the noble Lord means. If he means joint ministerial committee meetings, of which none has taken place, those would be covered by the usual procedure and the details of minutes would not be covered. As to concordats, there are copies of all of them in the Library. They are open and transparent.

Government Special Advisers
2.44 p.m.
Lord Renton of Mount Harry Lord Renton of Mount Harry asked Her Majesty's Government:
What is the estimated total cost of the Government's special advisers in the current financial year as compared to 1996–97 and what changes there have been in their duties and responsibilities.
The Minister of State, Cabinet Office (Lord Falconer of Thoroton): My Lords, the estimated cost of special advisers in the current financial year is £4 million. That compares to £1.8 million in 1996–97. With the exception of up to three posts in the Prime Minister's office, special advisers are appointed for the purposes of providing advice to Ministers. Successive administrations have used special advisers in that way.
Lord Renton of Mount Harry: My Lords, I thank the noble and learned Lord for that Answer. However, can I take it that there has been no overall change in the duties and responsibilities of special advisers? Given that they have unparalleled access to Ministers and, apparently, a "licence to leak" on behalf of Ministers, should there not be some standard as regards their qualifications? At present, most seem to have very little experience outside either academia or Westminster. I understand that the number of special advisers at No. 10 has gone up from eight under the previous administration to 25. Surely such a huge increase with no change in duties and responsibilities must, sadly, imply a lack of confidence on the part of the Prime Minister in the advice of his senior official civil servants—for example, the Secretary of the Cabinet or his Principal Private Secretary.
Lord Falconer of Thoroton: My Lords, it certainly implies no such lack of confidence. There is no basis for such a suggestion. The Neill Committee states in its report that special advisers have a very valuable role to play. The evidence of the First Division Association, the trade union for senior civil servants, said:
"Members say that a good Special Adviser is well worth having in any department … it is also fair to say that this government has used its special advisers in a much more upfront way. A good Special Adviser is an asset in a department, both to the Minister and the Civil Service".
The special adviser helps the Minister. He helps the civil servants in the department as well by providing a useful interface between the two.
Lord Barnett: My Lords, leaving aside the party political points made by the noble Lord, Lord Renton, as my noble and learned friend has quoted the Neill Committee, do the Government agree with the committee's Recommendations 19 and 20 in its sixth report that in a proposed Civil Service Act a specific limit should be named, and that any increase beyond that limit should be subject to resolutions of both Houses?
Lord Falconer of Thoroton: My Lords, the Government have indicated that they are considering all the recommendations in the Neill Committee report. They are very serious. The report is both weighty and worth while. We need to respond in a considered way rather than piecemeal. There is no suggestion at present that the numbers of special advisers are in any sense swamping the senior Civil Service. The senior Civil Service consists of 3,500 people. Sir Richard Wilson, the Cabinet Secretary, has said:
"I do not think the senior Civil Service of 3.500 people is in any danger of being swamped by 70 special advisers".
Lord Tebbit: My Lords, does the noble and learned Lord agree that there has been an extraordinarily large increase, not only in numbers but in cost to the taxpayer. Would it not be more reasonable if some of that cost—of what are essentially partisan political activities—was borne by the Labour Party rather than the taxpayer?
Lord Falconer of Thoroton: My Lords, as the evidence of Neill Committee report states, as was suggested by the evidence given to the committee by the First Division Association, and as Sir Richard Wilson suggests, special advisers improve the quality of government. The increase in cost is approximately £2.2 million. That is money well spent.
Lord Mackay of Ardbrecknish: My Lords, has the Minister noted that in his native Edinburgh the First Minister has lost two of his three special advisers in the last two or three months? Do they come under the heading of "good special advisers" when he has managed to lose two out of three? Furthermore, why does the Secretary of State for Scotland still need two special advisers when almost all his responsibilities have been devolved to Edinburgh? Is it in order that he can continue his "tough wars" with the First Minister in Scotland?
Lord Falconer of Thoroton: My Lords, as to special advisers to the First Minister in the Scottish Parliament, I can think of no more inappropriate person than myself to answer, so I shall pass. In regard to the Secretary of State for Scotland, as I have said, special advisers contribute to good government, both in his case and in that of other Ministers.
Lord Renton of Mount Harry: My Lords, I do not deny that "a" special adviser is a good thing. I had one when I was Minister for the Arts, and when I was at the Home Office the Home Secretary had one. Why does the present Home Secretary need four or five? That is the unexplained point, particularly if there is no change in their duties or responsibilities. If I remember the recommendations of the Neill Committee correctly, did not the noble Lord give the very clear hint that in his view the presence of so many special advisers could be a cause of distress and concern to official advisers; that is, civil servants?
Lord Falconer of Thoroton: My Lords, the response of the Cabinet Secretary, Sir Richard Wilson, which I quoted, indicates that it is not a cause for concern at the moment. As to the numbers, I dealt with that point in answer to my noble friend Lord Barnett. Special advisers contribute to good government and are regarded within the Civil Service as being of value to it. I believe that the numbers are a matter of judgment.

Yugoslavia: Proceedings against UK
2.50 p.m.
Lord Lloyd of Berwick Lord Lloyd of Berwick asked Her Majesty's Government:
Whether they intend to take a preliminary objection to the jurisdiction of the International Court of Justice in the proceedings brought against the United Kingdom by the Federal Republic of Yugoslavia.
The Parliamentary Under-Secretary of State, Foreign and Commonwealth Office (Baroness Scotland of Asthal): My Lords, the Government are confident of the strength of their case should the Yugoslav application ever reach the Merits stage. We regard this case as a shameless and opportunistic abuse of the Court, whose jurisdiction was accepted by Belgrade only three days before launching its application. The UK has substantial legal arguments for resisting the Federal Republic of Yugoslavia's application at the preliminary stage.
Lord Lloyd of Berwick: My Lords, I thank the noble Baroness for her Answer. I accept that there is a view among some international lawyers that the use of force is justified to avert humanitarian catastrophes, despite the clear language of Article 2 of the charter. Does the noble Baroness agree that there is also a great deal of authority the other way? Therefore, since the point is obviously one of major importance for the future of the United Nations, is it not better to let the International Court of Justice decide the point in issue—that is what it is there for—to affirm the existence of the so-called humanitarian exception, perhaps with the assistance of the Attorney-General and, above all, define the limits of the exception rather than take what I continue to regard as a thoroughly technical objection to the jurisdiction of the Court, which can only delay a decision on the merits?
Baroness Scotland of Asthal: My Lords, first, I understand the import of what the noble and learned Lord says in relation to this issue. However, the Federal Republic of Yugoslavia's case is a propaganda measure. It accepted the Court's jurisdiction only three days before it launched its application and seeks to deflect the blame by suggesting that NATO has responsibility for what happened in Kosovo. Milosevic is clearly responsible and has been indicted. We are confident that we have a strong legal case and will fight the Yugoslav case on its merits if we have to. We have a strong and substantial argument on jurisdiction and admissibility. If we have to send a clear message it must be that people like Milosevic cannot seek to take adventitious advantage of the procedure, which is precisely what he seeks to do in this case. We cannot let him get away with it.
Lord Lamont of Lerwick: My Lords, is it not the case that when Yugoslavia lodged its case on 29th April of last year and Mr John Morris appeared before the

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court he and his team argued purely on the grounds of a technicality, thus depriving public opinion in this country, and the world, of a definitive ruling on whether NATO's action was or was not within international law? If the Government have a good case, why do they not allow it to be judged by the court?
Baroness Scotland of Asthal: My Lords, the noble Lord is completely wrong in relation to this matter. The issue before the Court was a preliminary matter. As one knows, when dealing with a preliminary matter one should stick to the point. We did so and answered the point, and the Court found in our favour.
Lord Richard: My Lords, will my noble friend resist the blandishments of the noble and learned Lord, Lord Lloyd of Berwick, and the noble Lord, Lord Lamont, who appear to argue that this is essentially a legal and not a political matter? Can she confirm that the Government regard the setting of international limits on the doctrine of overwhelming humanitarian necessity to justify an intervention essentially as a political matter, which will have to be discussed in great detail among the various countries which are the prime movers in the United Nations? Can my noble friend tell the House whether such discussions are under way; if not, when does she hope that they will begin?
Baroness Scotland of Asthal: My Lords, the international discussions are incredibly important, and Britain is doing all that she can to raise these issues. Discussion is already taking place with our international partners and will continue to be pursued later in the spring.
Baroness Williams of Crosby: My Lords, the Minister will recall her eloquent defence of NATO in last night's debate. As to the jurisdiction of the International Criminal Court, can she tell the House something about the need to pursue war criminals in a situation where, in the absence of such steps and evidence, there is too great a tendency for people in Kosovo to take the law into their own hands?
Baroness Scotland of Asthal: My Lords, I certainly confirm what the noble Baroness says. It is important that these matters are taken seriously. We have played our part in identifying those who have committed crimes, and we have been, and will continue to be, supportive in pursuing those matters. This is a matter that the Government take very seriously. As always, there is much good sense in what the noble Baroness says.
Lord Chalfont: My Lords, in the light of some of the Minister's responses, can she say whether Her Majesty's Government now regard Article 2 of the United Nations Charter, especially that part which deals with non-interference in the affairs of other states, to be non-operative?
Baroness Scotland of Asthal: My Lords, those provisions are operative. Those in this Chamber and
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elsewhere who have to grapple with issues that arise from humanitarian disasters are aware that this is a matter on which we are moving forward internationally. This is an important issue—some would say of equal importance to the other elements of the Charter.
The Earl of Northesk: My Lords, does the Minister concede that in its hearings on the provisional measures the ICJ stated that,
"under the present circumstances … [this] raises very serious issues of international law"?
Furthermore, in light of the Foreign Secretary's belief that it is right that the action taken in Kosovo should,
"become the basis for an approach to future conflict",
does the noble Baroness agree that it is critical that the rules of international law on such military intervention should be spelt out more clearly than they have been so far?
Baroness Scotland of Asthal: My Lords, it is important that that should happen. However, the case brought by Slobodan Milosevic is not the only way in which that issue can be addressed. The difficulty is that he has been able to do something which is quite wrong. The international community is looking at the issue and seeks to define the basis on which it can act together in future, and that must be the most efficacious way to proceed.
Lord Lloyd of Berwick: My Lords, if the Government are so confident about the advice that they have received from the Attorney-General and his predecessor, is it possible for that to be published so that we can all benefit from it?
Baroness Scotland of Asthal: My Lords, I am sure that the noble and learned Lord will be aware from his long experience in dealing with these matters that neither the advice nor the substance of the case can at this stage be published. Obviously, once the case has been heard and dealt with matters may change.

Tharcisse Muvunyi
2.58 p.m.
Lord Rotherwick Lord Rotherwick asked Her Majesty's Government:
Whether they have had approaches from the United Nations War Crimes Prosecutor for the extradition of Tharcisse Muvunyi in connection with genocide in Rwanda.
The Parliamentary Under-Secretary of State, Home Office (Lord Bassam of Brighton): My Lords, it is government policy not to discuss whether extradition requests have been received in individual cases. I would, however, stress that we strongly support the work of the International Criminal Tribunal for Rwanda, established specifically to prosecute the

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appalling atrocities in that country in 1994. The tribunal has extensive powers to request assistance from states, and we have assisted it in the past.
Lord Rotherwick: My Lords, the House has just heard from the noble Baroness, Lady Scotland of Asthal, that the Government wish to identify any war criminals. Can the Minister say whether any investigation by the Metropolitan Police is ongoing to identify this man as a possible war criminal?
Furthermore, in the light of the Prime Minister's statement that there is no hiding place for war criminals and in so far as we are able we shall bring them to justice, what action are the Government taking to bring this alleged war criminal to justice?
Lord Bassam of Brighton: My Lords, we are fully in tune with our international obligations as regards the prosecution of war criminals.
It is unusual to comment on individual cases. However, I can advise the House and the noble Lord that I understand that the police are considering material submitted to them about allegations of torture by Lieutenant-Colonel Muvunyi.
Baroness Rawlings: My Lords, why did Her Majesty's Government allow a well-known war criminal, Lieutenant-Colonel Muvunyi—known as "the commander"—and his family to enter and live in the UK? Have they been given political asylum here until 2002, as reported?
Lord Bassam of Brighton: My Lords, I am unable to advise on individual immigration cases. That would be wholly inappropriate for reasons that I am sure the noble Baroness fully understands. I understand that that has been the practice adopted by governments for many years.
Lieutenant-Colonel Muvunyi followed his family here. That remains the case. At that stage we were not aware of allegations against Lieutenant-Colonel Muvunyi.
Lord Strathclyde: My Lords, if the Minister cannot answer that question, perhaps he can answer this one. Is this man in this country on the basis that he seeks asylum?
Lord Bassam of Brighton: My Lords, I am unable to answer that question. It would be inappropriate for me to comment on Lieutenant-Colonel Muvunyi's immigration status.
Lord Strathclyde: My Lords, from time to time we are advised of the number of asylum seekers in this country. Is the Minister saying that those people cannot be identified in any way?
Lord Bassam of Brighton: My Lords, in this instance I am unable to provide that informatlion. I think that it would be inappropriate for me to comment on that.
Lord Merlyn-Rees: My Lords, has the UN prosecutor the power himself to apply for extradition or does it have to come from government to government?
Lord Bassam of Brighton: My Lords, we do not have an extradition treaty with Rwanda. It is for the International Criminal Tribunal to make any applications to this country.
Baroness Williams of Crosby: My Lords, will the Minister confirm that there has been no request from
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the International War Crimes Tribunal or from the war crimes tribunal for Rwanda? If there were such a request, can the Minister pledge to the House that the request would be taken seriously and considered by the Home Office in order to uphold government policy on this matter?
Lord Bassam of Brighton: My Lords, of course, we would completely fulfil our international obligations; and we would, of course, respond positively to any such request.
Lord Waddington: My Lords, what is this new doctrine: that this House cannot discuss individual immigration cases? Have there not been countless debates on the Floor of this House about individual cases?
Lord Bassam of Brighton: My Lords, I have outlined the situation. I understand that it is the same as it has always been.
Lord Rotherwick: My Lords, in the light of the escalating asylum figures, and the appalling processing figures, what steps are the Government taking to prevent war criminals entering this country as bogus asylum seekers and then living on social security?
Lord Bassam of Brighton: My Lords, we have an active immigration policy. We have an index and register at our ports. We properly vet people when they come to this country. We shall continue to do so to the best of our ability. That is the position. That was the position under the previous government. No doubt they were as successful as we hope to be in the future.
Lord Hooson: My Lords, can the Minister explain further why he states that it is inappropriate for him to answer those questions? Whether or not this man is an asylum seeker is a simple question which deserves a factual answer. The House deserves that.
Lord Bassam of Brighton: My Lords, as a matter of course and of policy we do not usually discuss and debate individual applications that may be made to our Government. That has always been the case.
Lord Campbell of Alloway: My Lords, will the Minister think just for a moment? Does he accept that if judicial proceedings involve anyone concerned with immigration, of course no mention is made of that matter in this House; but does the noble Lord accept that time and again mention is made of cases, and properly so, when they are not subject to the jurisdiction of the courts?
Lord Bassam of Brighton: My Lords, in the circumstances to which the noble Lord draws my attention, there is, admittedly, widespread debate about immigration and asylum matters. That is right and proper.
Lord Tebbit: My Lords, what advice can the Minister give about how the House may proceed to

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understand the facts underlying this case if the noble Lord continues to shelter behind the doctrine that it is none of our business?
Lord Bassam of Brighton: My Lords, these issues are, of course, important for public debate. The point I make is that it would be invidious to discuss personal circumstances of certain individuals. That must be right and proper.

National Health Service
3.6 p.m.
Baroness Cumberlege Baroness Cumberlege rose to call attention to the state of the National Health Service; and to move for Papers.
The noble Baroness said: My Lords, in opening the debate I should like, first, to declare an interest as an executive director of MJM Healthcare Solutions, a consultancy firm serving the National Health Service. Like so many of your Lordships, I am also connected with several charities and professional bodies associated with the service.
The Attorney-General (Lord Williams of Mostyn): My Lords, I wonder whether those noble Lords who are leaving could do so quietly so that we might give the noble Baroness the courtesy of being able to hear what she says.
Baroness Cumberlege: My Lords, I am grateful to the noble and learned Lord. It was not of great interest. However, I hope that the following will be.
I grew up in the National Health Service. My father joined it in 1948 and, since patients came to the house, in my home we literally had blood on the carpet.
I know the Minister, if not from a medical family, has had a distinguished career in the National Health Service. As the former director of the NHS Confederation he won great respect not only from a succession of Ministers but also from within the field.
He and I worked closely together in our former lives; and I believe that neither of us can take any pleasure in the current problems of the National Health Service. It is like a fond but ageing aunt who through wear and tear is beginning to disintegrate. Neither of us wishes to watch this painful demise and, more importantly, nor do the people of this country. All parties, all peoples, are willing the NHS to succeed. We are terribly proud of it, and rightly so. The ethic is superb, but the delivery is wanting—not least because, like most government-run business, it suffers from the vagaries of politicians and the intransigence of the Treasury.
In this House we can have a civilised debate in the hope that the views of your Lordships are heard by the Minister and incorporated into policy. The Minister is able to talk freely in the almost certain knowledge that
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this debate is verging on the confidential, and if our views do emerge in government policy we shall not crow about it.
In the past 20 years we have watched governments divest themselves of the management of many industries from airlines to utilities. There are now even reports that the Government want all council housing sold by 2010, and stakeholder pensions to replace SERPS.
The Government are relaxing their hold on housing and social security, yet both are as important to people's health and well-being as are doctors, nurses, medicines and equipment. Yet in sharp contrast, the Government tenaciously keep a grip on the NHS in the belief that they can manage it successfully.
As a past Minister, I know that managing the National Health Service from Westminster and Whitehall is near impossible, especially with a centralised regime, as is this one. The NHS is truly a people's service and it needs sensitivity and intimate knowledge to make it work. But the challenges today are greater than style, organisation and form. Quite simply, the people's service is failing to keep pace with the people's expectations. Long waiting times, cancelled operations, days on trolleys, round trips of hundreds of miles to find an intensive care bed are simply not acceptable to people belonging to the world's fifth largest economy. As the noble Lord, Lord Winston, has said,
"The truth is that our services are much the worst in Europe".
In his recent interview on "Breakfast with Frost", the Prime Minister said:
"I am not going to sit here and say that there aren't problems in the NHS because there are and we have got to put them right".
I am not going to stand here and say that there were no problems in the NHS when we were in government, because there were, and we tried to put them right. The difference is that now we have a Labour Government which can make changes which will always be denied to a Conservative government. What is more, this Government pride themselves on their modernising zeal, a zeal which should focus on the NHS because those who work in it and those who use it no longer believe that the NHS is sustainable in its present form. Even the BMA, with a tradition of resistance to change, is seeking better solutions. The time is right for change.
The NHS is the largest and most complex service industry in the UK. It is run by a board of directors, Ministers, who are largely amateurs—though of course I exclude the noble Lord, Lord Hunt—and they are appointed and disappointed by acts of capriciousness; hardly the best way to appoint a top management team.
We all know that in the lifetime of a parliament, when a serious crisis occurs, there is pressure to "do something", and all a government can do within the timescale is to change the organisation. So there follows a time of disruption and huge expenditure. Those involved, fearful of losing their jobs, worry about where they will fit into these new structures.

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Understandably, they concentrate on the new bureaucracy and not the proper care of patients. In the vernacular, they take their eye off the ball.
Primary care groups, which came live in April—just 10 months ago—are already having to consider changes in geographical boundaries, mergers with neighbouring groups and disbanding their boards in order to become a different animal: a primary care trust. Managers in the health service are continually having to reapply for their jobs and as a consequence they get fed up and they leave. We need good managers, we need to keep them and, of course, many of these people come from clinical backgrounds: top nurses, midwives, professions supplementary to medicine and so on.
The irony is that users of the health service are totally unconcerned with organisational structures, just as they are disinterested in the management of, say, Tesco, where they want a quality product at a price they can afford. For the money they invest in the NHS through taxation, people want skilled doctors, compassionate nurses, prompt attention and successful outcomes.
Crises occur when the delivery of service fails, when people lie on trolleys, when operations are cancelled. Changing a committee structure or reorganising management hierarchies achieves little, if not in fact a considerable retreat.
Nearly 20 years ago when I first tried to tackle waiting lists, I found that people had waited seven years for a hip replacement. For those still alive, we packed them off to a private hospital paid for by the NHS. They were delighted to have been treated. They may have been surprised at being sent to a private hospital, but people in pain, people in fear of their lives, really do not care about committee structures or the political ideology of the system. They want to be treated.
As the Minister will remember, the greatest incentive I had when chairman of the South West Thames region was to overtake the Mersey region in the league tables. I was continually telling my people, "We have got to beat Mersey"—beat it on the shortest waiting times, the best run hospitals, the best clinical practice and the most comprehensive community services. Competition was a spur to ratchet up standards.
I would never claim that any region or any government can avoid every crisis in the NHS, but I believe that even the Minister will agree that this winter has been exceptionally bad. It is not acceptable that a bout of flu should cause such misery and havoc.
To meet the crises it is essential to have all options open. The NHS ought not to exclude as a matter of principle the private sector. It is inconsistent to do so when so much of the NHS is already privatised: private finance initiatives to build hospitals; the supply of medicines and equipment; contracted laundry and catering services and path labs are all examples. Competition is both a spur and a discipline. The Prime Minister has offered us the prospect of considerably more spending. We now know that, it is subject to
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sorting out some questionable maths and the small Brown print, but it is even more important that financial discipline should be maintained when new money is provided. But I really do believe that money alone is not sufficient.
What is lacking in the NHS is that the vast majority of the staff has no feeling of enfranchisement and no ownership. The deluge of new initiatives that spin their way from No. 10, and occasionally from No. 79, removes the incentive to experiment and to use personal inventiveness. It is remarkable that both this Government and the last planned to put the budget into the hands of GPs, who defend their position as "independent contractors". They feel ownership of general practice; though the least controllable, they are the most trusted. That should teach us something.
In the two reports in which I have been heavily involved, one on maternity services and the other on community nursing, the thrust was to give people power—mothers to choose how their babies are to he born, people to choose whether to see a doctor or a nurse; and at the same time to enfranchise midwives and community nurses to enable them to prescribe and to take responsibility. Where this happens—and I have witnessed it—recruiting and retaining staff is not a problem. Indeed, where caseload midwifery is introduced there is a waiting list—a waiting list for midwives to work in those units.
The pull in such a politicised service is always towards the centre, to Whitehall. Yet most politicians have only a scant knowledge of how healthcare is delivered to people. They only know about organisations. We are all trapped in a marvellously pure ideology, the ideal socialist dream. We all have to have dreams, but this one does not work. It does not work because it is isolated in a brutally competitive world which generates the money for unreal dreams.
Pure socialism in health works, or does not work, when it is set in a socialist world with a population which embraces it; every man or woman according to their needs, sharing and caring for each other. But I must admit that I am ashamed to say that this ideal has been overwhelmed by litigation; self interest has overcome the common good. It may be disappointing, but even new Labour has buried the socialist ideal.
So we have to devise a system which reflects today's ethic, the will of the people rather than their dreams. The awful realisation that the NHS may not he the best health service in the world is dawning. This is infinitely sad and it must be put right.
With elections looming, and the knowledge that changes take time, what is acceptable and what is not requires political reality, but there is always an opportunity for innovation, experiments, pilot schemes and evolution rather than revolution. Some might advocate putting a hospital or two under private management if only to prove that the Government can do it better. Again, a precedent was set in a totally different service: the prisons. If that is a bridge too far, we could try running one or more trusts as cooperatives with staff owning all the shares. We have to make staff feel real ownership in what they do; that

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they are both appreciated and rewarded for personal success as well as the success of their trust, primary care group or health authority.
We have to be humble enough to accept that time and again governments are proved to be poor managers and that other countries happily mix private and public healthcare to provide a better service, if not a better ethic. There is no need for a big-bang change. We can be broad minded, try and then pick the winners. What is so sad is that this Government ring-fence cash to ensure that their will is done. Central control produces mindless freaks and the arrogance of government in believing that they know the priorities of Truro and Barnsley, Medway and Mersey is facile.
We now have to restore the confidence of the British people in their National Health Service. I now believe that with their ISA, with the coming stakeholder pensions, people have got beyond believing that only through allocations from general taxation will we achieve an NHS of which to be proud. People are losing ownership of the NHS. It belongs, as the Minister will have discerned, to the Treasury. It is the Treasury which, scrabbling around in the till, decides who should be happy and who should not.
I would suggest that we should all pay, each according to his means, an NHS insurance premium, with everybody paying something so that all are enfranchised. The NHS will then compete against all corners. It should, like so many industries, have a regulator or an inspector, as we have for schools, enforcing standards, insisting on efficiency, dedicated to quality, owned by the people and at arm's length from politicians. The Commission for Health Improvement goes a little way towards meeting that requirement.
The NHS premium payment would be set, like the BBC licence fee, with some political involvement. Everyone with insufficient income would have their premium topped up from general taxation. Of course this is called "means testing", but then general taxation, which now pays for the NHS, is means tested. We should not be fearful. It would be an insurance payment which everyone understood.
Income tax could fall, allowances could be made for those with private insurance and private expertise could be used. It may cause a furore among old Labour, but who wants old Labour? Certainly not new Labour. We now know that creating more and more Ministers in England and, as we heard today, doubling the number of political advisers, have failed to get patients off trolleys. We should wrestle the management of the NHS away from the politicians. I believe that with my new funding arrangements that would be largely possible.
I am not advocating privatising the NHS. An undiluted private health insurance scheme is not the answer. With current schemes, so much seems to be excluded. And just when the need is greatest the premiums become unaffordable. But, strangely, even when patients from private hospital care are admitted to NHS hospitals because things have gone wrong there
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are very few publicly expressed complaints. This is because people pay for something specific; they have ownership and loyalty. That is what people are trying to feel for the NHS, but it is ebbing away. I do not blame this Government entirely—it is largely the passage of time and changes in attitudes.
The NHS and the people are wise enough and experienced enough to be weaned from the wet nurse state onto something more modern and solid. This Government are the government who can achieve it if they have the foresight, the wisdom and, above all, the courage. My Lords, I beg to move for Papers.
3.24 p.m.
Lord MacKenzie of Culkein: My Lords, I welcome the debate introduced by the noble Baroness, Lady Cumberlege, who has a long record of involvement in the National Health Service. Her report on community nursing, to which she referred, was one of the few published during the past 17 years to which I could fully subscribe.
One of my failings is that I sometimes indulge in mixed metaphors. When thinking about this debate, I was conjuring up a picture of the possibility of a fox in the NHS chicken coop—a Dr Fox—together with a concept of a Trojan Horse. Perhaps a mixed metaphor too far. But, then, perhaps not!
I am not a conspiracy theorist, but one does not have to be when one looks at the juxtaposition of two recent events. The first was Dr Liam Fox's description of a patient's guarantee. It sounds like good medicine, except that it turns out not to be what is on the label. Neither is it a placebo. Instead, Dr Fox said that it was "perhaps a Trojan Horse".
Secondly, we had the talking up of the difficulties arising from the influenza epidemic as a crisis, aided by parts of the media which were clearly intent on finding a crisis, whether real or imagined, with a view to dropping a match into the NHS petrol tank.
It would be foolish to suggest that there are no difficulties facing the NHS. Equally, it would not be sensible for the party opposite to suggest, as is suggested in another place, that they are the making of the present Government. For example, one cannot blame this Government for the reduction in nurses in training or in practice. We know that it takes three years to train a nurse—and more when one takes into account the time waiting to enter university and eventually becoming a proficient clinical practitioner. Many hospitals could open wards today, but there is a dearth of nursing staff.
In the mid-1980s there were in England some 3,988 whole-time equivalent nursing and midwifery staff. In 1997, the figure was 3,500 whole-time equivalents. I greatly value the essential contribution made by skilled managers and administrative staff to the health service, but let us look at the staffing figures. The 1987 figure for England was just under 114,000 whole-time equivalent administrative staff. By 1997, it was more than 153,000.
One can perhaps draw one's own conclusion about the priorities of the previous government. Were they clinical priorities, or were they the priorities of

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competition between hospitals in the internal market, which, happily, this Government have ended? And why else could it be that in the past few weeks managers and clinicians struggled to find beds, whether in ordinary wards or in critical care units, for patients with complications arising from the flu epidemic? Could it be because the number of hospital beds was reduced by one-third between 1979 and 1997?
Of course there must be continuing review, rationalisation and change in the health service. Medicine, surgery and psychiatry are all changing. But I venture to suggest that the bed cuts can go too far. I well remember being lectured by a Minister of Health in the previous government about the virtues of the Tomlinson Report on London hospitals. Events have, of course, proved him wrong. The Tomlinson Report was an object lesson in ensuring that co-operation between the health service, universities and other training institutions should be just that—co-operation. Care must be taken to ensure that the tail of the providers of education does not wag the National Health Service dog.
I welcome the fact that the Government have set up an inquiry under Sir Clive Smee into the provision of hospital beds. I look forward to his report and I hope that Sir Clive will also take account of the issues of future bed cuts which might arise from the PFI hospital building programme. We cannot continue to base future bed number assumptions on ever-faster patient throughput and on more and more day surgery. Too often, fast throughput leads to the revolving door. Beds are not always freed up and that can lead to great distress to patient and family.
I welcome the abolition of the internal market and the introduction of a new system of co-operation. I welcome the end of queue jumping by GP fundholding practices. As a nurse, I reject anything other than clinical need as a basis for priority.
NHS Direct proved itself during the recent flu epidemic. Even many detractors in the medical profession, who perhaps fear nurse-led initiatives, have come on board. Nurse-led, walk-in centres and the creation of nurse consultants are long overdue initiatives, but no less welcome for that. I look forward to their development.
Needless to say, I welcome the Prime Minister's statement about bringing spending up to the EU average. Yes, it will take time. There needs to be change so that the NHS becomes more user-friendly. There is, indeed, much more to be done. But I reject the real agenda of those who talk up crisis after crisis. I return to the Shadow Minister, Dr Fox, who spoke to a fringe meeting at the Conservative Party conference last October. He said:
"I think what we are proposing will revolutionise private health insurance in the way we revolutionised pensions in the 1980s".
Even those with short memories will remember some of the negative fall-out from that particular revolution.
I accept what the noble Baroness, Lady Cumberlege, said regarding the average patient not being concerned about structures. However, I believe that the population is concerned about the philosophy
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of funding the National Health Service. I do not believe that the Trojan Horse strategy will fool the public, despite the Shadow Minister's apparent assertion that they, the public, have not thought through the implications of the Conservative agenda.
I believe that the party opposite wants the National Health Service to deal with the expensive and the uninsurable. It hopes that its Trojan Horse will lead to privatisation, with patients paying for insurance and health charges, and no doubt for all minor surgery. I think not, my Lords. It would be much more sensible to recognise that the rhetoric of crisis, which has bedevilled every debate about health funding in this country, is as deeply harmful as it is destabilising.
Of course public and professional expectations will always be ratcheted upwards. Medical and pharmaceutical breakthroughs will always follow those expectations upwards. Better than rhetoric, which is great fun, is serious debate which acknowledges that this Government have made a respectable funding increase for the National Health Service and are tackling difficult issues. I hope that with serious debate we can concentrate on many difficult issues, such as priorities in tertiary care. If we do not do that, we shall be back in a crisis again, and next time it might be a real crisis.
3.32 p.m.
Earl Howe: My Lords, part of the difficulty with the Motion we are addressing is that the current state of the National Health Service is, to some extent at least, a matter of perception. Some parts of the NHS are of world-class standing; others, to put it at its mildest, fall decidedly short of that. However, if we wish to find a measure of the NHS's performance that depends more on fact than on subjective judgment surely we could do worse than examine the comparative data on health outcomes across Europe and the developed world.
In the year 2000, Britain—the world's fifth largest economy—has one of the worst records in Europe of deaths from coronary heart disease. Long-term cancer survival rates in this country are way below those of Germany or the United States. On their own, the prevalence of those two causes of death should prompt us to ask ourselves some searching questions about the kind of service which the NHS is now delivering and what can be done to improve it.
In highlighting those issues, I seek to make only one non-party political point: that there is a widely held view that, despite the commitment and expertise of those who work for it, the NHS is failing us. That view is reinforced by the intense pressures experienced by hospital upon hospital during the recent winter flu crisis. Those pressures were entirely predictable and, only a few years ago, would have been absorbed with relative ease. We read, too, of,
"people spending hours on trolleys waiting for admission. patients being discharged more quickly than is safe, and surgical beds being filled with medical emergencies, leading to even longer waiting lists"—
not my words, but those of Professor Sir George Alberti, President of the Royal College of' Physicians and a friend of this Government.

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When the noble Lord, Lord Winston, speaks, as he will today, it is right that we should sit up and listen to him. I do not seek to misrepresent the noble Lord in any way and I hope that I do not. However, if there was one emotional thread that seemed to run through his recent comments about the NHS (even though he later qualified those comments) it was, I venture to say, a mixture of sadness and frustration and the feeling that the NHS which we know today is, as he put it, a "gradually deteriorating service".
As the noble Lord observed, the Government's usual reaction when confronted by a less than flattering commentary on the NHS is to blame it all on the previous administration. It has not escaped my notice—I say this to the noble Lord, Lord MacKenzie—that the Conservatives fought and lost the last election. However, the commitment of the last administration to the NHS should no more be doubted than that of the present Government. Between 1979 and 1997 NHS spending increased by 74 per cent in real terms. That period saw capital investment go up by 66 per cent in real terms, including the largest sustained building programme in the history of the NHS. Nurses' pay went up by 67 per cent and nurse numbers by 55,000. By the end of the Conservative Government there were 23,000 more doctors and dentists than there had been at the beginning. That is no mean record.
The record of the present Government will, of course, be apparent only at the end of their term of office. They have promised substantial additional sums for the NHS and those are most welcome, even if the Government's manner of presenting their figures owes something to the art of spin. Yet, all the time, spin or no spin, the demands that are being placed on the service are outstripping its capacity to deliver.
If this country comes out badly on output comparisons, the same is no less true of inputs. The UK has the second lowest number of doctors per head of any country in Europe. Germany has twice as many as we do; Italy three times as many. Despite our poor performance in cancer survival rates, the amount we spend per head on chemotherapy is a third of what is spent in France. It is only 6 per cent of the per capita spend in America. Those are not short-term deficiencies in the NHS; they are systemic.
The Government have already made substantial changes to the health service. The Minister reminded us of some of them last week. I suggest that the jury is still out on most of them; notably, NICE, primary care groups and NHS Direct. But with the best will in the world, none of those, however much they may come to prove themselves, can do more than scratch the surface of the larger issues to which I have referred.
If there is one area where I fear that the Government's reforms have done real damage, it is in our specialist referral centres. Before the reforms, a doctor could refer a patient to a specialist in another part of the country if he believed that that was clinically appropriate. Yes, there was some bureaucracy involved to ensure that the money
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followed the patient. However, the freedom to refer was there. Now the money does not follow the patient. As a result, the system acts as a deterrent to out-of-area tertiary referrals. My fear is that some of our centres of excellence will simply wither on the vine and that, simultaneously, patients who need a higher degree of expert care will not get it. That is a heavy price to pay for getting rid of some paperwork.
The Government have, of course, recognised cancer as a priority issue. However, nothing we have seen or heard from them will remotely address the gap that needs to be bridged. Professor Karol Sikora, our leading expert in cancer, has described the Government's so-called "cancer pledge" as window dressing. If we are to improve our record in combating cancer we need several hundred more specialists, much more equipment and more chemotherapy. That is the investment which the Government must make if they are serious about cancer.
If it is true that the problems of the NHS are systemic, the issue comes down to resources; not a small amount of money, but very substantial sums indeed. That is what the Prime Minister recognised when he spoke on television a few days ago. He spoke of our reaching the EU average in healthcare spending within five years. That sounded at first like a bold new promise but a couple of days later it bore all the hallmarks of policy-making on the hoof. The Prime Minister now says that his words were not a promise but that he is confident that the target can be achieved. That is pie in the sky. There is not a respectable economist around who thinks it remotely realistic, let alone sustainable in terms of the effect on the wider economy.
The trouble with the Government's position is that they are inflexibly set on the idea that healthcare should, wherever possible, be delivered by a monopolistic state provider. Nobody in the country, no political party, wants to do other than support and improve the NHS. But only the Labour Party has set its face against promoting a mixed economy of state and private health provision. In this it is out of step with every other developed country in the world. It is the extent of private, more than public, spending that differentiates the British health system from those of France, Germany, Holland and Denmark. I believe that, sooner or later, we shall need to encourage many more people to provide for some part of their own healthcare and in so doing relieve the burden on the NHS.
If in pursuing their health policy the Government are intent on remaining a one-club golfer, they must show why they are choosing to ignore the alternatives. All sides agree that total capacity in healthcare provision needs to expand. The question to the Government is: how will they bring that about?
3.41 p.m.
Lord Clement-Jones: My Lords, first, I thank the noble Baroness, Lady Cumberlege, for initiating this important debate. I apologise to both the noble Baroness and the Minister for the fact that a

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longstanding engagement means that I shall not be able to he here to wind up on behalf of these Benches. I am extremely grateful to my noble friend Lady Thomas of Walliswood for stepping into the breach with such enthusiasm.
The state of the NHS is by far the biggest issue for the general public, as recent opinion polls show. Delivery on the NHS will be crucial to the Government's election chances. The key question will be whether they have delivered on the promise made before the last general election to save the NHS.
Several of the reforms the Government have made since the general election have been welcomed on these Benches: NHS Direct, the setting up of primary care groups and trusts; the much greater emphasis placed on clinical governance; the setting up of CHI, the Commission for Health Improvement; the acceptance that evidence-based medicine must lie at the heart of the management of the NHS; and the institution of NICE, the National Institute for Clinical Excellence. But why is the Secretary of State hiding behind it by giving it "affordability" as one of its criteria for approval of drugs and new treatments?
We also welcome the rolling out of national service frameworks. Until the flu crisis, the Government convinced themselves that some of the longstanding problems of the NHS, bequeathed by the previous government, were being tackled. But once again, during that crisis, we had the sight or patients waiting on trolleys for hours while a bed was found. Even then the Government thought that declaring an epidemic early, before the 400 cases per 100,000 figure was reached, would give them a cast-iron alibi.
After the recent crisis, it is clear that the Government miscalculated massively. By sticking to the spending plans of the previous government in their first two years yet making exaggerated claims about the amount of money they are spending now, they have raised public expectations. There is little they can now do to meet such expectations in the next 18 months or so before the next general election.
It is clear that there are huge problems. There is a lack of beds, particularly for intensive care. Doctors and managers warned of impending problems before Christmas. According to the NHS Confederation, most trusts are operating at 95 per cent capacity which makes it impossible to run an adequate system. Year on year, so-called "efficiency savings" have cut into the essential capacity of the NHS.
Where is the national beds inquiry report? Is it simply that the conclusions are too embarrassing to publish? Where is the corroboration of those 100 extra intensive care beds which the Government claim to have provided this year? The problem is exacerbated by the lack of resources for older people to transfer from acute hospitals to nursing and residential homes.
There is a massive shortage of nurses—17,000 against 8,000 when the Government came into office— and midwives. The consequence has been a disgraceful further rise in expenditure on agency nurses from £264 million in 1998–99 to £344 million in 1999–2000.
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Despite the new deal for junior doctors, their hours are spiralling out of control with one-third working more than the nationally agreed limits.
As regards health trusts and authorities, their combined deficit this year will be at least £400 million. Worse is to come in the next financial year. Yet the first instinct of the Secretary of State and the chief executive of the NHS was to shoot the messenger, not to respond to the problem. Their behaviour is similar to that of No. 10.
Postcode rationing exists for essential treatments such as the chemotherapy drugs Taxol and Taxotere; Aricept for Alzheimer's; Beta interferon for multiple sclerosis; and Clozapine for schizophrenia. Those are all well-accepted cases of postcode prescribing. As mentioned by the noble Earl, Lord Howe, outcomes in the key areas of cancer and cardiac illness compare extremely unfavourably with almost every other European country. Cancer survival rates, for example, are worse than those in Poland. As also mentioned by the noble Earl, there is an extremely poor ratio of doctors to patients, worse than in almost all OECD countries. Finally in this category of failure, we come to the issue of mixed-sex wards, which we debated a few days ago. The Government have failed to meet their pre-election pledge to phase them out by the end of 1999.
Many such problems clearly have their roots in a lack of resources. The key question that now needs to be answered is: what is the Government's commitment of NHS spending and where do they propose to raise the money? They also need to answer the question of why they are persisting with their tax cut this April of 1p in the pound rather than spending the £2 billion or so raised on the NHS as the public clearly want them to do. What precisely is the Government's pledge as expressed by the Prime Minister? Will the Minister make that clear? Is it to reach the European average ratio of health spending to GDP within five years? Is it to raise real spending on health each year for the next five years by 5 per cent in real terms? Indeed, is it an aspiration, a commitment, or both? They may have a 10-year plan, but there is little comfort for those who wish to see early improvements in the health service.
The Government are clearly in a spin, in more ways than one. This is a millennium wheel of their own construction. Let us have some hard commitments. The one fact I am clear about concerning the events of the past fortnight is that those with an interest in the future of the health service have the noble Lord, Lord Winston, to thank for extracting what pledges are now on the table.
Increased expenditure on private insurance, as the Conservative Party seems to believe, is not the answer. I am perfectly happy with a mixed economy in health. Indeed, use of spare capacity in the independent sector makes sense. But I believe that the NHS should be a comprehensive service, free at the point of delivery and we should not be incentivising patients to obtain their treatment outside the health service.
Unlike the Conservative Party I have confidence in the future of the NHS and the willingness of the British people to pay for it. Set by the side of their so-called

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tax guarantee, which assured us of an ever-falling rate of tax, how can that amount to a commitment to the NHS?
These are the problems of today with which the Government have failed to deal. They have also not yet come to grips with the problems of tomorrow. I refer, in particular, to the issue of long-term care for the elderly. Despite the elapsing of many months since the Royal Commission report on long-term care for the elderly, we have still not had a proper government response.
In conclusion, this Government have a long way to go before they stand a chance of convincing us that the NHS is on the path to recovery.
3.50 p.m.
Lord Walton of Detchant: My Lords, it is almost 55 years since I graduated in medicine. Since 1948 I have been a fervent supporter of the National Health Service in which I worked for much of my professional life, first as a consultant and subsequently as a clinical academic. Then, some eight years ago, I received a letter from the Oxford Health Authority telling me that now I have reached a certain age I can visit the hospital for social reasons but cannot use the clinical facilities. However, I have kept in touch with the NHS since that time.
Since I began to work in the NHS I and many other professionals have repeatedly pointed out that the percentage of gross domestic product spent by this country on health has been totally inadequate: 5.8 per cent now from public funds, plus 1.1 per cent from private sources. Only 8 per cent of the costs of the NHS come from the National Insurance Fund because of the demands of social security.
I must say that I do not believe that the private sector is a threat to the NHS; it is a valuable partner and generates NHS funds by the use of private beds in hospital. I had hoped that new Labour would have discarded outworn, left-wing ideology and kept tax relief on private insurance, but that is another matter.
My profession has repeatedly been accused of scaremongering, of shroud waving and of making dire predictions about the terminal decline of the NHS, which have been subsequently unfulfilled. But I am convinced that grave concern is fully justified. Morale is at a critically low ebb. I become weary of saying, as the noble Earl, Lord Howe, made clear, that we have far too few doctors and nurses in this country in comparison with many of our overseas competitors.
General practice in this country has improved out of all recognition. Of course, we are all deeply disturbed and appalled by the recent frightful events in Hyde. If the General Medical Council had previously possessed the powers it now has I believe that that frightful situation may have been averted. But general practice has improved enormously in the UK. However, we have only half to two-thirds the number of GPs per unit of population compared with France and Germany. Doctors are stretched to such an extent that, as a rule, they are only able to allocate five to seven
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minutes for a consultation. Is it surprising, therefore, that 40 per cent of the population have now turned to alternative and complementary medicine. Apart from the value and benefits derived from such measures, they are buying time in the consultation process.
Already there is a major decline in the number of young GP registrars entering the service. We are now seeing for the first time in the past two years a decline in the number of young people applying for entrance to medical school. Last week the BMA News Review published the results of a questionnaire exercise which showed that 62 per cent of those doctors consulted now believe that we no longer have the best health service in the world, but one of the worst in Europe. No fewer than 83 per cent felt that a comprehensive medical service free at the point of delivery, with present levels of funding or even with modest increases, would, in the future, be impossible.
The position in the hospitals is no better. In many respects it is worse. As we heard, beds have been closed; intensive care beds are not available when needed. Even in the small community in which I now live in Burford in the Cotswolds, to save funds the Burford Community Hospital—a major outlet from the acute wards of the John Radcliffe—has been closed and at the moment I am involved in a massive fundraising campaign to try at least to keep the day hospital open through private funding.
Those are some of the critical issues. There are not enough beds and not enough doctors; and 12,000 nurses leave the NHS every year. Indeed, there is a problem in relation to all hospital specialities. Report after report from the Royal Colleges demonstrated, as the noble Earl, Lord Howe, said, that we have one-quarter to one-half the number of specialists in all specialties that many other developed countries have. I speak of cardiology and oncology. It is not surprising that our cancer survival rates are much lower than in many other countries. In my speciality of neurology, to quote one example, there are fewer than 300 neurologists in the UK compared with 400 in Finland, which has a population of only 4 million.
That is something which must be corrected. Many of those in the hospital service are grossly overloaded. In academic medicine the position is parlous. So many of those in lectureships, readerships and chairs in clinical specialities are being required to carry such a heavy clinical load that the time available for their major responsibilities of teaching and research is limited and seriously eroded. There are now 67 vacant clinical chairs in the UK for lack of suitable applicants and, sadly, there is a flood of early retirements by consultants in the NHS.
We are faced with an ageing population; massive technical advance; and, as others have said, the development of new and effective but expensive drugs. As the recent publication of the ABPI Hitting the Target has shown, the British pharmaceutical industry is making outstanding contributions. But there is also another massive spectre looming on the horizon. That is the genetic revolution. Gene therapy and prevention by the identification of genetic susceptibility is going to generate huge public expectation.

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What can we do? The Government's pledge to give an additional 5 per cent year on year to the NHS is welcome but will not be enough. I find the idea of charges being imposed at the moment of sickness or need unattractive I have argued for years that the principle of hypothecated taxation, despite its disadvantages, by means of an income-related, index-linked health tax is one major issue that must be thought through. It is time to listen. Will this Government have the courage, unlike many previous administrations, to recognise that the situation is now critical? Although many of us here believe passionately in the future of the NHS, the time for an urgent and radical review of funding of the National Health Service must now be upon us.
3.57 p.m.
Lord Biffen: My Lords, I should like to record my appreciation to my noble friend Lady Cumberlege for the choice of this topic and for the manner in which she introduced it. We must learn that there are great political issues that can be pursued without recourse to adversarial politics. The speech of the noble Lord, Lord Walton of Detchant, is an indication of how one can address the portentous developments with political challenge, but none-the-less in a way which deserts the and field of Labour-Tory acrimony.
I want therefore as my modest contribution to consensus to suggest that we could well employ the resources of the Health Select Committee of another place to consider the problem that we are now discussing with a view to seeing to what extent a broader agreement can be canvassed than has been the experience of the past few weeks. I shall try to assist in that self-appointed task by suggesting four areas for consideration. I know that others will have much wider and indeed more profound matters for consideration.
First, I should like some idea of the likely future demands that will be placed upon national health. That goes beyond the health service, though it is central to the challenge. Of course, we are all well aware of the demographic factors that have dominated recent developments and which I believe will continue. We know that the developments in medical technology and in pharmacy have added to health costs. This afternoon we have added the spectre of gene therapy. All of that necessitates that we have some idea of the parameters of the challenge, the challenge in health terms, the challenge in financial terms and ultimately the challenge in political terms that attends us.
Secondly, I should like a little refinement of figures that have been thrown into the debate in the most careless fashion over the recent weeks, which is the costs of the health service in France and Germany. The sums that are impressed suggest that the most enormous increases are required for our own health provision. That may be so, but I should like a little more detail about this. I should like a little more argument and details and rather less in headlines. I should like to know whether compulsory private insurance is, in fact, a more ex pensive way of delivering healthcare than the system we have
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operated in this country, because the answer to that question is crucial in determining some of the arithmetical challenges that await us.
Thirdly, I should like to say that I have an interest to declare. I am a trustee of the London Clinic. I must say that most of my thinking on health inevitably must be the health of the community in which I have been brought up. I wish to say that, without going into a great theological argument about these matters, I do feel that the provisions for healthcare are limited by the relatively modest contribution that is made to it by the private health sector. I believe that that could be reasonably expanded without undermining the basic ethos of the National Health Service. The point was made forcefully by my honourable friend, Lord Howe, and I was delighted to see that it was reinforced by the noble Lord, Lord Walton of Detchant. We simply cannot afford to neglect something from the private sector which may be contributive to overall national health any more than—and nobody today has suggested it so far—we should scrap prescription charges because, certainly in the very early days, they are thought to be antipathetic to the philosophy of the health service.
I now go to my fourth point. However one considers these matters—and to some extent I am anticipating what may be the judgment of the departmental Select Committee—I believe that we are going to have to spend more on the health service, financed out of taxation. Therefore, we have the prospect of increased spending and increased taxation. I say that because, quite frankly, I think there is an anxiety to avoid that central question, to believe that somehow administration or some other technique will excuse one from this disagreeable choice. It is the more disagreeable because it is going to have to be our choice, a choice of a British Parliament answering to a British public. It cannot be willed off to anyone else. In my view, it stands central and ahead of any other consideration one might have about convergence and all the other modish terms which are now prayed in aid, because taxation is at the very heart of political judgment and that judgment itself reflects what kind of people we think we are and for which we will make collective decisions and collective sacrifices.
I have, more or less, said what I wished to say. I should like the prospective Select Committee to be encouraged in the whole philosophy of trying to disavow that there is something for nothing in this world. I regret to say that the area of welfare has often been disfigured by the arguments of "something for nothing". Take the example of National Insurance— and I say this with deference to the Liberal Benches. In 1911, Lloyd George devised the term "nine pence for four pence". This referred to the fiddling around with the contributions of the government and the employers. The riposte of the public to this was "nine pence for nothing". That is the course of unreal economics in these matters.
I quote from a another—preferred—Welshman, Aneurin Bevan. He said that the language of priorities is the religion of socialism. That remark is provocative in the presence of New Labour. But I will say that the

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judgment of priority and the difficulties of priority lie at the heart of trying to redesign the factors I have mentioned. I wish this Government and any other government warm support across the floor of this Chamber in trying to devise something that will be measurably better than we have now.
4.4 p.m.
Lord Desai: My Lords, it is a pleasure to follow the noble Lord, Lord Biffen, who has, like the noble Baroness, Lady Cumberlege, set a standard in discussing this issue in a non-partisan manner because we are all interested in seeing a better National Health Service.
I was briefly involved, for no more than 40 winks, when I used to stand opposite the noble Baroness when I was a shadow Minister for Health. Luckily for both of us, it did not last very long. I remember the noble Baroness's commitment to the National Health Service, which she has shown again today.
I think that we ought to have an all-party pact with regard to the National Health Service because the numbers being bandied about are very confusing. Every government claim that they increase funding to the National Health Service by so much, but of course the proportion of GDP spent on it has not budged for a very long time. Is a proportion of GDP a good measure? Our criticism of state-owned enterprises was normally that they had excess capacity and overmanning. The National Health Service is the exact opposite. It has no excess capacity. It is short of staff. From one point of view, we ought to separate out certain shortages and certain improvements, but we ought also to consider the fact that, overall, no other country has as efficient a health service. That is worth saying. Of course, a lot of people are working very hard in it.
Perhaps I may say this about health outcomes: there are headlines about cancer and about coronary matters, but what about the other outcomes measures, such as life expectancy? I do not think they are going to show that badly in comparison. We need better outcomes measures and better measures of quality of healthcare, and not just those relating to certain headline causes of mortality. Let us not measure only inputs. Let us also find out how the inputs are deployed. Let us have better measures of output because we do not have them now.
I have lived here for the past 35 years and I have never seen a headline saying, "NHS in good health; nurses happy; doctors say NHS will flourish". I have only seen headlines such as, "Nurses' morale has never been lower". This goes on. I should love to see the graph of nurses' morale to see how it goes down all the time. We properly love the NHS, but our crisis-mongering is the only way we can love it. We cannot love it happily. We can only love it with conflict.
There are two important points to emphasise. One which has not yet been discussed is that while we affirm the principle of healthcare being free at the point of use—and I want to re-affirm that—we think only of
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the financial cost and not of the real cost to patients. We have allocated healthcare by time, by queuing, and by inconvenience. People often do not go to their general practitioner because it is too time consuming. This is what happens when people talk about "postcode treatment". We have also rationed healthcare by non-visible measures of cost, non-financial measures of cost. That is why certain sorts of social difference persist.
We need to move away from money sums and input numbers. We need to ask about access to quality health services and what price people are paying—and, indeed, in what terms they are paying the price—when they have free access to healthcare. If we are to improve our service while keeping it free at the point of use, we shall have to consider such questions.
Another major question is also one which has not yet been discussed; namely, the rationing of healthcare. We cannot be in denial about this. Of course healthcare is rationed, but it is rationed by the producers of healthcare, not by governments. Historically in every country, we have—quite rightly—allowed the medical profession to ration healthcare. Therefore, there are gatekeepers who will decide who gets what. For various reasons, the time has now come for this producer-domination of a major service to be questioned. Consumers want not only more information; they also want more say. So we ought to have a debate, like the debate in the state of Oregon, about what problems people think require priority treatment. For example, how would people prioritise hip operations versus some other problems? There are also acute and elective problems, but we should let people say, "We think that these treatments are top priority which should be supplied at all times, anywhere".
There are other areas where waiting is not a problem: or at certain times it is a problem but, at others, it is not. We should not say that the NHS should be free at the point of use and completely non-rationed, and then be surprised when we have problems. As I said, we ought to have a major debate on rationing. We must admit that there is rationing now. Such an admission is not in any sense a criticism of the National Health Service. Indeed, very few things that are provided free of charge in financial terms are free from rationing. It is just not possible.
Finally, I turn to a somewhat contentious problem. It has classically been known in economics that medical care is a very peculiar product because consumers do not know what they want: the producer tells them what they need. Therefore, we always approach the problem of healthcare in a state of ignorance. Due to that problem there is no consumer sovereignty. But, at the same time, the self-regulation of producers will be questioned, which will not be very popular with doctors. However, if the events of recent days have shown one thing it is the fact that self-regulation does not work in medicine, as was the case with financial markets. That is another reason for us to have a proper debate. Such debates will improve the National Health Service. In the mean time, we can continue to discuss the question of numbers.
4.13 p.m.
Lord Crickhowell: My Lords, in an admirable introduction, my noble friend Lady Cumberlege referred to the start of the National Health Service in 1948. That start immediately exposed a fundamental miscalculation. Nye Bevan and his officials comprehensively under-estimated what it was going to cost. They actually expected that the cost of the service would grow less as the population became healthier. They failed to foresee that, far from declining, the demand for treatment, once freed from financial constraint, would prove literally infinite and the capacity of the medical profession and drug companies to devise expensive new treatments scarcely less. As the noble Lord, Lord Desai, indicated, since then the problem of infinite and uncontrolled demand has dogged every government. In his account of the conduct of policy under Harold Wilson and the noble Lord, Lord Callaghan, the noble Lord, Lord Donoughue, described how,
"the problems of the NHS ranged from the acute to the merely chronic".
Despite all these financial difficulties, under both Labour and Conservative administrations the services of the NHS have been expanded to a remarkable degree. Despite constant Labour propaganda that Conservative governments neglect the service, a great many of the most substantial advances have taken place while my party has been in power. If I take the period from 1979 to 1987 as an example, it is simply because I have the record of my own time in government ready to hand. Over that period expenditure on the health service grew by nearly one-third in real terms, we employed more doctors, nurses and professional staff than ever before and the NHS treated close to a quarter more patients in hospitals. We undertook the largest hospital building programme ever; and there were other important initiatives to improve the services. Early in this debate my noble friend Lord Howe gave the figures which show that those improvements continued over the next decade.
These were huge advances and yet large problems remained. They were brought home to me vividly during the frequent visits that I was paying at that time to King's College Hospital in London for treatment. Like many others, I was left several times on a trolley in a passage—yes, it even happened to Cabinet Ministers at that time—and was able to observe many things that were badly wrong with the service. A few years later, while visiting my dying mother-in-law in a mixed ward, which she hated, in Cheltenham, it was all too apparent that this was not the way to treat those who are seriously ill.
Despite the firm commitment of successive Conservative governments and our very substantial achievements, the Labour Party has succeeded in creating the myth that Conservatives are hostile to the health service, and has so sanctified the service that its worship has become almost a religion. A situation has been created where criticism is regarded as sacrilege. That is the principal reason why Conservative administrations have concentrated their efforts on
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administrative reorganisation rather than on a fundamental re-examination of the financial structure; and why such an enormous obligation now falls on the present Government. The need for reform is now clear to everyone. There is a heavy duty on new Labour to face that obligation—not with meaningless promises, but by an open examination of radical options in which the other political parties must be prepared to participate constructively.
In his memoirs Norman Fowler described how he argued the case against moving over to private health insurance and concluded that there was little to he gained from a substantial change in the financing arrangements; but he advanced the argument against the background of a "think tank" paper produced without public or ministerial consultation. He makes it clear that it was concern about "a probable political whirlwind" that was a dominant factor in Ministers' minds as they considered the issue.
My noble friend Lord Lawson of Blaby in his memoirs also advanced the case against private insurance as a primary method of NHS finance. But he acknowledges that with a system of taxpayer finance,
"when finite resources, however substantial, are faced with infinite demand, there will always be frustrated demand",
and painful consequences. Unwilling to risk the political fallout and dubious that there was an obvious solution to be discovered in the arrangements of other nations, Conservative governments have settled on attempts to reduce costs and improve efficiency by means of internal reorganisations. Important though these have been, they could not be solutions to the fundamental problem. Effective reform of health or social security systems requires open review and widespread consultation; but that was just not possible in the circumstances.
Having promised to think the unthinkable, after its election triumph New Labour was uniquely in a position to do so, but the Prime Minister funked it. It is characteristic of the Prime Minister's approach that, in opposition, he should flagrantly misrepresent the attitude of Conservatives to the health service, ruthlessly exploit the public's concern and shamelessly offer a promise swiftly to put things right, without having the smallest idea how to deliver that promise. It is equally characteristic that, a thousand or so days later when faced by the fact that things had got much worse, he should again come forward with a promise described by Anatole Kaletsky, in a cogently argued article in The Times on 20th January, as "arithmetically nonsensical"; and almost immediately half withdraw that promise. If Mr Kaletsky is even half right in his argument, it looks as if Britain will suffer from an inadequate health service for a long time to come.
In the situation that we now face, I am not convinced by the arguments accepted by colleagues in the 1980s that we should be content with internal reorganisation, and that there are few lessons to be learned from the experience of other countries Is it not at least possible that a competitive market in the sources of finance and in the provision of services might produce real improvements?

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As Frank Field was asked to think the unthinkable, before being sacked for doing so, should we not start by debating his proposal to rebuild health expenditure around a national insurance base that would permit a new dialogue with the electorate about how much should be committed to health expenditure? Should we not relook at the possibility of more private spending on drugs, on routine visits to doctors, on accommodation, and on optional procedures? Should we not consider supplementing basic health provision with a number of approved and perhaps compulsory insurance schemes which would provide people with a choice of their level of contributory expenditure and the type and scale of service that they would then receive?
Is it not possible that people in France are getting a better service because the share of cost taken by private insurance is greater? Is there not room for much greater contracting out of services to improve efficiency and cost competitiveness? The National Health Service is lagging far behind private business and local government in contracting out services. Right back in the early 80s my noble friend Lord Roberts of Conwy and I achieved dramatic improvements in the efficiency of the renal dialysis service in Wales by contracting out the service delivered inside a number of National Health hospitals in Wales.
The time has come to accept that what we have is not sacred, perfect or even the best; and that this is the moment for an open and radical review of the options. If the Government tackle the problem in that way, they are entitled to expect a full and constructive contribution from the Opposition. I only wish that I had more confidence that the Prime Minister had the understanding and courage to follow that course.
4.22 p.m.
Baroness Sharp of Guildford: My Lords, I join others in thanking the noble Baroness, Lady Cumberlege, for initiating this extremely important debate.
Just over a year ago, I made my first major speech in this House on the Second Reading of last year's Health Bill, as it then was. In that speech I drew your Lordships' attention to the conundrum facing the health authority in the part of the world I come from: namely, Guildford in west Surrey. As I put it then, in terms of population we are one of the healthiest and wealthiest health authorities in the United Kingdom. Because we are healthy and wealthy our needs are judged by the NHS, quite rightly, to be low. But, because we are wealthy, our expectations and aspirations as to the level and quality of service that we should receive are high.
There is, therefore, an unbridgeable gap between the resources supplied and the resources demanded—a gap which currently measures some £10 million on a budget of some £370 million, and has been as high as £20 million, leaving a millstone of debt to be repaid as well as finding economies needed to close that gap. Every service has, of course, seen its share of the cuts:
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the community and mental health services, the ambulance service, the acute services and district nurses. Now, in spite of a clear lack of capacity in the three accident and emergency departments that serve the area, it is rumoured that one will be closed down. The Government are unyielding. The massed ranks of Surrey's Conservative Members of Parliament orchestrated an Adjournment debate two weeks ago in the other place. They pleaded with the Minister to forgo the repayment of the £18 million debt that is hanging round our necks. The Minister firmly told the assembled Members that the £18 million has to be repaid because this Government are interested in a sustainable and long-term investment.
As a Liberal Democrat the cynical thought crosses my mind that, of course, the Government have no seats to lose in Surrey. What does it matter? Why worry? I worry because it seems so crazy. We have a modern, new district hospital and wards that are kept closed, yet we are short of beds. We have a refurbished accident and emergency department, on which £2.5 million has just been spent, which provides a 13-bed observation ward. Therefore, although last Monday one 71 year-old had been waiting for 40 hours for a bed, at least he was not waiting on a trolley in a corridor. However, it now appears as if we do not have enough money to keep that observation ward open. Staffing is a constant problem. Seven of the nurses in the accident and emergency department have resigned; and it is not just a question of pay. They resign due to the constant pressure of work and the need to put in extra shifts to keep the department open, knowing that they cannot, in the accident and emergency department, provide the nursing care that is required. Resignation is the most potent form of protest that they can make.
Therefore, the hospital will have to hire more agency nurses, placing a greater load of responsibility on the remaining staff nurses. That will add further to the budget problems. But why should the agency nurses, who are paid far more than the ordinary staff nurses and can pick and choose their hours, avoid all these heavy responsibilities? It is no wonder that NHS-trained nurses leave the NHS for agencies. I believe that today there are 2,500 fewer nurses working for the NHS than there were in May 1997 when the Government came to power. In Guildford we have just had our vacancy rate cut from 15 to 10 per cent. Why is that? It is because we have recruited a team of nurses from the Philippines.
Of course we need to spend more on the National Health Service. Many noble Lords have mentioned the amounts that are spent. Our expenditure per capita on health in this country is half that of Germany or France, and lower even than that of Spain. If we consider the matter in terms of absolute amounts spent per capita, we join Greece and Portugal at the bottom of the league table in Europe. Yet we pride ourselves— listen to what the Prime Minister said at Davos—on the strength and vibrant growth of our economy. In these circumstances, it is crazy for the Government to cut taxes ahead of providing more resources for the

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National Health Service, as we Liberal Democrats have said time and time again. Every opinion poll says the same thing. People are willing to pay more tax, provided they know that it is going to the National Health Service. But somehow we have to ring-fence that money.
The noble Baroness, Lady Cumberlege, spoke of having a tax that was hypothecated towards the National Health Service. Others have mentioned national insurance. I should like to see us impose a 2 per cent surcharge on national insurance, and to ring-fence that for the National Health Service. That would make a reality of many people's illusion that part of their national insurance payment goes to health.
However, money is not everything. Many noble Lords may have read the article in the Economist a couple of weeks ago which pointed out that Britain has fewer doctors per thousand of the population than any of the other G7 countries. Italy, which spends only a little more per capita than the UK, has three times as many doctors as the UK per thousand of the population. Germany and France have twice as many doctors per thousand of the population as the UK. This is not accounted for in terms of the difference in the proportion of GNP spent on health. France and Germany have twice as many nurses as the UK. Yet these are high income countries where salaries cost a great deal.
On the other hand, the noble Lord, Lord Desai, mentioned our efficiency in this area. We are incredibly efficient if one considers the number of operations performed; the number of patients seen by doctors in surgeries: and the number of day operations performed. We are top of all the league tables in those respects. However, are we in danger of confusing quantity with quality? Why am I, a British woman in my early 60s, more likely to die if I have a heart attack here in Britain than if I have one in France? Why are our survival rates from cancer so poor? Why is my husband, who has a totally untroubling and slight hernia, being taken into day surgery next week when there are urgent cancer operations which have had to be postponed for week after week after week?
I believe that we have become transfixed by quantitative indicators and that we have lost sight of the qualitative. It is cheaper in the long run to pay nurses decent salaries, to train them and to keep them in teams in our hospitals than to continue down the present route of outsourcing nursing services. It is cheaper to recruit more doctors than to lose so many to the present very high levels of stress and early retirement. If we could measure the quality of life, we should see that it is infinitely cheaper to provide a new hip quickly now than to allow people to suffer the pain, the inconvenience and the costs of waiting two or three years for an operation.
We need to rethink where the health service is going. The Government's record is not brilliant. I believe that they inherited a very flawed system, which has been made unnecessarily difficult by their acceptance of the budget set by the Conservatives. I applaud some of the
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initiatives that have been taken—NHS Direct, for example—but the Government have failed to do with the health service what they failed to do in education: to rethink the ethos of the public service.
I join the noble Baroness, Lady Cumberlege, in suggesting that we need to look forward and that we should explore different initiatives.
Lord Burlison: My Lords, perhaps I may remind the noble Baroness that this is a timed debate and that she has exceeded her time.
Baroness Sharp of Guildford: My Lords, I am finishing. We need to explore different initiatives and we need to go forward from here.
4.31 p.m.
Lord Forsyth of Drumlean: My Lords, in listening to the debate, I find myself in an extraordinary position. I congratulate my noble friend Lady Cumberlege for initiating it because not only has she given us an opportunity to discuss this matter at a topical time— she delivered a splendid speech, if I may say so, summarising the position and drawing on her considerable experience—but I believe she may have given the Minister and the Government a window of opportunity. Listening to the debate and the speeches, it is quite clear that the view, certainly in this House, as in the country, is that the game is up. The days of pretending that it is possible to have the kind of health service that our people are entitled to and, at the same time, pledging no tax increases, are at an end unless other sources of funding to meet the needs of the health service are being suggested.
The Government, through the discussions which take place in the Budget, are effectively setting a ceiling on the quality and quantity of healthcare that people may have in this country, and are also preventing alternative providers from providing competition to the health service and thereby improving quality. At the end of the debate the Minister should say that two things have changed. He should say, "We are going to stop claiming that we can have the health service that we all believe that we need and to which our people are entitled without finding additional resources"; and he should say also, "We shall stop going around saying that we have the best health service in the world'.
If we are talking about the people in the health service—the doctors, the nurses and all the others—I am prepared to accept that we may very well have the best health service in the world. But if we are talking about the resources and the range of treatments available to patients, it is no longer the case. A number of suggestions have been made in the debate for additional sources of revenue.
Can we please end this partisan, political point scoring of whose statistics on the health service 'were better; who spent more money; who did what. The truth is that we all tried to do what we could for the health service—we have all seen the budget increasing—but we have all shied away from ideas such as hypothecation and insurance. If the Tories

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stand up and say, "Insurance", the Labour Party stands up and says, "Private insurance is privatisation. They want to destroy the health service", whereas the truth is that you can have mutually funded insurance schemes and privately funded health insurance schemes. As my noble friend Lord Crickhowell indicated, such schemes need to be looked at.
I have been surprised by some of the figures I have seen in articles in the press—mainly driven by the excellent work carried out by Dr. David Green of the Institute of Economic Affairs—on comparisons with other countries in Europe. For example, he has estimated that if we were to match the percentage of the GDP spent on health by Germany, we would have to spend an extra £30 billion. That would mean— assuming no reduction in yield—an increase in the basic rate of tax of nearly 12 pence. Not even the Prime Minister, Mr. Blair, can deliver that kind of additional resource without contemplating that kind of increase in tax.
My noble friend Lord Biffen said that it may not be necessary to increase spending by that amount, but, as the noble Baroness, Lady Sharp, pointed out, we need to look at the outcomes in these countries and compare them with the outcomes in this country to see the extent to which our people are being cheated. A British person is twice as likely to die from heart disease as his neighbours across the Channel. That is not all down to diet. Lung cancer patients in Germany have twice the five-year survival rate as patients in Britain. Women with ovarian cancer have a 30 per cent chance of surviving for five years in the United Kingdom; in Sweden it is 45 per cent. Other countries in Europe, such as France and Germany—and some of them have pretty socialist governments—do not find it necessary to have the state running the hospitals, employing all the nurses, employing all the doctors and funding all their healthcare out of taxes. Is it just possible that we might be out of step with the others and that we might learn from their experience?
The Government will claim that they are spending more—as indeed they are—but they are also introducing rationing. For the first time the drugs budget in the NHS is cash limited. I have a brief from Central Office but I am not going to read out any of the examples. We all read the newspapers; we know that people are not getting the cancer drugs they need; we know that there is postcode rationing. I do the Minister the courtesy of acknowledging that he would not wish it to be the case, but it is the case that we have rationing and it is the case that the Government's organisation—paradoxically called NICE—has a brief to take that forward on an institutionalised basis.
One of the things that I miss about being in this House rather than in the other place is the constituency post. I made some enquiries about the constituency post of someone I trust implicitly—my wife. She has been a House of Commons secretary for 20 years; 14 years with me. She tells me that she has never seen a constituency post on the health service such as is coming in now: tales of people on trolleys; tales of people in difficulty. I know that every January is the
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same: there is always a crisis in the health service. It was the same under the previous government; it is the same under this Government. The reason for the crisis is that we are not able to staff for the peaks of demand. Whatever speeches are made, whatever inquiries are made, whatever initiatives are taken by the Government, I can guarantee that next January there will be another crisis in the health service. There is a crisis of manpower and funding which needs to be urgently addressed.
Insurance schemes could add resources. The withdrawal of the tax relief on private insurance has resulted in a quarter of a million people cancelling their policies. That is a quarter of a million people—whose medical care will have to be funded out of an overstretched budget—who would otherwise have added to the resources of the health service as a whole. There is a philosophical question here. Surely as people get wealthier they should be asked to make more of a contribution towards their health care. They certainly should not be prevented from doing so, which appears to be the prevalent view in certain quarters.
We do not have to have a service which depends on staff being overstretched and overworked. In this day and age, it is ridiculous that we rely on doctors who work 60 and 70 hours a week to carry out their tasks.
Finally, I do not know how he does it, but the Prime Minister seems to lead a charmed life. He is standing high in the opinion polls; he is respected in the country; and he was elected on a platform to do something about the health service. He is uniquely placed now to take action on the funding of the service, to set up a Commission to look at the funding and to try to proceed on an all-party basis. His administration will then be remembered as one that did something of real worth for our country.
4.39 p.m.
Baroness McIntosh of Hudnall: My Lords, I join other noble Lords in thanking the noble Baroness, Lady Cumberlege, for initiating the debate, to which I contribute with great humility.
I cannot match the knowledge and expertise manifest in some of the speeches that have preceded mine, and which will no doubt be further manifest in those that come after. I have never worked in or around the National Health Service and I am glad to say that, so far, my family and I have had need to use it relatively sparingly. None the less, I regard it as one of the UK's—and, I venture to say, the Labour Party's—finest 20th century achievements.
In referring to the NHS specifically as a 20th century achievement, I should like to draw attention not to the difficulties and disappointments of the present—on which some noble Lords have understandably wished to dwell—but to the challenges of the future; and, in particular, how we can learn to understand and make better use of the health services that will be available to us as the century goes forward.
As medical science and technology have advanced, which—as other noble Lords have pointed out—they have done at a startling rate over the past 30 years, the

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expectation has grown that medicine can and should put right all the ills to which flesh is heir. As others have said, it is that level of expectation as much as any other factor which is putting the National Health Service under such intense strain. If such expectation grows unmediated by informed public debate, it will never be satisfied, no matter how much money is flung into its open mouth.
It is reasonable to expect that our taxes will be used wisely to provide a comprehensive and inclusive health service. There has never been any question about the Government's support for that principle, which perhaps could not always have been said of the previous administration. The Government have done a great deal in their short life to improve the quality and reach of the NHS, adding both significant new money and important new initiatives, such as the introduction of NHS Direct and NICE. But in respect of health services, we are extremely disinclined to accept that we cannot have everything, that choices have to be made and that systems have to change. It seems to me unlikely that we shall ever arrive in Utopia, where enough is not only available but seen and understood to be so by everyone. We shall always face great questions about the allocation of resources. Making the best use of resources, both human and financial, will require in future a commitment from each and all of us to understand what we can and, equally importantly, what we cannot expect a health service to deliver.
In recent years we have learned to identify ourselves primarily as "customers" or "consumers". All organisations supplying products and services have had to adjust to the idea that the customer rules. Of course that is not in itself a bad thing; indeed, in many respects, it is a good thing. We should expect that those who provide us with milk, gas, insurance, or, indeed, theatre, will do so in a way that suits us. If they do not, we can take our custom elsewhere the next time we want something similar. But we have come to apply the customer test to everything and I wonder whether seeing ourselves as consumers" of healthcare is, as it were, healthy.
Of course, the old-fashioned paternalistic model of the doctor/patient relationship will no longer do. We have seen in recent days, unfortunately, a dreadful example of what may happen when it is too heavily relied upon. But that relationship between ourselves as patients and our doctors as service providers, whether they be general practitioners or the hospital services to which we turn, is not like the one we have with the gas company with which we contract for a safe supply of gas at an agreed price. It is, or should be, much more in the nature of a partnership—and indeed, that is how it is now often described. The point about a partnership is, of course, that both parties have expertise to offer and responsibilities to discharge.
I fear that if we cannot learn to see ourselves as active participants in decisions about our own health, rather than merely as consumers of a service, we shall never become sophisticated enough as a society to deal with the complex, and often contradictory, challenges
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with which advances in medical science, demographic change and constrained resources will increasingly present us.
The way that the NHS and health issues in general are discussed in the press and other media has not always helped us to think constructively about the difficult questions we face. The relentless concentration on crisis and on individual cases, whether, as it were, "tragic" or "miraculous", distorts our perceptions, creating heroes, fuelling witchhunts and appealing to sentiment rather than reason.
One most revealing recent example concerns the case of Jaymee Bowen, otherwise known as "Child B", who, noble Lords may remember, died aged 11 of leukaemia in May 1996 following a highly-publicised confrontation between her father and the Cambridge Health Authority over whether she should receive further treatment. A team of researchers al the University of York analysed the media coverage generated by the case. How confused and reductive public debate on that issue may become is illustrated by what they show. That is not to say that the matter was not treated seriously by the media, which it certainly was; nor that all commentary was simplistic, which it certainly was not. The question is whether we, the public, were equipped to make sense of the information available.
I should like to highlight a few of the conclusions reached by the research team, which seem to have general application:
"Media coverage of the Child B case might be seen as an indicator of a widespread expectation that modern medicine can cure every ill and provide a solution to every problem.
It is not clear to what extent media coverage of this case would have helped people understand the limited nature of available research evidence about the effectiveness of health care interventions or about the inherent uncertainty attached to medical decision making.
Our study suggests that while the media may raise awareness of the issues which need debating, and may influence people's perceptions of these issues, they do not provide a solid base of information which would allow people to participate in debates in a particularly informed way, and their coverage itself does not constitute a full public debate".
It is not my intention to lay all the blame for the inadequacy of public understanding entirely at the door of the media. That would be easy, but hypocritical. If we are to do better in future, it will not be through pointing the finger in that way, or indeed, in any other way. It has been helpful that a number of noble Lords have referred to the NHS as an issue which needs to be dealt with in a non-partisan, nonparty-political way. However, if we are to raise the standard of debate, we must do so by devoting more time and energy within our education system to addressing some of the painful choices which will face us both as individuals and as a community. The reality is that living in a grown-up democracy means living with complexity and contradiction, and, as T S Eliot famously remarked,
"Human kind cannot take very much reality".
I hope that your Lordships will forgive me if, at this late moment, I briefly introduce a subject dear to my heart: the use of the arts in education. One of the best

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ways of helping young people to get to grips with difficult issues and to recognise the personal responsibility involved in good citizenship is by using the arts as a medium for discussion. On a previous occasion I have drawn the House's attention to several examples of how that can work, particularly in the area of health, and I know that the Government are interested in, and supportive of, some of the initiatives already under way.
The Government have not shirked the challenges that sustaining a comprehensive National Health Service presents. However, we cannot leave it to Government alone to face those challenges. The future health of the National Health Service lies in our collective ability to value it, support it and understand it in an informed, mature way. I do not expect that that can be achieved overnight, but I hope that we can by slow degrees reduce the danger that public perception of difficult issues will for ever be dominated by political opportunism and journalistic hype.
4.48 p.m.
Baroness Emerton: My Lords, I thank the noble Baroness, Lady Cumberlege, for introducing this important debate on the state of the NHS. There is no doubt that in this country we have much to be proud of within the NHS. The recent millennium preparations demonstrated how good interagency planning can deliver a service to meet the needs of patients. I hope that the excellent work undertaken will not be put aside, but developed still further. However, the millennium period was followed, as we have already heard, by extreme pressure on the services due to the outbreak of influenza and its complications. Those pressures, which were referred to as "winter pressures", cannot be ignored.
Research evidence shows that an efficient hospital runs at 85 to 86 per cent occupancy. My experience is that the hospitals in the trust which I currently chair are running at 96 to 98 per cent—sometimes 99 per cent—occupancy, and not just confined to winter pressures. I understand that that experience is shared by many other trusts, as was stated by the noble Lord, Lord Clement-Jones, earlier in the debate. That cannot be an efficient way of running the health service.
There is no doubt that the health inflation rate is not met by the national inflation rate. It is perhaps best described as an irresistible force of healthcare demand and the requirement for quality service meeting the immovable object of inadequate resources—for example, in bed capacity, especially in intensive care units; shortage of manpower and money; and with ever increasing numbers of elderly people in the population requiring more healthcare. Research shows that elderly people—those over the age of 85—need four times as much healthcare as those aged 65 to 75. The Government have allocated 6.7 per cent more cash. However, once the unfunded pay awards and the European working time directive, which will take up 2.5 per cent. the NHS superannuation pension scheme, 1 per cent. prescribing cost increases, 2 per cent. and inflation increases, 2.5 per cent. have been deducted
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then, when allowing for a planned 3 per cent efficiency gain, there is little resource available for health authorities to allocate to primary care groups and NHS trusts, where there are competing priorities—for example, in replacing out of date equipment essential for modern diagnostic and treatment procedures, investment to meet the target of single sex wards, to say nothing of the manpower requirements in all healthcare professions and the exciting new models in primary healthcare teams and community developments.
The NHS is one of the largest and most complex organisations in the United Kingdom. The Government's policy to modernise the NHS is welcomed by, I would say, almost all health professionals. But change cannot happen overnight. There is a need for time, for change management expertise and for resources to effect the changes. Currently, employees—be they managers, doctors, nurses, physiotherapists, pharmacists, to name but a few—are all engaged in the day-to-day delivery of care, desperately trying to maintain high quality care and to meet government imperatives on waiting times. The reconfiguration of services requires clinicians to spend time discussing, planning and programming changes to their services. Yet they are expected to continue with their clinical programmes. To attain the modernisation programme, a realisable target timetable must be set and there must be the manpower resource to plan and implement it, which requires additional resources. Can the Minister indicate the Government's intention with regard to resources being made available for planning and implementing the modernisation programme?
Within the past 10 years, the nursing profession has been transformed into a more confident forward-looking profession with enormous potential to prevent disease, provide high quality care for the sick and promote healthier lifestyles. One example of the way in which a more cost-effective and more efficient service could be established is to expand the various models of high quality, cost-effective healthcare through nurse-led services, NHS Direct, assessment and pain control clinics, screening clinics, specialist roles in endoscopy, colonoscopy, nurse practitioners, Hospital at Home services and a range of community services within the primary healthcare team and expansion of the nurse prescribing programme. It would be helpful if the Minister could say whether the development of these nurse-led models which result in high quality cost-effective healthcare will be supported by the Government? For example, one of the UK studies demonstrated that nurse practitioners were more cost-effective in all areas of care, with 84 per cent of patients reporting a high degree of satisfaction. Hourly rates for a nurse practitioner are £11 to £15 compared with £25 for a general practitioner.
The promotion of the integration of clinical services and information for health within the framework of clinical governance is an integral part of delivering a high quality health service. We need reassurance that there will be a continued drive by the Government to implement that.

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The NHS is very important to the people of the UK. The healthcare professionals a re dedicated to providing a high quality service. That dedication needs to be fostered before good will runs out. There is a limit to how much more pressure the current workforce can take. As was pointed out by the noble Baroness, Lady Sharp, earlier in the debate, nurses are resigning. I urge the Minister to bear this in mind as the Government unfold the much needed modernisation programme, which needs to be more radical. As the noble Lord, Lord Forsyth, suggested, this debate presents a window of opportunity.
4.56 p.m.
Lord Rea: My Lords, noble Lords may have some apprehension at the prospect of being addressed by a GP such as myself, with a grey beard and a grey moustache, but I can reassure the House that I have no malevolent intentions. As the Shipman case is still headline news, perhaps I may welcome the Secretary of State's prompt and wise choice of the noble Lord, Lord Laming, to head the inquiry into the case. I am sure that most doctors will agree that the General Medical Council should tighten its follow-up procedures for those doctors who have been disciplined, as was Dr Shipman in 1977. Single-handed practitioners need particular support and appraisal.
The paradox of Dr Shipman is that he seems to have been a good Dr Jekyll when he was not being a Mr Hyde—apparently, a caring, concerned man in whom many put their trust; in fact, the very kind of doctor who was typical of a past era that is mourned by many. The current stereotype of a general practitioner or a hospital doctor is one who is in a hurry, under stress and has a reductionist or technical approach. As my noble friend Lord Walton said, that may play a part in the current popularity of complementary and alternative medicine.
I intend to raise three points and spend perhaps one and a half or two minutes on each. My first point concerns NHS Direct. It is a popular service and is now to be expanded. What evaluation of the service has or is being done? When can we expect to see a report? I was always sorry that the scheme was not integrated more closely with primary care groups—in particular, GP off-duty rotas or co-operative schemes—or that it did not involve practice nurses. Perhaps more practice nurses could have been added to practices for that purpose. They would be able to liaise more directly with GPs when that was necessary, as it so often is. It is not too late to do that. Continuity of care would be much better if there were closer local links between the nurses who give advice through NHS Direct and local primary care groups or practices. Perhaps my noble friend will be able to give a progress report.
I turn to the present bed crisis—always with us at this time of the year but particularly acute this time round. I am concerned that the PFI-built hospitals now coming on stream will exacerbate the problem rather than solve it. In nearly every case fewer beds are
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provided in the newly built PFI hospitals than in those they replace. For instance, according to a BMA report in May last year, at Dartford hospital,
"The loss of 75 beds compared with the existing provision in the three hospitals will require a further shift to more out-patient and day case treatment".
"Yet hospital consultants already work on average more than 51 hours a week, and 1 in 6 junior doctors is working in excess of 56 hours each week. The BMA regards a rise in work intensity of this nature as unsustainable"—
let alone the burden on nurses, which is equally great.
Regarding the new PFI-built Royal Infirmary in Edinburgh, in which bed numbers will fall by no less than 21 per cent.
"The British Medical Association has warned for several years that the hospital would prove to be too small given the need to provide a profit margin to the PFI consortium".
The PFI has been very useful in giving a boost to the hospital building programme, but it seems that short-term gain is being obtained at long-term cost—not only in numbers of beds and pressure on staff, but also by passing higher than necessary interest rates on to future taxpayers, whose governments will have to find the money from their current National Health Service expenditure, causing costs to escalate further. The British Medical Journal uses the phrase, "perfidious financial idiocy", in describing the PFI. I hope that we shall have time later in this parliamentary Session to discuss the whole issue of the PFI and how it is developing.
Finally, I should like to congratulate the Prime Minister on his avowed goal of reaching the average European Union percentage of GDP spent on health. We must beware, however, that it is a moving target. As we still spend a lower proportion of our health budget on administration than other EU countries, we should do quite well if we can reach that average, providing we continue to fund the NHS, as we do now, from general taxation, as well as possibly from national insurance contributions with the upper ceiling removed. That might have the same effect as the proposal of the noble Baroness, Lady Cumberlege. I am also attracted to the hypothecated tax suggested by my noble friend Lord Walton.
My main fear is that increased funding for the National Health Service will result in a reduction in resources for the other departments whose responsibilities have an equal or greater effect on the health of the population than the National Health Service. The major public health problem in the United Kingdom—and for that matter most of the rest of the world—is the inequality in the health of the poorest and that of the better-off. Poverty, poor education, poor housing and inequity of income lie at the root of this, as has been shown in study after study.
In his introduction to a new book, The widening gap, published by a team from Bristol University, Professor Peter Townsend states:
"If the Conservative government had not reduced social security benefits, it can be estimated that the poorest 20% of the population would today have about £5bn. or 20%, more in aggregate disposable income, that the ratio between the richest

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and poorest 20% would be reduced from about 9:1 … to 5:1, and that poverty by European standards would have been reduced by more than a third".
A greater long-term gain in the health of the nation would be achieved by eliminating poverty and reducing income inequity than any amount of expenditure on the National Health Service. An improved National Health Service is politically and socially necessary. But the Government should not deviate from their main self-appointed task; namely, to work towards a fairer society. That would also be a happier and healthier society.
5.4 p.m.
Lord Chadlington: My Lords, I am, in common with other noble Lords, most grateful to my noble friend Lady Cumberlege for introducing this important debate.
As always, my noble friend has spoken with customary grace and good sense. In a weak reflection of those excellent opening words I, too, urge the Minister to ask whether the time has not come for the health service to be taken out of the day by day political ping-pong and point scoring of modern politics. Is it beyond the resolve of all the political parties to find common ground on certain aspects of, for example, the NHS delivery system? There seems to me to be something fundamentally unacceptable about political point scoring when dealing with the health and lives of the people of Britain; the health and lives of the very people we in these Houses of Parliament are here to serve.
When I was a member of the NHS Policy Board between 1991 and 1995 there was much debate, often encouraged by my noble friend Lady Cumberlege, about the possibilities of establishing an independent board to run the NHS, staffed by executives and non-executives from the private sector, thus distancing these day by day issues from the politics of the day.
However that is done, the need is urgent: put the NHS above party politics, agree common ground across the main parties and establish long-term strategies to invest in and develop the NHS which will not be altered on political whim or simply when there is a change of government.
The opportunity is dramatic. The scale is enormous: a million people working in the NHS; 800,000 people treated every week in hospital out-patients departments; 700,000 going to a dentist; 8.5 million prescriptions; 10,000 babies delivered; £47 billion of public money a year.
Consistent with fulfilling the constraints of the proper stewardship of public funds, as other noble Lords have said, we must find a way of rebuilding public confidence in the NHS. In the White Paper, The New NHS: modern, dependable, prepared in December 1997, the Government propose,
"to rebuild public confidence in the NHS as a public service, accountable to patients, open to the public and shaped by their views".
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In a similar debate a year ago, I urged the Government to trumpet the everyday triumphs of the NHS. I have just listed the vast weekly output of the NHS. Much is wrong, but the overwhelming majority of its activities are not subjects of complaint or dissatisfaction. To the contrary, many of those who use the NHS praise its quality and praise those employed within it. Those achievements go largely unheralded.
I spoke previously of the importance of building a reservoir of goodwill upon which to draw when things go wrong. The goodwill towards the NHS is too often lost by one single picture in one single tabloid suggesting that the norm is a bed in a corridor or the inability to afford certain drugs or treatments. We should not rest until those inequalities are removed, but they are still the exception and not the rule.
But the good news of the NHS—so essential to the confidence of patients and to the morale of all those who work with such selfless determination within it—has not been promoted. In fact, the situation has deteriorated. In the light of my earlier comments on de-politicising the NHS, I turn, rather reluctantly, to the Government's record. I do so because it underlines once more the public dissatisfaction with that politicisation, and adds weight to my noble friend's basic proposition.
A recent Gallup poll found that more than half the respondents confessed to dissatisfaction at the way in which the Government are running the NHS. A similar poll in the Observer reveals the depth of scepticism: two-thirds of the public simply do not believe that waiting lists are getting shorter. The same poll found that only one in three people expect the NHS to improve over the next three or four years.
But this is not just about perception; it is about reality. The New Labour manifesto declares:
"We want to save and modernise the NHS".
But let us consider the facts. Waiting lists, and their coverage in the media, are what the public see. They are the bell-wether of public confidence. Labour pledged in its manifesto to cut inpatient waiting lists by 100,000. However, while the headline waiting list figures have come down by 87,000, the number of those waiting for more than three months for outpatient appointments has more than doubled from 250,000 to half a million—solving one problem and creating another. We were promised that 18-month waits for inpatient treatment would be eliminated by 31st March 1998. At the end of November 1999, 69 patients had been waiting for inpatient treatment for longer than 18 months.
Seeing a specialist is not the end of the line. According to the NHS Quarterly Review, the number of last-minute cancelled operations rose from 11,470 in the second quarter of 1998–99 to over 12,000 in the second quarter of 1999–00. That was the highest ever second quarter figure since records began.
I also draw attention to waiting times to see a specialist in cases of suspected breast cancer. The Government's White Paper stated that by April 1999 everyone with suspected breast cancer would be able to

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see a specialist within two weeks of the GP deciding that the patient needed to be seen urgently. Figures available from the NHS Executive for the quarter ending September 1999 suggest that even six months after the deadline has passed this has not happened. Over 10 per cent of suspected breast cancer patients were not seen within the required two weeks. That is simply not acceptable.
I conclude with a five-point agenda. First, can we take some, much or all of the NHS out of the daily political exchange? Secondly, can we initiate a programme to publicise the successes of the NHS to raise the confidence of the public and the confidence and internal morale of the organisation? Thirdly, if this or any other government sets targets can we ensure that they are met? It is better to set low targets and build confidence than macho targets and fail. Fourthly, can we establish a better way to measure outputs which the media also regard as meaningful and can be agreed across the party divide, rather than the artificial measure of waiting lists?
The fifth point is the most worrying of all. For the first time there are strong indications that the public approval rating of the NHS is dropping among the young. It may be a blip but I believe that it is a trend. A political system which does not deliver a health service for the young of which they can be proud fails the country as a whole. As my noble friend Lord Forsyth of Drum lean clearly stated, it is a unique agenda for a young modernising Prime Minister to change for the better the future of every man, woman and child in this country. He should grasp it with courage and enthusiasm.
5.12 p.m.
Lord Davies of Oldham: My Lords, I express gratitude to the noble Baroness, Lady Cumberlege, for introducing this debate. She will recognise from the way in which she introduced this subject, and the subsequent speech of her noble friend Earl Howe on the Opposition Front Bench, that this debate poses as many problems for her side as for the Government. We all recognise that one of the great features of the National Health Service is the very long-term nature of the policies related to it. All of us who are involved in the public debate when the electorate makes its choice every four or five years in the general election recognise that the timespan of some issues, which are exceedingly difficult to deal with, goes way beyond that period. That is certainly true in considering the resources of the National Health Service.
It takes eight years to train a doctor and many more years before a newly-qualified doctor achieves consultancy status and can play a significant part in the health service. Therefore, it is inevitable that in this debate we use catch 'phrases to identify the particular priorities of the moment. We recognise the limited significance of a policy to reduce NHS waiting lists against a background where it is an earnest of intent by which the Government can be measured given the short timescale within which they are forced to operate. This debate gives us the opportunity to look
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at the longer term, and I hope that in the course of my short contribution I shall be able to concentrate on some of the issues in that context.
It is noticeable that in the debate thus far no one has commented on one contribution that the Government have already made to morale in the health service. I am all too well aware of the strains on health service staff at every level. Can anyone in this House recall when a government last decided to implement in full the recommendations of the review bodies concerned with health service pay and conditions? Surely, that is an earnest of very real intent.
But we accept that we have finite resources to meet an infinite demand. Demand increases with demographic changes. The ageing population alone increases the demands upon the health service. Technology, whether it be the development of new and expensive drugs or surgical techniques which become more generally available, produces its own cost escalator; and the expectations of people rise 'with every new discovery. Therefore, the inflation index that is appropriate for the health service is higher than that applied to the broader economy simply because NHS costs have an escalator within them. For that reason we need to concentrate on lower cost solutions.
There is no doubt that we can do a great deal more by concentrating on preventive rather than curative medicine. Emphasis on primary care and education, in whatever form, to ensure that people adopt strategies that make them less dependent on the expensive resources of the health service will assist. I also have in mind the more intelligent use of the support professions; for example pharmacy. In France, access to doctors is reduced because a significant amount of assistance is offered by pharmacists—far greater than ours are empowered to provide—at lower cost. We should look at international comparisons in relation to that practice, which I do not believe gives rise to concerns about political ideology.
I drafted one part of my speech in advance of the horrors of the past few days. I wanted to emphasise how important it was to change the relationship between those who consume health services—the general population—and the health professions. I find it difficult to express general points at this stage when the Shipman case illustrates with all its horror the particular problems that arise when a doctor abuses trust in such an extreme way. We all know that that was a bizarre, horrific and unique case, but, surely., the issue with which we should be concerned is the need for an effective way to measure performance and competence, let alone probity, to reassure people.
We should recognise the steps that the medical profession has taken to develop techniques to improve the measurement of competence. The assessment of GPs on a regular basis is being introduced. That system looks at whether a GP's practice, whatever his level of experience, is perhaps somewhat dated compared with the rapidly changing world in which we now live. His competence will now be adequately measured, and I believe that that will go a considerable way to meet the kinds of concerns raised by the

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previous speaker, who spoke about the re-establishment of confidence in health service delivery. I agree that that is of supreme importance to all of us.
Despite the general propositions referred to in this debate, how can there ever be division among well-meaning people as to the desirability of providing the best possible healthcare that the nation can afford? Perhaps I may add to the aspiration adumbrated by these and other Benches. There are considerable merits in a health service which provides care at the point of need irrespective of ability to pay.
However, as regards increasing resources, while we on this side of the House envisage great difficulty in increasing the tax burden upon our people, private insurance as a solution is a non-starter. At present, private insurance aids the queue jumper and the advantaged against the ordinary member of the public. Private insurance concentrates upon those who are good risks in healthcare rather than the poorest. The private health service concentrates upon operations with high success rates which are relatively cheap. And—one might ask the Americans about this—a private health service is enormously costly to administer.
5.20 p.m.
Lord Lucas: My Lords, we no longer have time for Ministers who say that there is no crisis in the National Health Service. Those of us involved in the service—I have seen a great deal of it in the past two years from a patient's point of view—can only conclude that the NHS is in deep and almost intractable crisis. It is a time for honesty, openness, and facing up to facts. We need to think long term. We need to cast aside dogma and—I look hard at my Front Bench—political point scoring.
Looking back, we had every reason to be proud of the health service. We are proud of the people who created it. We are grateful to the people who serve in it now. But it is hard to be proud of the NHS now. Why do we put up with waiting lists? Other countries do not have them. Waiting lists do not serve any clinical function; they cause a great deal of distress to those who endure them. Why should we put up with the fact that we are not seen by a doctor until after midnight when we have arrived at casualty at five o'clock with a broken leg? Why should a person have to wait in casualty for six hours to see a doctor when, for example, his child has swallowed a coin and has to be kept calm, without food or water? Why should we put up with hospitals which are decaying, under-staffed and under-equipped?
Why should we put up with GPs who are so overstretched that they have no time for patients or to keep themselves up-to-date with modern medicine? If I wanted to book an appointment it could be the middle of next week before the GP would see me.
We are an increasingly wealthy country. There is no reason why we should put up with a National Health Service in this condition. If we paid personally for the service, it would have gone long ago. We would not put
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up with being treated in that way by Tesco or any other supplier. It is only because it is paid for by government. It is because over the years my government and other parties have imposed cash limitations far below the amount that we, the people, would wish to see spent on healthcare that the service is in its present awful state.
We know that we have to pay more for the National Health Service. We do not need to look as far as Europe for a comparison. All we need to do in England is to bring our spending up to the standards that we provide for the Scots. The figure is 30 per cent higher per capita in Scotland than in England. I find it hard to understand how we can justify not bringing ourselves up to that standard. It proved impossible for my party to do so in the face of fire from the Labour Party on the financing of the National Health Service. It should be easier for the Labour Party to achieve that.
The solution is surely for the Government to involve all the people in the difficult decisions government must take. They must carry the public with them in decisions on how the NHS should be financed. If we were part of that decision-making process, we would not criticise the Government when they increase taxes or impose a specific levy to fund the NHS.
The Government should carry the public with them as regards the limitations of the NHS. Clearly there must be limitations because technology is racing ahead. Those limitations should be agreed by consensus. There must be a process whereby public opinion is taken into account by the NHS. Such a process was instituted as part of the GP fundholding scheme. While it may have had faults, it was a start in the right direction. Having destroyed that start, the Government have a duty to begin again.
We have to consider how we pay for the National Health Service. I share many of the doubts expressed by noble Lords opposite about the efficacy of insurance funding. It tends to introduce extra costs into the system. For instance, with car repairs insurance companies may pay twice the amount paid by the individual who pays for the repair himself. We should make comparisons with France, Germany and other countries which share similar beliefs about the social contract between government and people. There are other solutions to be considered.
The noble Lord, Lord Desai, raised some pertinent questions about a service which is free at the point of delivery "but you can't have it"—a form of rationing. We need to face up to these problems. We in this party need to ensure that we do not cast caltrops in the path of the Government merely to make their existence painful, thereby disadvantaging our citizens who need the Government to take long-term and difficult decisions.
We need a government who will give more information on the health service. We are becoming more capable, more involved citizens. In order to participate, we need information. We should institute a system of inspection. Clearly the results achieved by a doctor, say, in cancer surgery are significant. Some doctors achieve far better results than others

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performing similar operations. A patient cannot judge that. One does not know the circumstances or the patients. We need a qualified inspectorate. Those inspection reports need to be made public, at least to GPs. GPs need to be able to refer their patients to the specialist of their choice. We may be able to compare one hospital with another but a GP has no choice for referral. He has to take what the local hospital offers. That is not good enough. We need choice for GPs and for patients.
We also need choice as regards conditions in hospitals. It is possible to find one ward in a hospital where the quality of nursing care makes one think one is being looked after by angels; and 30 yards away in another ward the staff have horns and pitchforks and make the patient's life a misery. There is no control or check. There is no auditing of the quality of care for patients. We need proper information about what is happening within the NHS.
People who work within the NHS need to be able to keep up to date with information. The systems are primitive. There is so much information that it is hard to absorb. The Internet will be a great boon, in particular when we have high data rates on it. The Government should pay a great deal of attention to that aspect.
We need a fundamental consideration of the roles of those working within the NHS. Why do we insist that an individual who wishes to become a GP has three of the best A-levels? We want them to like people and to have a certain amount of common sense. We are training the wrong people for the wrong job.
We need to ask many questions. We should not make it difficult for the Government to answer them. We should judge whether the Government are prepared to address those issues honestly and openly, and involve us in the discussions.
5.30 p.m.
Lord Harris of Haringey: My Lords, I declare an interest, first, as a non-executive director of the London Ambulance Service and, secondly, as adviser to a number of companies with an involvement in health matters. Perhaps I may thank the noble Baroness, Lady Cumberlege, for introducing the debate. She has a long history within he health service and our paths have crossed on a number of occasions in various guises.
The noble Baroness made a most interesting speech. Most notably she spoke of the inexperience of today's top management team in the NHS which is subject to the capriciousness of political change. That made me think about my time from 1987 to 1998 as director of the Association of Community Health Councils. I calculated that I got through seven Secretaries of State for Health. Six of them were Conservative and I claim no part in that. However, I remember them all vividly because at one stage or another they all publicly denounced me—as did my right honourable friend Frank Dobson when he was Secretary of State. Clearly, I was doing something right—or wrong— during that period.
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However, to say that there is a problem with the NHS because of that political system of management raises big and wide issues about our system of government. I suspect that they are beyond the terms of the debate and perhaps beyond the terms of the noble Baroness's proposals.
Having heard the speech of the noble Lord, Lord Chadlington, I am confident that the purpose of the debate is not to capitalise on the difficult few weeks experienced by the NHS and indulge in political point scoring. After all, we are in what the noble Lord, Lord Forsyth, called the annual January crisis. But the events of the past few weeks have triggered a significant debate on NHS funding which I believe has been based on false premises. The speech of the noble Lord, Lord Lucas, pointed up the problems with the Conservative's solution of insurance: that it is likely to cost a lot more. We shall require a greater contribution from GDP if we go down that route.
It must be recognised, first, that the NHS cannot do everything for everybody and it is proper to debate the limits to what is or is not appropriate for the health service. But it is also proper and right to debate the effectiveness not only of new treatments and drugs but of existing and long-established treatments. It used to be said that only 10 per cent of treatments were proven to be beneficial, that another 10 per cent were probably harmful and that the rest were unproven one way or the other. I am sure that that is apocryphal and I am not sure that anyone is in a position to test it. However, it is right and proper that we should institute arrangements which demonstrate whether the bulk of expenditure in the health service on particular treatments and procedures is well spent, appropriate and in the interests of the public.
In that context, the promise made by the Prime Minister on David Frost's sofa is enormously important. It is probably the most important statement made about the future of the health service for many years. It is a major long-term commitment of government investment in the NHS. However, I am worried that the tone of the debate has often suggested that the NHS is a drain on the nation's GDP. In fact, it makes a major contribution because the fact that the NHS succeeds in making us healthier means that we are all able to make a greater contribution to the nation's income.
The Government have already done a great deal for the health service. There has been a substantial cash improvement—more in real terms per annum than during previous governments. A major building programme is under way. The Government have recognised the importance of quality, introduced clinical governance and the Commission for Health Improvement. They have brought general practice into the managed framework of the NHS, which, as the NHS Confederation points out, is crucial in enabling improvements to quality. They have introduced the national service frameworks and they are introducing the drop-in centres and NHS Direct.
The noble Baroness, Lady Cumberlege, talked about her two reports and the theme of giving people power. There is a trend which one can discern over a

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number of years; first, from a time when we all expected doctor-led decision-taking: the doctor knew best. More recently, there has been an expectation that doctors will listen; that the GPs will take decisions having elicited the patients' views.
We are now moving into an era in which we should expect shared decision-taking; where the GP and the patient share information and then together reach a decision on the appropriate course of action. But I suspect that we shall rapidly reach a place where there is patient-led decision- taking; where the GP provides the information and advice and the patient decides on the basis of it.
Yesterday, I spoke to a GP who confirms that most days someone visits his surgery who has already looked up his condition on the Internet and is equipped with a great deal of information about it. I am told that statistics show that half of Internet users access health sites. Indeed, health matters are almost as popular as pornography on the Internet!
However, using the Internet, it is difficult to find specific information in respect of health. There must be questions about whether or not the information provided is accurate. Often it is sponsored by those with an interest; for example, a drug company. So what the public need is evidence-based information to help them make decisions. It could come through NHS Direct, whether by telephone or the new Internet service, but also through leaflets and videos. Most patients welcome more information. It leads to less conflict with doctors and it changes behaviour. There is evidence, for example, that surgery intervention in prostate treatment declines substantially if people are provided with sufficient information. Patient information leads to better healthcare, better compliance and better outcomes.
I am concerned that NHS Direct is being offered as a solution to the problems which may or may not exist in acute care. The monitoring information that I have seen about one pilot suggested that, yes, it was true that the number of people who were otherwise planning to call an ambulance or take themselves to A&E were persuaded that that was unnecessary. However, a larger number than those who were dissuaded, who had been planning perhaps to wait and see their GPs, were told to go to A&E or to call the ambulance service. Therefore, it is a fallacy to believe that these services will reduce demand on acute services.
My view is that NHS Direct and the drop-in centres are new, valuable services but they might not reduce pressure on established areas of service. They provide an opportunity to create a modern people's NHS. As NHS Direct protocols develop, and as the computer systems develop, there is an opportunity to provide a universal system of triage; one which can be applicable in a GP's surgery, a hospital waiting room and used in a variety of contexts. Once you give everyone a smart card and unique IDs containing their medical records, that information can be accessed as part of the service,
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forming something which is truly interactive. Vitally important opportunities exist and they must not be lost because people expect too much from NHS Direct.
The NHS is popular; it is a people's service, and it needs to prepare for the future in which patients expect much more in the way of information, choice and respect from NHS professionals.
5.38 p.m.
Lord Addington: My Lords, I thank the noble Baroness for introducing the debate. I hope that noble Lords will bear with me if I go off at a slight tangent, although I do not believe that I shall be totally alone.
Most of the debate has been about someone dealing with a pool of water in his house. I want to talk about prevention; in other words, I shall be the person who says, "You should have had that pipe fixed", and not offer to get a bucket to get rid of the water.
Much of what is done in the health service involves people who suffer from a more sedentary lifestyle. We are always hearing about bad sport facilities at schools, fat teenagers and the problems of obesity. A great deal of that is due to the fact that we lead a sedentary lifestyle: we do not walk to work and most jobs do not involve physical activity. That has led to huge cultural shifts and certain medical gains. People no longer have compressed spines or arthritis in their fingers. However, it is undeniable that lack of physical activity leads to health problems early on in life.
However, the discipline of sports medicine may be able to help with those problems through the better training of doctors to give advice. Sports medicine does not exclusively address sport and most certainly does not concentrate only on sport at the elite level. Athletes working at the elite level are operating at 100 per cent of their physical capacity in one particular narrow range of activity. Usually they are trying for 101 per cent. I would not expect the NHS to deal with such activities, for the simple reason that if an athlete had to join a waiting list to get help with a fitness regime for an international event, the athlete would miss the event and clog up the system.
In 1977 a definition of sports medicine was universally adopted, brought forward from the foundation of the Institute for Cardiology and Sports Medicine in Cologne in 1958:
"Sports medicine includes those theoretical and practical branches of medicine which investigate the influence of exercise, training, and sport on healthy and ill people, as well as the effects of lack of exercise, to produce useful results for prevention. therapy, rehabilitation and the athlete".
That suggests that we can learn from sports medicine.
Unfortunately there is no career structure in this field within the medical system of the National Health Service. There is no provision for people to be trained. The House has just heard a speech which rightly pointed out that information is extremely helpful. Doctors need to be able to give out accurate information, but often doctors are not well qualified to help their patients with lifestyle information.

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I approach this subject from the point of view of a sportsman, complete with the familiar horror stories that are shared by many sportsmen of my age. When you visited the GP with a leg injury, he would stare blankly as you described what had happened and then say, "Rest for six weeks". If pressed, he would then say, "Rest for 12 weeks". The muscle on the damaged leg would lose both quantity and quality, the ligaments would shorten and the entire limb would be weaker. When you returned to play there was an excellent chance of incurring the same injury again.
All forms of exercise can be of benefit and all forms of exercise enable people to become healthier individuals. The athlete is only an extreme example of that. Older people would benefit from exercise by becoming healthier. In old age one or the main forms of disability is when a person can no longer achieve a sitting position unaided. That is in fact a definition of disability. It is caused by loss of muscle tone and quality. Osteoporosis is helped by changing from a sedentary lifestyle. The simple act of walking will toughen bones. Such activity—I shall not go into detail because far too many doctors are contributing to the debate today—must be encouraged.
However, unless doctors are trained to give correct advice, which at the moment they are not, the problems will continue. While I appreciate that the general medical education of doctors will cover all these areas, doctors—like everyone else—need plenty of specific information. That is because they are important conduits of information to help everyone achieve a healthier lifestyle.
Furthermore, provision must be made for everyone to be able to change to a healthier way of life. Diet is of course vitally important, along with adequate advice on alcohol consumption and smoking. Nevertheless, concentration on physical activity is one of the most effective methods of achieving better health. However, if you live in a town with no gymnasium or swimming pool—in recent years my own City of Norwich has lost two of its public gymnasiums and a swimming pool—it can be very difficult indeed to take proper exercise. Trained staff must also be on hand to give accurate advice and help to implement the doctor's plans. If this form of medicine were taken more seriously, by ensuring that consultant posts were established, that would send a clear message and provide a strong incentive for the area to expand.
I do not know whether the provision of gymnasiums should be part of the remit of the health service, but I do believe that they could be justified as part of a wider health programme. Such provision would eventually cut down on the number of people making demands on the health service. A healthy and strong person will throw off the effects of flu far more speedily than someone who is not. We should adopt a holistic approach and, to an extent, implement joined-up government in this area. If we did this, we might also produce a few more first-class athletes, as well as get rid of some podgy teenagers.
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I believe that well-structured fitness regimes forming part of the whole healthcare programme would have many benefits. For instance, it would be possible to speak at length on the wider benefits of sports activities such as greater social inclusion. However, until the entire approach to fitness and exercise changes, we shall not be able to deal with increasing levels of poor health that are the result of the basic fact that people have allowed themselves to deteriorate and are looking to the National Health Service to provide a Band-Aid for a bad lifestyle.
5.45 p.m.
Baroness Hogg: My Lords, I am delighted to rise from my sedentary position and congratulate my noble friend Lady Cumberlege on her timeliness in initiating this debate. Its quality attests to the high standard she set in her introduction. Since the wider health debate erupted recently, I felt at first a twinge of sympathy, first, for the noble Lord, Lord Winston, on whose Select Committee I have had the honour to serve, and, secondly—dare I say this?—for the Prime Minister. That is because I have been there. An interview hits the headlines, the Prime Minister must respond, somebody grabs a line to take, the Treasury erupts and the department has not got a clue what the Prime Minister is talking about. It is all very familiar.
However, my sympathy has been somewhat eroded because of a tendency on the part of the Government to cover up confusion about the figures by saying that it is someone else's fault, notably the Government's predecessors. I am glad to say, however, that this afternoon's debate has been almost entirely free of such comments. However, I have taken the trouble to make some basic calculations derived from published data. If one examines what has happened to net spending on the health service over the past decade, it is clear that over the seven years of the premiership of the previous Prime Minister, real spending on the health service increased by 3.5 per cent a year. In the first two years of this Government, net spending has increased by 3 per cent a year. I mention that not so much to make a statistical point, but to emphasise the importance of looking at outcomes. As anyone who has ever battled over numbers with the Treasury knows, the truth is that plans rarely turn out exactly as may have been indicated.
That is not only because of annual juggling to cope with temporary crises, but because those plans also depend on forecasts for inflation. Even with the low levels of inflation this Government were lucky enough to inherit, small movements in inflation can push the real increase in health spending up or down by as much as one half. That is why it is important to focus on outcomes because that enables one to look at what has happened to costs in the health service. Many speakers have emphasised the fact that costs in the health service do not always move in line with costs in the economy as a whole. Over the past two years, it is clear that the Government have been squeezing down costs, basically by holding down health service pay.

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I do not believe for one moment that there is some kind of entitlement to a rate of pay. However, I do say that those who run the health service have a responsibility to deliver rates of pay that will attract and retain staff. It is simply no good to say that it is all a matter of long-term planning if good staff cannot be attracted and retained. A great deal has been made of the recent increases in pay, but as the noble Baroness, Lady Emerton, graphically pointed out, a large chunk of this year's increase for health service costs will be absorbed by extra changes, notably, I am sorry to say, in regulation. Therefore, there will continue to be a squeeze, and it cannot last.
For approximately 100 years hospitals in this country relied on dedicated but not highly paid work by women because there were not many other respectable jobs that women could do. Those days are long gone. Approximately 88 per cent of the health service still consists of women, for which the health service has to compete in a completely different labour market. It will not recruit or retain unless it pays the rate to do so.
The Prime Minister has given a commitment to increase spending on the health service. I am sure that we shall hear from the Minister rather more about what that commitment means. He started by saying that he would raise spending in this country to the average for the European Union as a whole. I do not need to take a great deal of your Lordships' time to say that it has been pointed out by many people that 5 per cent increases in health service spending simply will not fill that gap. Not on the most favourable interpretation over a five-year period can they even fill half of the gap. However, we are then told by Downing Street that the Prime Minister was referring to the gap between public sector spending in the United Kingdom and the rest of Europe.
On that point, I am a little puzzled. Is the Prime Minister saying that the gap in health spending between this country and Europe will be filled by private healthcare spending? It would require us to treble private healthcare spending over a five-year period in order to do so. If that is his policy, I should be most interested to hear it. I do not believe that that is what voters at the last election heard.
Leaving aside that issue, there remains the question of the use of the private sector. Given the direction of some of the policy which comes from Downing Street, I find it puzzling that at the moment the Government should be so reluctant to use the resources of the private sector to fill gaps in the National Health Service. Quite clearly, the system is running at the edge of its capacity. There is capacity in the private sector. As the Financial Times rightly said in a recent leader, it displays a disturbing degree of ideology that Ministers are not prepared to make use of that capacity to provide operations for people who need them, who have their operations cancelled and who have a long wait for their operations.
That is redolent of another attitude which I find very strange. That is the emphasis on the size of the waiting list rather than the length of time one waits for an
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operation. It is of very little interest to someone who has a long wait to know that other people are waiting too. What is important is the length of the wait and how many times an operation is cancelled.
I may have spoken rather strongly. If I have, I apologise to your Lordships. However, I feel that in some ways I have earned the right to do so. The government for which I had the honour to work showed their commitment to the National Health Service in terms of reforms, underpinned with financial resources. Of course, they did not solve all the problems. I have the deepest sympathy for the Minister in managing the health service, acquiring the resources from the Treasury in order to do so, and exploring new means of delivery and financing. However, I am sure that in his reply to the debate we shall not have any nonsense from his Benches about a monopoly of commitment and concern for the health service.
5.53 p.m.
Baroness Ashton of Upholland: My Lords, as chairman of a health authority, I am well aware of the difficulties and problems and also the successes that have faced the health service over the past few weeks. I, too, should like to pay tribute to the noble Baroness, Lady Cumberlege, for initiating the debate, and for the work that she has done for the health service in her years as a Minister, before that, and beyond. I was interested in her comments about the inexperience of Ministers, with the exception of my noble friend Lord Hunt of Kings Heath. With regard to our public services, I wonder whether she agrees with me that the role of government can perhaps best be summed up as that of "steering, not rowing".
I hope, too, that the noble Baroness will forgive me if I disagree with her on the issue of competition. When I became chairman of a health authority, I found two hospitals less than 20 miles apart which were attempting to provide exactly the same services for their populations. Having taught them to collaborate under the direction of the Government, they have now released a new energy to support services for their people. I believe that that has been to the benefit of our population.
Many noble Lords have spoken about the financial questions and issues. I do not propose to try to emulate the speeches that have gone before or those that will come after mine. I add simply that, when we look at finance, we should take care also to look at the demands that we place on the health service and the changes in demand which will occur in the future. We need also to be clear that the drivers for change in the health service are not only money but also issues of accreditation and technology.
When I read the title of the debate, I tried to work out how I would describe the state of the health service. What would be the backdrop against which I would judge it? I could look at the history of the health service and see what state we are in now compared to where we used to be. However, I know that it is foolish to do

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that. One cannot look backwards, particularly in relation to healthcare, which is constantly changing. The past is, indeed, another country.
In the past few weeks, many people have suggested that I go to look at other countries. The Caribbean has been mentioned, which is a very nice idea! In view of the number and type of statistics which have been put to me about different countries' experiences of health services, I was going to suggest to the noble Lord, Lord Biffen, for whore I have enormous sympathy, that perhaps he and I might have a field trip there together!
However, I want to look forward. If I look forward 20 years to the kind of health service which I wish to see for my children, who will then be 28 and 30 years old, I have three clear objectives for them. First, life expectancy should he the same for all, regardless of social and economic background. Secondly, regardless of where they live, they should have access to high quality healthcare, including treatment and drugs. Thirdly, they should have improved their own health, learning over the years how better to take care of themselves and, indeed, of their families.
In order to achieve those objectives, a huge investment is required. However, that involves not simply an investment in the health service. We know that life expectancy has far more to do with the kind of life that we live, the kind of work that we do, the housing that we live in and the places that we visit. We know, too, that we must be flexible in the investment that we put into the different parts of our economy. We need to be able to move money around.
In my own health authority, many people become bored when I talk about the need to move away from the crisis management, for example, of elderly people in the winter. It is too late when they end up on trolleys in our hospitals with hypothermia. In my health economy and, indeed, throughout the country, we need to be able to make sure that, by using the money creatively and wisely, elderly people do not even reach the point of arriving at hospital. That requires a whole range of services to work together.
We need to have an overview of the quality of healthcare and to be sure that we know what level of quality we have. We need also to have an overview in terms of deciding which drugs we shall use. Various drugs have been mentioned today. However, speaking from my own experience, it is incredibly difficult to know the marginal benefit of some drugs when one's public health people are very busy and are trying to give a measured view. Sometimes that view contrasts with the one put forward by the pharmaceutical industry. We need to make sure that we have an independent assessment of drugs. Most importantly, we must design our healthcare systems to improve health. I have in mind the old adage of "prevention, not cure". I hope also that those objectives will be used to measure the state of our health service.
Having set out some of my objectives for the future, I looked at where we are now. We have greater investment in the health service. In ray pot of gold at my health authority, I have £20 million more than I had last year. That is a real increase. As the noble
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Baroness, Lady Hogg, said, it is true that a great deal of that will go towards increasing the amount of money paid to staff. However, I was fortunate that this winter I used no agency staff in my health authority. Only one patient was transferred away, but that was one too many.
Now I have the flexibility to move money around. I want more flexibility, just as I should like to have more money. However, I want to be able to do more in terms of working with other agencies to support the health of the people of my community. I know that we now have the Commission for Health Improvement and NICE. They support me in the job that I do in making decisions about how best to spend the money to provide the best possible care. Sometimes it is not the drugs that will provide the best care. Investment in other aspects of healthcare, in therapies of a different kind in support for people, is money better spent.
Most of all, we have the health improvement programme and that is the backdrop against which I have to design all healthcare. That means that I am able to look at the population of my health economy; to look at the areas that need support and the different kinds of people who live in my area; and target and invest in helping them to stay healthy and to be cured when they are ill. That to me is fundamentally important for the future. I do not forget the problems that we have at the present. I am well aware that we have to do a great deal, but I am very confident that if you start to project forward and work backwards, which is always my view of how best to plan, we can develop a healthcare system within the public finances that will support our people for the future.
6.00 p.m.
Lord Bell: My Lords, I too thank my noble friend Lady Cumberlege for introducing this debate and in particular I would like to thank my noble friend Lady Hogg for her brilliant contribution—even if it did contain most of what I was going to say. Nevertheless, I must admit that that I am somewhat confused. Is our National Health Service something we should cherish and regard fondly as a truly wonderful service on which we must lavish attention and support because it is so good? Or should we see it as a badly-run, bureaucratic structure which makes terrible mistakes and is constantly in need of more funding that can never be satisfied?
I am no longer clear on the matter, such are the mixed messages of the day, including those in this debate. We have all seen the headlines and they lurch from screams of "under-funding" to "another fatal mistake by the NHS". I take this opportunity to extend my sympathies to the relatives of the victims of Dr Harold Shipman, who committed such terrible crimes. I endorse the Secretary of State for Health's comments that the public should not take this one man as an example of the classic relationship between patients and doctors.
What I am clear about, however, is the great respect we attach to nurses and doctors, surgeons and consultants. Those are the people we see as having the

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power of life and death in their hands. It is a powerful attraction and a right one. It is right that we should hold them in the highest regard and expect the highest standards. I am also struck by the very low regard we seem to have for administrators and managers.
I have personally experienced the health professionals' work in both the private and the public sectors; as a child with a rare blood disease and as an adult fighting cancer. Both experiences were positive and good—after all, I am still here.
The noble Lord, Lord Chadlington, rehearsed the everyday successes of the National Health Service and while agreeing with him, I do not want to repeat them. My noble friend Lady Cumberlege is so right in saying that patients do not care about administration and structure but just wanted to be looked after. Despite that, I do not claim to be an expert on the health services—I am not a doctor, merely a patient—but I have experienced all three sectors: the public, the private and the voluntary. As regards the latter, I am a trustee of Bacup Living with Cancer, as is the noble Lord, Lord Clement-Jones, who spoke earlier today— a rather odd Liberal Democrat and Conservative partnership. There are also the innumerable fundraising campaigns that I have helped to run for many charities all designed to help people with health problems. I have seen the private and the public sectors working happily and effectively together. The question in my mind is why the Government cannot see those sectors working together and think all solutions to healthcare lie in more work and money for the National Health Service.
Yes, the National Health Service is the focus of political debate, but I do not believe that any discussion on the National Health Service, or healthcare for that matter, can be constructive if it is driven by political ideology. The NHS is about saving lives and improving the quality of life. It is far too serious an issue to be at the mercy of political persuasions and pandering.
I wish to raise four points about healthcare today and I hope that at the end of it at least some of your Lordships will be convinced, if you are not already, by the point made by the noble Baroness, Lady Cumberlege, that the NHS should be left to be run by the health professionals. That should be done in as financially supportive environment as is possible, taking great support from the other two providers of our nation's healthcare services—the private and the voluntary sectors—and not under-selling or over-promoting any of them. Only then will we have a chance of delivering to the British people what they want and are entitled to—first-class healthcare.
First, the Labour Party claims that it has a monopoly on caring and that that is what makes it the best steward of the National Health Service. Further, it claims also that the Conservative do not care. That is patent nonsense and narrows the debate to a party argument instead of a constructive discussion.
My company employs 600 people. We provide private health insurance for all our employees and that insurance can be used also for the immediate family.
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We also contract two general practitioners and pay for any member of staff requiring their services urgently. Additionally, we often cover the expenses for treatments that have become a part of everyday life; be they alternative therapies, addiction clinics, counselling or care for those suffering personal tragedies or misfortunes. We extend that care through the very real community which is our workforce. We are, I feel, a truly caring and compassionate employer, the like of which should be actively encouraged by any government, and I am a Conservative.
Would it be too large a dose of common sense to suggest that the smallest of measures—perhaps the removal or reduction of tax on private health insurance—might go a long way towards encouraging other businesses to behave like mine and take their employee's health provision into their own hands, particularly small businesses in our enterprise economy, in much the same way as the Government encourage the elderly to provide for their long-term care? Would that not reduce the burden on the NHS and enable it to offer more care to people in need? Of course it would. Private insurance does not cover every need but private and public partnership does.
As my right honourable friend the Leader of the Opposition said last week, over the first 1000 days of New Labour, each day an extra 264 people joined the waiting list to see a hospital consultant. A perfectly predictable outbreak of flu became an epidemic, or at least a half an epidemic, according the noble Lord, Lord Hunt, at Question Time a week or so ago. That outbreak threatened to overwhelm the NHS despite the large numbers of people who looked after themselves.
Obviously the NHS does have a problem and it needs a solution. The Labour Party's caring for the NHS helps it to win elections—but it should not. Certainly it played politics with health in 1997 when it used the phrase "24 hours to save the NHS". It was not true then and is not true now. The NHS is not any better, as Labour promised it would be.
The winter crisis gave people their first real opportunity to judge this Government's stewardship of the NHS—they could judge both word and deed. What they heard were all too many words and what they got were all too few deeds.
Secondly, the Labour Party is completely wrong when it labels members of the Conservative Party as extremists because, it alleges, they want to privatise the National Health Service. We do not and have never wanted to privatise the National Health Service and I thought my noble friend Lady Hogg made that very clear in expressing the view of the previous government.
What the Conservatives want to do is apply common sense policies to the NHS to make it better and not to allow stubborn ideology to stand in the way of the commonsense and practical solutions that will work. It must be right to encourage the traditional three-way health partnership and so drive up standards of care. It must be right to encourage the voluntary sector that provides so much—the Red

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Cross, St John's Ambulance, medical research, cancer nurses, hospital car services, leagues of friends, major fund-raising initiatives for hospitals and so on. For example, tax relief on donations to medical charities would be no bad idea. It is not yet Conservative policy, but I shall keep trying.
It must right to allow the professionals in doctors' surgeries and clinics in hospitals to take decisions about how to deliver a strong healthcare system, based on medical need and not political priority; to provide them with the funds and not to tell them how to do their jobs.
It must be right to use the resources of the private sector in a real public-private partnership with the NHS. We do so already and we do in almost every other public service in Britain today; namely, in transport, in education and even in welfare.
Such ideas are not extreme, but Labour's policy is. Labour wants to deny the independent sector any role in making the health service better. It thinks it is better to leave intensive care beds in independent hospitals empty than to save lives. Labour wants all decisions taken in Whitehall by politicians. Total national ownership and management has been discredited for so many years but that does not stop it being Labour's recipe for modernising the health service.
Its recipe for modernisation involves dismissing the private sector and ignoring the voluntary one. What we really need to do is to use every means we can to lever new energy and support into all three parts: public, independent and voluntary. I am not saying that we can take the politics out of health but surely we can rid it of ideology. For the Government those sectors are in competition not complementary. For them, choice is an enemy to be fought rather than a friend to be embraced. People support all three sectors with money and commitment. They should all be listened to because they are all citizens. The private sector is so much bigger than is generally recognised. It is not just a question of healthcare insurance, private appointments and independent hospitals, it also embraces the whole area of self-medication, the advice of chemists and the complete range of health-promotion activity developed by the private sector.
Millions of pounds are spent every year encouraging prevention and cure, not to mention the private sector's vital research in the development and manufacture of drugs and medical equipment. Any mention of private sector partnership is dismissed as a sinister plot to privatise the NHS; it is not. The Government should recognise that. NHS Direct is a sensible and modern initiative and should be welcomed.
Lord Burlison: My Lords, perhaps I may point out to the noble Lord that this is a timed debate. This is only the second time that anyone has gone past the allotted time.
Lord Bell: My Lords, I am sorry to have gone beyond the time allowed. My noble friend Lord Chadlington told me I would and he was right. I shall listen to him in future.
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My message to the Labour Government is: stop accusing the Conservatives of wanting to privatise the NHS—we do not; stop claiming that Labour has a monopoly of caring—it does not; stop claiming that more money is the only answer when it is not; the NHS can be run like a modern business; pay people properly, supply proper working conditions and training; create direct, decent facilities; stop talking about caring and ideology and do something. Empower the people who run the NHS.
6.10 p.m.
Lord Prys-Davies: My Lords, like other speakers, I am grateful to the noble Baroness, Lady Cumberlege, for having given us another opportunity to discuss the state of the NHS. It is right that this subject should be before the House regularly.
The debate has attracted a long list of speakers who have a great level of expertise and profound knowledge of the NHS. I am not so qualified. I am merely a patient of the NHS but I owe it a great debt. I want to refer briefly to three issues: first, the well-founded anxieties that the NHS is inadequately funded, which have dominated the debate tonight. It does not allay our concerns that almost from its inception the NHS has been under-funded. It has always been up against the growing pressures and demands stemming from huge advances in scientific knowledge and technology, and fundamental demographic changes which are still at work in our society.
I understand that over the next 25 years the number of people over 60 in the countries of the European Union is estimated to increase by almost 50 per cent. Therein lies a challenge in financial terms and in terms of delivery of service.
I wonder whether there is an answer to the question, "How much money do we need to run the health service?". All I know is that the NHS must ask for every penny it can possibly get. The justification for such a demand on public finances is that it is providing best possible value for money; that it is using the resources in the most effective way possible. I accept that.
One is bound to accept—it is undeniable—that the NHS requires an injection of substantially more cash. At the same time, I agree with the comments of the noble Baroness, Lady Cumberlege, that the arguments should not focus entirely on the issue of funding. I believe that another policy message is coming through: that the solution may not always lie in more of the same measures as were served up in the past. There is a need to encourage more innovation. I note that my noble friend Lord Rea has been rather cautious in his approach to NHS Direct. I submit that NHS Direct is a striking illustration of the importance of innovation. Can my noble friend the Minister say whether the Government are contemplating any further innovations possibly based on the experienced gained by and within NHS Direct?
I turn to my second point; that is, the needs of the medical schools for more funds to enable them to pay proper salaries to the teachers of medicine and their

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staff. The noble Lord, Lord Walton, who is specially qualified and interested in this subject, eloquently made the case today, and not just today; he also made the case in the debate on universities on 8th December last. It struck me as very worrying indeed that today there are at least 67 vacant clinical chairs across the specialties in the UK. I believe that half of them have been vacant for more than one year.
I welcome the news that there is to be a substantial increase in medical student numbers. But the quality of their education and training, and the quality of the National Health Service that we will need in the future, lies to a considerable extent in the hands of teachers of medicine today. When the Minister winds up the debate, I should like to hear from him that the proper funding of the medical schools is an ingredient that will go into the calculation of the current comprehensive spending review.
My final comment concerns the NHS and devolution, which has not been touched upon in the debate tonight. However, it is now nine months since responsibility for the health service in Scotland and Wales was transferred to the Scottish Parliament and the National Assembly for Wales. I greatly welcomed the devolution settlement. But the devolved institutions will also work in partnership with the departments of the UK Government.
It is important that, when the functional departments in Whitehall are considering new policy initiatives or formulating new primary or subordinate legislation in the area of or affecting the devolved subjects, the Assembly officials in Cardiff should be informed at an early stage so that the views of the Assembly can be fed in at an early stage and vice versa. That leads me naturally to ask: what steps have been taken to agree a concordat between the Department of Health in London and the Welsh Assembly executive?
I also believe that it would be of interest to the House generally to know how many new powers for making delegated legislation relating to health functions in Wales are included in primary legislation introduced since last May. I suggest that the answer may be one point of reference in the debate about the future role of the reformed House. If my noble friend the Minister cannot answer these questions today, I should be grateful if he could let me have the information in due course.
Be that as it may, I conclude by reminding noble Lords that the health services in the four countries of the United Kingdom are part of the National Health Service based on an Act of Parliament which remains, in the opinion of most of us, among the most progressive legislation of the past 100 years.
6.17 p.m.
Baroness Seccombe: My Lords, I wish to add my thanks to my noble friend Lady Cumberlege, who, as always, spoke with distinction and informed knowledge. I begin by declaring an interest. I am the unpaid deputy chairman of Nuffield Hospitals, one of
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the country's largest charities. I hope that your Lordships will accept that I am not speaking on behalf of Nuffield Hospitals but on a point of principle.
There is no need for me to tell your Lordships that the NHS is in dire straits and so, for the sake of everyone, we all have to search for initiatives which will alleviate this serious problem. One of the first measures that the newly-elected Labour Government took in May 1997 was to remove the modest tax allowance available to those older people who had private medical insurance. At a stroke the Government increased the demands on the NHS and, as my noble friend Lord Forsyth of Drumlean stated, an extra quarter of a million people, who had stretched themselves to pay the premiums, were no longer able to cope.
It is the elderly who need the service the most. As a consequence, many of those who had prudently catered for their medical requirements became an additional responsibility on an already fully-extended NHS. We have an ageing population who naturally want and expect to benefit from all the developments in techniques and drugs to enhance the quality of later life.
It seems incredible that a political party can be so hidebound and blinkered by dogma that it is not willing to accept the consequences of its actions. For the Prime Minister to state that private health insurance is not the answer is a disgrace. Of course it is not the complete answer, but it could go some way to relieving pressure on an over-burdened service whose loyal staff do their best to cope with a dreadful situation. It is our duty to provide high quality care to everyone in this country, regardless of his or her financial situation.
It was with revulsion that we read of gravely ill people being bussed hundreds of miles in search of the necessary care when I understand that local private hospitals in London were not even consulted as to whether or not any intensive care beds were available. I found the mealy-mouthed words of the Minister in answer to my noble friend Lord Howe quite unacceptable when he said that national health trusts could make their own local arrangements with the private sector. Surely when people are dying from lack of beds and lying on trolleys for hours, the Government should have taken the lead by welcoming and supporting the involvement of private hospitals, wherever possible, for the common good of all our people.
Personally I believe that the tax concession should be restored to those who had it previously, and in addition should be extended to anyone who wishes to provide for their care. It is strange that the Government are so hostile to private medicine when the NHS, with 25 per cent of all private beds, is the largest provider. NHS trusts would benefit from the increased income generated. In the public debate that must now ensue it is vital to see, as we have heard from many other noble Lords, how other countries manage their healthcare. It seems clear that in France and Germany private involvement is providing a much higher quality of care than in Britain.

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I remember with incredulity the commotion over Jennifer's ear in the run-up to the 1992 election. There was a problem, but not one that can in any way be compared with the crisis of today. Mr. Blair appears to be at best complacent over the situation which has arisen during his stewardship. Like my noble friend Lord Bell, I shall never forget the scandalous advertisement that appeared the day before polling day in 1997—"24 hours to save the NHS". Inflammatory remarks like that can only cause fear and anguish for many elderly people. I am sure that many of those who were seduced and voted new Labour the next day regret their actions as they contemplate the service today when one cannot even arrange an appointment with a consultant, never mind get on to the waiting list for a hospital admission.
I was alarmed that the pay increases for nurses and other staff over and above inflation are not to be funded. That will undoubtedly lead to cuts in some services, thus reducing patient care. The time has come for the Government to stop listening to their spin doctors and face reality. The noble Lord, Lord Winston, a most highly respected, distinguished and dedicated consultant, criticised the Government's handling of the NHS. I understand from the press that he was treated most shabbily by Alastair Campbell for stating the truth. But people are not stupid and are much more likely to believe the noble Lord than the propaganda machine of new Labour.
The most frequent toast given any where is "Good health". We have always accepted that good health is a gift much treasured, but today it is even more essential to stay fit and well as we do not know, should we fall ill, how the system will care for us. Will we receive treatment? Will we be given essential drugs?
Some people will receive the care we expect. But some—the old, the weak and the vulnerable—may not. It is up to us, collectively, to do everything in our power to ensure that those who need care receive it with dignity as and when it is required. Our goal must be an NHS of the highest standard and a beacon of excellence that we can cherish.
6.24 p.m.
Lord Patel: My Lords, I thank the noble Baroness, Lady Cumberlege, for making it possible to conduct this debate and for leading it. I regret that, due to my NHS commitments this morning, I could not be here at the start of the debate. I was particularly sorry to miss the contribution of the noble Baroness, Lady Cumberlege. I hope that I can be forgiven for this transgression by your Lordships, the noble Baroness, the Minister and all those who spoke earlier, and I thank all for allowing me to speak at this late stage of the debate.
There can be no one in this House or in the land today who is not affected by the pain and suffering inflicted on the relatives and friends of the victims of the evil deeds committed by an evil man. I extend my deep-felt sympathy to all relatives and friends of those who suffered at his hands.
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The fact that that evil man belonged to my profession—a profession privileged to have the skills to save lives—puts a responsibility on me and others in my profession to do whatever is necessary to ensure that that never happens again. But the profession must do more if it is to regain any lost public confidence and maintain the privilege of self-regulation. It must rid the profession of incompetent doctors; be more accountable and transparent; and, above all, regulate only in the interests of the public. That is what the profession must pledge to do, whatever else the government inquiry recommends, for the relatives and friends of those that were murdered.
I also believe that many thousands of doctors who work in the NHS, in the best interests of the patients, will also wish that. No doctor should ever abuse the trust and confidence placed in her or him by patients and their relatives. If they do, they cannot remain members of the profession. We must also demonstrate that we practise to high moral and ethical standards and remain competent.
I should like to say something about the state of the NHS today. It is an NHS destabilised by the reforms of an internal market; with clinical services starved of funds by the resources spent in establishing, maintaining and then dismantling that internal market. Now we have fewer beds, and a shortage of nurses, midwives and doctors. There is low morale among those who provide the service. There are long waiting times and waiting lists. To tell a lady that she needs surgery but cannot have it for at least eight months is not pleasant. We have poor outcome indicators of diseases, including cancer, and a service that is under-resourced.
With the will to go with the intellectual thinking, there is no reason why the NHS cannot deliver a world-class service in every aspect; a service with which the public will be pleased; of which those who provide it will be proud; and a service for which the politicians who make it happen will receive the credit. Surely a worthy aim is a service adequately resourced. I hope that the Minister agrees.
6.28 p.m.
Baroness Fookes: My Lords, it is with a real sense of diffidence that I rise to speak tonight because I am very much a layman amid a galaxy of experts of all kinds.
I should like to place on record my own good feelings in relation to the NHS and my family. A few years ago, an elderly relative of mine was found to be suffering from cancer. The treatment she received was swift, excellent and kept her alive for six years. My personal recollections, therefore, are good.
However, I know that there are many ways in which the NHS is a creaking machine and it behoves all of us to try to seek a consensus, as others before me in this debate have indicated. Alternatively, if not a consensus, we should seek at least a constructive debate as to the best way forward without impugning base motives to other parties. I have seen this over the years in my political life in the other place. I found it increasingly depressing that the NHS was treated like

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some political football. At the beginning of this new century, surely we ought to turn over a new leaf to try to look for ways in which we might go forward together.
I was much interested in the suggestion of my noble friend Lord Biffen that this might be the subject of inquiry for a Select Committee in the other place. I should like to go one step better than that. I think that the ideal Select Committee would be here, in this House, where there are so many people who could contribute because of their deep knowledge and experience. I hope that this might be something which could be seriously considered, and soon. I hope that such a committee would not rule out, as, sadly, the Prime Minister seemed to do, the possibility of using the private sector. I do not think that anyone is suggesting that total reliance on an insurance scheme or anything else would be the ideal or something for which we should be working. There are many compromises; many other suggestions that might be made. It would be disappointing if the Prime Minister ruled out all of those as a matter of principle. I hope that he may be persuaded to think again on that particular issue.
Certainly, we may need to look to greater taxation. I suspect that the public would be far more willing to accept higher taxation if the taxes raised were earmarked for that purpose. I believe that the technical phrase is "hypothecation". I am very well aware that this will be deep, dark heresy so far as the Treasury is concerned. Throughout my political career, the Treasury has taken absolutely every care to ensure that it has a free rein in how they dispose of the money that comes in through various sources of taxation. None the less, I think we should still look at this; Treasury mandarins notwithstanding.
I turn to other issues that are of concern to me. One is what I call this obsession with targets. We have seen this notably in the drive to shorten waiting lists. It seems to me that unless the means—either of money, manpower, equipment, hospital beds or nurses—are there to support this, it is really an unrealistic expectation and it can only lead to distortions in care. I do not know how much truth there is in this, but it seems to me quite feasible that it would easier to take the easy operations rather than the difficult ones in order to reduce one's waiting times. That does not seem to me to be excellent healthcare. I do not think that we should put the practitioners in the National Health Service under that kind of pressure unless we are prepared to will them the means to carry it out in a reasonable fashion.
I turn to the issue of dentists who have had hardly a mention in this debate so far. There is a very great shortage of dentists. I know that the Government have what I think they call "easy-access centres" to try to increase the numbers of those seeing a dentist. I understand from the British Dental Association that it calculates that up to 4 million people are waiting to see a dentist and do not have one under the National Health Service. If that figure is correct—or even if it were half that—it seems to me a very great worry,
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bearing in mind that neglect of dental problems can lead to other health problems as well. I know that in my latter years as a Member of Parliament, one of the recurring worries that constituents brought to me, either through letters or at advice bureaux, was inability to find a dentist. So far as I can judge, the situation has changed very little at all. In fact, it is probably worse.
I turn to the question of the shortage of nurses. I am sure that my noble friend Lady Hogg put her finger on it absolutely when she pointed out that as there are many other careers open to young men, and particularly to young women, there therefore needs to be far greater incentives to bring them into nursing. Although I am quite sure that good pay will be an incentive, the conditions in which they work also seem to me to be important. If they are working in poor conditions under great stress, I do not think that money will be enough, either to bring them in or to retain them.
That brings me to those nurses who have already left the service, having trained. I have spoken to one or two friends who have been nurses in the past. I have asked them why they do not go back, even if only on a part-time basis. They seem slightly scared of the changes that have taken place in medicine, understandably—it is a period of great change and improvement in many ways—and they worry that they will not be up to standard. It is very important that there is real encouragement and understanding of those fears so that we may bring back more women. In particular where they have other responsibilities, we must ensure that working hours and shifts match their requirements. I think we have long passed the stage where a hospital can say that staff will have to do this, this and this. They must see what women are prepared to give, and work out a sensible compromise.
I should like to make one further point on the question of drugs, not on the issue of whether new expensive drugs are rationed but on whether drugs that are routinely dispensed are to some extent wasted by patients, and whether there is room to reduce that wastage and, therefore, to reduce the cost. I have one small anecdote from a distant relative who was something of a hypochondriac. When she died and a cupboard was opened, there was revealed the most immense number of half-used prescriptions. If she was anything like typical of others, that must have represented a great waste of National Health Service resources. Surely, that is something in our hands with which we should deal.
I see from the clock that my time is up. We have a very distinguished contributor to come next, so I resume my seat.
6.37 p.m.
Lord Winston: My Lords, I am deeply grateful to the noble Baroness, Lady Cumberlege, for introducing this debate. I am also grateful for the offers of salve for the wounds on my back. It is curious to note that most of the offers of salve have come from the Benches on the opposite side of the House.

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I am going to take the unprecedented step, at least for me, of sticking to a prepared written submission. I am not going to apportion blame to any side. I do not think that there is any point in doing that and it was never my intention when giving the interview to the journalist in the New Statesman. It is inevitable that journalists do perceive slants of a particular kind. But it is true that as a country we have never really faced what it is that we want from our National Health Service. Until that question is asked and answered we cannot begin to address the question about what it should cost, nor how much we are prepared to pay for it. In the latter respect, one of the only comparators that we have comes from other countries.
We repeatedly "talk up" our National Health Service. We keep on saying what an asset it is and how much more excellent it is than those of other countries. There is a growing conviction that these views are harder and harder to sustain.
According to the figures issued by the Government, which are likely to be the most favourable available, our total healthcare expenditure is certainly not excessive by the example of most other civilised countries. It runs at about 6.8 per cent of GDP, of which roughly 5.9 per cent is NHS spending. The rest, as my noble friend. Lord Walton said, is mainly private. Despite the protestations of different governments, this percentage of GDP has actually remained unchanged since 1992, even though costs have increased. The managerial bureaucracy has also increased; for example, in the hospital service it has increased fivefold, which is quite considerable.
How do we compare with other countries? The United States spends the most. Even allowing for its largely privately-funded health service, we see an overall picture of 14 per cent of GDP being spent on healthcare. None the less, US public spending is 6.8 per cent of GDP, which is considerably more than we spend. Indeed, we spend less than nearly every other civilised country, including Germany, Switzerland, France, Canada, Sweden, Holland, Australia and Portugal—all of which spend more than 8 per cent of GDP. We even spend substantially less than the Czech Republic, both in public and in private terms. Of the OECD countries, only Hungary, Poland, Mexico, Turkey and Korea spend less than we do in terms of a proportion of our gross domestic product.
All this may be what the British people want, but it is certainly something that needs proper debate. We have to accept that an increase must imply either increased taxation or some form of insurance scheme, in addition to what currently operates. We cannot stand on our own perception of our record. I believe that we need to study in greater detail, with a good deal more honesty and some humility, what actually goes on in other comparable countries such as Holland and Belgium, which have gone into this in some detail. In this respect, it was extremely encouraging to hear the Prime Minister's commitment to raise our spend to the European average, even though that, in itself, is a slightly vague and difficult area.
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One of the particular problems is how this spending is distributed. Many of my adverse remarks were made because I come from London. There is no question that London is poorly financed in many ways. We have a poor population in this city and that adds further to NHS costs. Although we have a National Health Service, it is worth pointing out that it is regional in distribution. The spend per capita in England is around £741. That is a substantial sum and it has risen considerably. Incidentally, I should tell my noble friend Lord Prys-Davies that the spend in Wales is now around £823 per head, while in Scotland it is £904. Sections of the community in Northern Ireland might complain about the British Government, but we spend almost 30 per cent more there per head than we do in any other part of the United Kingdom; indeed, I believe it is about £1,023.
The problem with this is very clear: much of the driving force behind the NHS is in the academic sector; and it is primarily England that is being starved. It is a real problem. We have the risk of a skewed service and one of the problems is that government action can skew it further.
That brings me to my next point. As I say, the reason for much of our pride in the NHS is its excellence. It is excellent in research; it is excellent in innovation; it has excellent public databases, which lead to better population-based clinical research than that in nearly any other country—except, possibly, Iceland; it has a highly-educated workforce, linked to some of the best higher education in the world; and it is assisted by an industrial base linked to some of the finest industries, particularly the pharmaceutical industry, which is undoubtedly excellent and adds to our international economic competitiveness. This excellence drives it to be capable of providing medical care that is unparalleled in most other countries and a dedicated hard-working workforce which, at its best, is highly respected internationally.
However, there is no questioning the fact that this excellence is under threat. This is not journalistic hyperbole; it is a perception held by virtually every medical academic in this country. The universities are stretched as never before, but the university base is a major reason for our clinical and research excellence. We now have a situation where the Government, not unreasonably, have focused on primary care and on a GP-led service. That has major implications for the real driving force for excellence in the NHS—our secondary and tertiary services. They are what we ourselves, and our elderly relatives, face when the chips are down. That is where we meet the NHS interface, whether it is in casualty or in hospital.
Specialist services are increasingly under pressure and are often working in hospitals where, frankly, the fabric of buildings is shameful, at least in cities like London. Unacceptable waiting in casualty is accepted surprisingly stoically and dirt and crowded bed spaces are far too common. The number of nurses is inadequate and there is fatigue, disillusion and understaffing. Our figures for cancer treatments are among the worst in Europe. We only have to look at the breast cancer services to see, for example, that

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Northern Ireland, Scotland and England all do worse than almost any other country in Europe. Although we focus on cancer services, they are only one example: they are a paradigm of many of these specialist services.
We have serious problems with nursing recruitment and training. In many ways, Project 2000 was misguided. It was an excellent idea, but it was the wrong way to give nurses status. What we need is caring in the hospitals. We also have problems with medical training. The Calman system has not been an unqualified success. The fragmentation of the NHS into free-standing trusts has led to poor medical manpower control and we are turning out doctors who, frankly, do not have sufficient experience to be entirely safe, particularly in the surgical and anaesthetic fields. That is partly to keep in line with Europe. The training system is a matter of great concern.
Due to the time factor, I shall finish my remarks very shortly. However, I have one final point to make. We keep on saying that we have abolished the internal market. But we cannot say that. It is simply not true. We have not abolished the internal market. Truly we have not. We have replaced it with a different kind of market and a new kind of bureaucracy—the primary care group is now to become the primary care trust. It is a significant problem, which still skews things because it means competition between trusts, which we also claim to have abolished. One only has to look at the situation in West London to see that that is not true.
I have been a little disappointed in the contributions to this important debate from this side of the House. For example, with all due respect to my noble friend Lord Harris, it is not fair to say that the NHS needs respect from its professionals. That will resonate very severely in our profession. Noble Lords from the professions who have spoken in today's debate actually have great respect for the NHS. It is out of that respect that we wish to speak.
Lord Harris of Haringey: My Lords, before my noble friend sits down, perhaps I may point out that I did not say that the NHS needed respect from the professionals; I said that it needed to respect the people who use the service.
Lord Winston: I am sorry, my Lords. I misunderstood.
6.47 p.m.
Lord Rotherwick: My Lords, during a debate in February last year I drew the attention of the House to a list of community hospitals that were threatened with closure, and that applied especially to the Burford Community Hospital in Oxfordshire. On Monday, telephone calls made to six of the units on that February list resulted in the following responses: Burford, no answer; Winsford in Devon, number not available; Edward Main in Cornwall, number not recognised; Poltair in Cornwall, no answer; Stroud
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Maternity Unit, still open with closure not expected; Lynton in Devon, now a resource centre with no beds available. Although this Government pledged themselves before the last election not to close hospitals, five out of the six rural cottage hospitals checked out are clearly no longer functioning normally as national health hospitals.
What is the community deprived of when a health authority closes a cottage hospital? It loses local nursing and medical care for the acutely ill; local compassionate care for the terminally ill; local rehabilitation facilities; local half-way house care after specialist treatment at a big acute general hospital; and local respite care.
The meaning of the word "local" varies according to where you are. In central London it probably means a mile and a half; in Oxfordshire it will be more like five to 10 miles. London has the Underground, the bus and taxi services. Unfortunately, most of those affected by rural cottage hospital closures will have to travel considerably further than 10 miles to receive treatment. Burford to Oxford is a round trip of about 50 miles. There is no tube. There is an irregular bus service and taxis whose drivers charge what they think the market will stand. Car ownership, or knowing someone who does not mind giving lifts, is helpful. Anyone from a rural area where the local cottage hospital has closed must surely be prepared for few visitors, at well-spaced intervals, if they have to stay in a far away general hospital.
During the debate in February last year my noble friend Lady Byford drew the attention of the House to some of the other problems facing rural communities. She pointed out that rural counties have more elderly people; for example, they make up around 21 per cent of the population in Devon and 19 per cent in Norfolk and Lincolnshire, compared with an average for England of around 16 per cent. When a cottage hospital is shut in these circumstances the local vulnerable people are indeed badly served. However, it is not only that. What happens to the nurses? Do they travel 50 odd miles a shift to work in the John Radcliffe?
During the debate in February last year the noble Baroness, Lady Thomas, told us that the Secretary of State had set up an inquiry into the provision of beds and that early results showed that there were not enough NHS beds. Why have they been further reduced since that date? Records show that occupancy rates have risen from around 70 per cent in the 1970s to over 90 per cent now. No wonder the flu outbreak caused so much difficulty. Mr Milburn described it as an epidemic, but that was with only 192 people having flu per 100,000. A true epidemic has double that number of people having flu per 100,000.
The closure of cottage or community hospitals is a series of double whammies. Patients will have to be transported further for initial treatment, check-ups, further tests, etc. Relations and families will also have to spend more time and money in visiting the sick. The second part of the double whammy is that the general

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hospital will have to spend more of its resources and use more precious, expensive bed space on sub-acute conditions, respite care and convalescence.
Publicly funded healthcare, free at the point of delivery, has been pledged by all the major parties. In the case of new Labour, however, the point of delivery for those who dwell in the countryside and in more remote areas is certainly less likely to be at the point of need and threatens soon for all practical purposes to vanish from sight.
Like many others, I have recently been appalled to discover that the NHS has funded gay sex material. I take the example of Place West which produced the Gay Sex Now book. I shall not discuss the sordid pictures of this material which promote this lifestyle, but can the Minister say whether it is correct that the underfunded NHS should squander its money on funding such promotional material when lesser sums of money could have saved many of our community hospitals, especially the Burford Community Hospital?
6.52 p.m.
Baroness Whitaker: My Lords, I, too, congratulate the noble Baroness, Lady Cumberlege, on initiating this debate. She drew attention to the health service as a whole, as have other noble Lords. I wish to discuss a narrower, but often neglected area; namely, the need for mental health provision. I should declare an interest as a non-executive director of the Tavistock and Portman NHS Trust, whose new work on the outcomes of psychotherapeutic treatment and recent TV series have demonstrated the value of mental health intervention.
One in six of the UK population is likely to experience mental illness of greater or lesser degree—commonly an episode of depression—sometimes no more than the mental equivalent of a bad bout of bronchitis. However, it is not regarded as that by the public or the media, nor by employers. There is a great deal of stigma attached even to healed mental illness. Recruitment panels probe any sizeable gap on CVs with mental breakdown in mind; would-be parents can be refused by adoption agencies if there has been depression in the family; and I know of at least one effective employee who contemplated falsifying a health declaration to omit chronic mental ill health that was perfectly well controlled by medication.
When it is not properly treated, mental illness can have the most serious consequence of all. Of the 6 per cent of the population who suffer from depression, some 15 per cent will commit suicide. Most of the 4,000 suicides in the UK are associated with depression. But, common as it is, incapacitating as it is and treatable as it is, mental health expenditure attracts only just over 16 per cent of the national average budget, and in some health authorities the figure is as low as 11 per cent.
In children the incidence of mental health is also disturbing—about 10 per cent of five to 15 year-olds in England, Scotland and Wales. Some reports say that it is increasing. The need far outweighs the resources. I am sure that we would all want to reduce this cause of
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acute distress and erosion of the capacity to cope, often at critical times in the school career, including for those traumatised refugee children who have had among the most damaging experiences a child can have.
There are some useful initiatives in this dearth. Will my noble friend the Minister say what he thinks of the development of community child mental health services which aim to increase expertise available to families and to make services more accessible in a way which reduces stigma by using specialists attached to GP surgeries and training all those who work with children? Have these initiatives been evaluated and are they to be replicated?
In conclusion, anyone aware of mental health concerns will know of the grossly disproportionate number of black patients who are confined in secure psychiatric units. It is not clear whether the disproportion happens in causation, in the diagnostic process or for some other reason. However, the existence of this disproportion is deeply disturbing. Can my noble friend say what research is being carried out to find out why so many more of our black fellow citizens are incarcerated in mental hospitals?
6.57 p.m.
Viscount Bridgeman: My Lords, I am well aware of my position in the speaking order and I shall endeavour to break into a trot! First, I thank my noble friend Lady Cumberlege for her excellent introduction to the debate.
I want to say something about nurses which I am well aware could have been included in the excellent debate last week initiated by the noble Baroness, Lady McFarlane, but as nurses are the artery—if I may be forgiven the metaphor—of the National Health Service, it is just as appropriate to mention it in this debate. After talking to a nursing director a few days ago, I am prompted to refer once again to Project 2000, to which the noble Lord, Lord Winston, briefly referred in his excellent and inspiring speech. This is not a political point. I am well aware that Project 2000 was an initiative of the previous government and was very much inspired by the nursing profession. Let us be quite clear of the totally laudable aims of that initiative; namely, to acknowledge the higher standards of education of trainee nurses and to reflect a sophisticated programme of academic training for them. Indeed, the noble Baroness, Lady Emerton, has given an impressive list of nursing specialties for which a high level of education is required.
The effect on the wards has not been good. Previously, the ward sister could count on, say, five good nurses training in practical nursing who were able to take the load off the trained staff and, at the same time, gain excellent patient experience. Nowadays, trainee nurses under Project 2000 come on the wards for a restricted period. They require closer supervision—which in itself is a vicious circle as there are many fewer trained staff to supervise and to instruct—and they are not so effective with the patients. Who suffers? It is, of course, the patient.

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Project 2000 has been in operation now for more than 10 years and there is much that it has achieved. What should be addressed now is the question of balance between academic and practical training. I urge the Government to put in hand an early review of Project 2000 to see how this shortcoming can be addressed. In that respect, I welcome the remarks made by the noble Lord, Lord Hunt, when he replied to the debate last week. Certainly the message coming from the senior nursing staff on the wards is a plea for a much greater clinical element in the training of nurses—to the benefit of the patient, to the benefit of clinical administration, and, last but not least, to the benefit of the training of nurses themselves.
I turn now to the recent pay award for nurses. This is wholly welcome. But let us be under no illusion that this award must come out of the NHS purse, in which, as I understand it, there will be no increase. My noble friend Lady Cumberlege referred to this, as did my noble friend Lady Hogg. Can the Minister enlighten us as to what adjustments will be made in the National Health Service budget to reflect this increase?
May I, with an involvement in the private sector, reinforce a plea for greater interface between the private and state sectors, a point made most eloquently by my noble friends Lady Cumberlege and Lord Howe? Admittedly, the use which can be made of the private sector will inevitably be limited in value because of the relative sizes. However, in the case of the independent charity hospital with which I am associated, we have a regular programme of outplacements of student nurses, for the technical training of such people as ECG technicians, and a wholly beneficial mutual arrangement with a major teaching hospital for a regular rotation of housemen, who, in many cases, are studying for membership of one of the Royal Colleges and who provide a quality of RMO of which any hospital, of whatever kind, would indeed be proud.
Relations at hospital and local health authority level between the two sectors are excellent and wholly beneficial. Higher up in the management of the health service, the jury, I suggest, is out. The "them and us" attitude, to which my noble friend Lady Seccombe referred quite forcefully, is still there—although I am happy to say that it improves by the year. I hope that the Minister and his colleagues will do all that they can to foster and encourage this improvement.
The Labour Party has always regarded the National Health Service as its own cause, to the frustration and irritation on many occasions of my party. We have had a number of hagiological speeches from the party opposite on which my noble friend Lady Hogg has poured some statistical cold water, which is very welcome.
However, I finish on a constructive note. This magnificent service requires the intellectual efforts of all of us to see how it can be improved. My noble friend Lord Forsyth has suggested that there is a unique window of opportunity and my noble friends Lord Biffen and Lady Fookes have made some practical
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suggestions with regard to a Select Committee. I hope that the Government will give them serious consideration.
7.3 p.m.
Baroness Warwick of Undercliffe: My Lords, I apologise to the House for speaking in the gap. There was a mix-up as to the debate in which I was listed to speak. I thank the noble Baroness, Lady Thomas, for her indulgence and the Whips for their forbearance. I know that I must be very brief.
I should like to make two brief points that have not been alluded to. The first point concerns the contribution that higher education can make to the modernisation of the health service. I declare an interest as the chief executive of the Committee of Vice-Chancellors and Principals. Universities, in partnership with the NHS, now provide virtually all pre-registration education for the nation's doctors, dentists, nurses, midwives and all other professions allied to medicine. They are also significant providers of post-graduate training and continuing professional development—CPD—in all the health professions.
We hear regularly—we have heard much today—about the shortages of many of these staff, an inheritance which the Government are now addressing. They have made available funding for an additional 1,000 medical students, the biggest expansion in medical student places for 30 years. A successful recruitment and retention campaign for nurses and midwives last year has raised the profile of those professions. Applications for nursing diploma courses have risen by 18 per cent and for nursing degree courses the increase is even higher at 24 per cent.
Several noble Lords have mentioned pay. Recent evidence suggests that successful recruitment and retention in the health service depends as much on the ability of the NHS to provide staff with continuing professional development opportunities as it does on pay. So the key to recruitment and retention depends on the NHS developing CPD and there is a need to bring the level in all the health professions up to the level of the best.
The Secretary of State for Health has noted that the way the clinical professions train and work together is the key to unlocking the potential of the 21st-century health service. Together, universities and the NHS can ensure that professional preparation of the nation's doctors, dentists, nurses, midwives and all the other professions allied to medicine, captures leading-edge practice and prepares healthcare professionals for a fast-changing working environment.
The National Health Service has rightly been set challenging targets for service delivery by the Government. It is essential that there are sufficient healthcare professionals who are educated and trained to high standards and who are fit for the purpose to enable these targets to be met. Quality patient care is at the heart of the Government's strategy for the health service. They are determined to address long-standing deficiencies, and the university/National Health

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Service partnership is a mechanism for moving forward the modernisation programme to deliver quality patient care.
7.6 p.m.
Baroness Thomas of Walliswood: My Lords, on looking at the clock I think that we are, if anything, two or three minutes ahead of schedule, but I will not, I hope, extend my time for that reason.
I should like to congratulate the noble Baroness, Lady Cumberlege, on introducing the debate. Her formidable experience and knowledge in this field are beyond dispute. I know that when I first came into this Chamber she was a Minister on the other side. I always thought that I would have to be very careful before I tangled with her because she was—and still is—such an expert.
The noble Baroness asked for a civilised debate and, on the whole—with perhaps one or two exceptions— we have had one. It has certainly been very wide ranging—from the noble Baroness, Lady Whitaker, who spoke about mental health problems, to the noble Lord. Lord Rotherwick, who spoke about the problems of services in rural areas. The noble Lord, Lord Walton of Detchant, gave an insight— repeated by the noble Baroness, Lady Warwick—about the problems of staffing the essential higher education services upon which the training of all our doctors depend. If I may say so, the whole debate was set alight by the passionate and expert speech of the noble Lord, Lord Winston.
January has been a bumper month for "Crisis in the National Health Service" stories. There have always been such stories, of course, but last month seems to have been particularly severe. Whether or not there has been a flu epidemic, let us hope that we have seen the winter crisis peak in terms of the stories that people have been able to write about patients lying on trolleys and similar sad stories.
Individuals have been speaking to me about the kind of healthcare that members of their family have experienced. They have spoken about incidents in hospitals of which I thought I would never hear. They have spoken about dirty wards and, much worse, dirty lavatories, and about rather skimpy and incompetent care. I am referring to the care of a seriously injured patient.
The fact that there is a crisis in winter is not new. As a non-executive director of a National Health Trust hospital until the end of 1997, I was aware that the summer case load was already up to what had been previously considered a winter case load level. The rapid decrease in the number of beds, despite everything that the hospital was able to do in terms of day case treatments, put the hospital under an impossible strain when anything went slightly wrong.
All those factors are underlaid by long term problems, as a number of noble Lords have pointed out. The NHS is still in some ways a "national sickness service" rather than a National Health Service. The noble Baroness, Lady Ashton, addressed that syndrome in a most interesting speech., as did my noble
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friend Lord Addington. They both referred to the necessity of preventive care. Other noble Lords referred to low-cost approaches to improving the level of care and to the importance of good examples of care being spread further within the service.
Recent news stories have emphasised the poor equipment available in hospitals. Surely that has something to do with a history of underinvestment. It is not this year's problem, but a long-term problem. The number of beds has been under pressure for years, which has resulted in some of the most extraordinary efficiency rates of which anyone could conceive. It has led to extremely high bed occupancy and turnover of patients—some people believe too high. because of the aftercare problems that may arise—and an inability to cope with the peak and the crisis moments.
Some noble Lords put forward the interesting idea that we must not only take action over the longer-term trends, but also do something about patients' own ability to look after their own healthcare and negotiate their own treatment. If that idea is taken up, it will place new challenges upon the health service, but also possibly new opportunities to ensure that health rather than sickness becomes the preoccupation of at least part of the NHS.
A crisis or acute strains in staffing are features of many stories. They are reflected in the levels of stress and disillusionment expressed by medical staff themselves. Official representatives of doctors have recently been outspoken—I am talking not only of the noble Lord, Lord Winston, but of others—about levels of stress and disillusionment and their fears about what is happening in the health service, which is not only their employer but also the service to which they have dedicated their lives. The BMA has decided to conduct a fundamental review of the NHS because, despite record levels of funding and the extra investment currently going in, the system remains overstretched.
The decision—to which the noble Lord, Lord Davies of Oldham, referred—to pay the recommended full wage increase and to pay it at once rather than in stages is obviously welcome. I am also much struck by and in agreement with the well made point of the noble Baroness, Lady Hogg, about the need to pay people to some extent what the market offers outside. Fewer and fewer people are going into nursing in particular. Surely that has something to do with the level of pay.
There has been much talk of a crisis in funding. Again, there is nothing new in that. The previous government's approach led to a continuous squeezing of performance out of resources which did not keep pace with overall inflation. NHS inflation is higher as a result of new technology. Meanwhile, people's expectations of what the NHS should deliver to them are rising all the time as they become better educated, more well-off and more demanding as consumers. I do not believe that patients like to be called "consumers", but technically one may call them that. They prefer to be thought of as patients and the notion of a patient-doctor rather than a consumer-seller relationship within the health service is important.

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Many recommendations have been made in the debate as to how the funding crisis—the mismatch of funds to demand—could be solved. The noble Lord, Lord Biffen, the noble Baroness, Lady Cumberlege, the noble Lord, Lord Desai, and the noble Lord, Lord Bell, produced a variety of approaches. As always, the noble Lord, Lord Desai, was erudite in his economist's approach to the way that we should cost and measure inputs and outputs.
The noble Lord, Lord Biffen, was more down-to-earth. He said that we need to be honest and to tell people that extra costs are involved—as did the noble Lord, Lord Forsyth—and that if they do not want to pay them in one way they will have to pay in another way. The most likely and possibly the best choice is on the whole for the NHS to be funded through taxation. We on these Benches support that policy. As my noble friend Lord Clement-Jones said in his opening remarks, we are still committed to an NHS funded largely by the public purse through the system of taxation. It has been said that taxation is the price we pay for living in a civilised society. Despite the many attacks made on that point of view, I still believe in it.
On the other hand, I see no reason why—as other noble Lords have suggested—we should not make better use of excess capacity in the private sector to solve some of our capacity problems. That would be one way forward. If we could move towards more preventive medicine in the long term it might slow down the rate at which costs increase. I do not believe in solutions such as proceeding with a totally insurance-based system or relying heavily on the PFI, which, as the noble Lord, Lord Rea, sapiently remarked, merely increases costs. Neither of those suggestions would provide long term solutions.
January was a rotten month for the Government. The millennium bug—okay; the Millennium Dome— not so good. There were rumblings from the Robinson case and chaos in the NHS. The situation was not made better by some rather clumsy efforts to control the expressed opinions of the noble Lord, Lord Winston. It was capped by the resignation of Mr Kilfoyle from the Government so that he could serve his locality and the Labour Party better. That is an interesting combination of things going wrong. It has nothing to do with international problems. It is, as a former Prime Minister said, "Events, dear boy, events".
My noble friend Lord Clement-Jones reminded the Government of our support for some of their major initiatives. I remind the Minister also that my noble friend asked about the whereabouts of the 100 extra intensive-care beds, the national beds inquiry and the Government's response to the Royal Commission on ageing and care for the elderly, which is, of course, another long term problem. I should like to ask the Government a different question. Do they have the honesty and quality of leadership to take the British people into their confidence to explain clearly what the problems are and that they cannot all be solved—just as doctors cannot be educated—in a month or a year or perhaps even in five years, but that the Government
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will make efforts to solve them? That might have the effect of giving people greater confidence in what is happening in the NHS, so that when minor things do not go right they will understand that the general progress of the NHS is nevertheless going along in the right way.
If the Government show leadership on that issue they will probably be able to take the public with them. If not, they will have more disastrous Januarys.
7.19 p.m.
Lord Astor of Hever: My Lords, I, too, congratulate my noble friend Lady Cumberlege on enabling so many distinguished and expert Members of your Lordships' House to consider the state of the National Health Service. We on these Benches very much welcome the opportunity and the timing of the debate. The Conservative Party believes passionately in the NHS and our commitment to its future is unequivocal.
This has been a constructive debate. I doubt, though, that the Government will welcome the public spotlight on their recent management, or rather mismanagement, of the NHS. The Government's election manifesto proclaimed in very large letters:
"We will save the NHS".
My noble friend Lady Seccombe told us that the day before the general election the Prime Minister warned the British people:
"You have just 24 hours to save the Health Service".
Many people believed him. Many fewer do now, according to a recent ICM poll in the Observer, as my noble friend Lord Chadlington told us. Why? Because, despite spin doctors seeping into every part of the NHS, and an obsession with manipulating figures, the public knows that the Government are clearly failing to deliver on their healthcare promises. The NHS is in crisis, and the Prime Minister in panic.
His "pledge" for increased public spending on the NHS, announced, inevitably, on television rather than in the House of Commons, has subsequently become merely an "aspiration" and then, in a matter of days, only a "conditional commitment". Moreover, this is a "conditional commitment" that is untested, uncosted and unrealistic. A Whitehall aide apparently told The Times:
"Of course Tony wasn't meant to say it. He can't make huge financial commitments like that".
Can the Minister, therefore, spell out clearly for the House what the Prime Minister's "conditional commitment" means? Are extra resources entirely dependent on the future health of the economy? Are they to be funded through tax rises, or is the money to come from other departments?
These are important questions and I hope that the Minister will answer them when he winds up. I shall look forward to his reply. I certainly associate myself with the remarks made by my noble friend Lady Cumberlege about the Minister personally.
I turn now to one of the Government's five key election pledges: NHS waiting lists. Labour's manifesto promised to take 100,000 people off the

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waiting lists. The reality, as everyone knows, from NHS staff to the general public, is completely different. My noble friend Lord Bell told us that for every one of Mr Blair's first 1,000 days, an extra 264 people have joined the waiting list to see a hospital consultant. Clinical priorities have been replaced by political ones. Decision-making is being taken away from doctors and hospitals and centralised in Whitehall to help the Government's re-election programme rather than to improve patient care. There is now a considerable backlog of complex surgical procedures, which have been postponed to rush through straightforward ones. The sickest patients are waiting longer. This is currently a dangerous country in which to fall seriously ill. The noble Baroness, Lady Sharp, made that point very well.
I should very much like to pay tribute to the valiant efforts of all NHS staff during this winter's flu outbreak. The noble Lord, Lord Clement-Jones, questioned whether it really was an epidemic. Although the number of reported flu cases fell well short of an official epidemic—with the system haemorrhaging all round—the spin doctors decided to put their own interpretation on the statistics. I do wish that the Government would concentrate on real doctors rather than spin doctors.
Why was the immunisation programme so limited? Only 30 per cent of the "at-risk" groups received anti-flu jabs, compared to 75 per cent in France, where the mortality rate has been far lower. Why, particularly, were vulnerable groups and hospital staff not immunised? Large numbers of the most vulnerable people caught flu from those caring for them. Why was there no publicity campaign urging people to get their jab? Perhaps the Minister will outline what immunisation programme the Government will put in place for this coming winter?
The Conservative Party believes that it is now time to put patients before politics. As my noble friend Lady Cumberlege said, we are the world's fifth largest economy, yet we suffer second-rate standards in many casualty departments and a scandalous lottery of care for life-threatening diseases. My noble friend Lord Bridgeman referred to last week's very interesting debate on nursing, in which we heard of a shortage of 17,000 nurses. Like the noble Lord, Lord Clement-Jones, and my noble friend Lord Howe, I have a sister who is a trained nurse. She is married to a consultant surgeon who runs a vital department in a provincial teaching hospital. He sees it as a matter of professional pride to keep the service running. But the spring has now been stretched beyond its elastic limit.
The current crisis must be a turning point. The truth is that, as a direct result of government policy, the system is unable to cope, at times, with the demand for basic services. The failure to tackle structural reform of the NHS means that real people suffer as the Government stand by preparing the next excuse. Given the continuous advances in expensive medical science, the need for substantial future wage rises to retain trained staff and an ageing population, the refusal to admit that the current system needs to change shows an alarming lack of realism.
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The Government's old-fashioned, dogmatic, socialist objection to working with the independent health sector is every bit as damaging to the nation's physical health as was Clause 4 to the nation's economic health. The ability of people in Britain to afford private medical insurance makes a greater difference to their standard of healthcare than is the case in other health systems in Europe. As my noble friend Lord Forsyth said, other socialist governments in Europe see private medical insurance as a supplement to state spending. We can surely learn from other countries, as the noble Lord, Lord Winston, said. I agree that the noble Lord set the debate alight. We need to encourage both individuals and firms to utilise the resources of the private sector as well as the NHS. Currently, this Government actually penalise, through the tax system, those who seek to alleviate the burdens on the NHS by using private healthcare.
It is for all these reasons that we have invited the Government to begin a meaningful dialogue on the future of the National Health Service—a request that has fallen, so far, on deaf ears. The Government show no enthusiasm for radical thinking.
The Conservative Party sees the NHS as the mainstay of healthcare provision when we return to government. We will increase its funding in real terms, and we will put clinical priorities back—where they belong—above political ones.
We on these Benches urge the Government to make a fresh start and introduce an uncharacteristic level of honesty into the debate on the NHS. We believe that to ignore the present situation and the challenges it presents is a betrayal of this country's future. We urge the Prime Minister to show real courage and leadership and to do the same.
The Parliamentary Under-Secretary of State, Department of Health (Lord Hunt of Kings Heath): My Lords, this has been a fascinating debate. I begin by offering my congratulations to the noble Baroness, Lady Cumberlege, on her initiative in securing it. She brings to this House enormous experience of the NHS. Working with her in the past was a great pleasure for me. I am glad to be able to debate with the noble Baroness once again these important issues relating to the future of our National Health Service. I also acknowledge the contribution made by so many noble Lords to our discussions about the state of the NHS. I assure the noble Lord, Lord Astor, that I welcome the spotlight being placed on the NHS and on the Government's stewardship of it.
At the heart of the debate is the sustainability of the National Health Service. The noble Baroness, Lady Cumberlege, has returned to a theme that she developed in a debate on the NHS in this House a year ago. She, the noble Earl, Lord Howe, the noble Baroness, Lady Sharp, and others have posed questions about the ability of the NHS to continue to provide an all-embracing service, faced as it is with so many new pressures, given the pace of medical science and technological advances and as the genetic revolution comes upon us.

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The answer must be in the affirmative. I want to make the Government's commitment to the NHS and the case for the sustainability of a tax-funded system available on the basis of need alone.
There is a terrible danger in over-emphasising the problems that the service faces. That is not a political point; it is one to which I held when the noble Baroness, Lady Cumberlege, was a Minister. We are sometimes in danger of talking up the problems of the National Health Service and talking down its successes. I strongly agree with the noble Lord, Lord Chadlington, on that point. Also, I warmed to the noble Baroness, Lady Fookes, when she described her experiences and those of her family at the hands of the NHS.
The NHS has served the nation well for 50 years. I believe that it will continue to serve us well. Of course, the siren voices warning us that the NHS is not sustainable are not new. We have heard them over almost every decade since the NHS came into existence. Experience has shown that the NHS has faced up to the new challenges placed upon it year after year.
Of course, the changes faced by the NHS in the last century will be nothing as compared with the challenges that it will face in this century. Just as society has changed over 50 years and people have come to expect 24-hour access to personalised services, so the NHS will have to change again. And just as we want to modernise the nation as a whole, so too we need to modernise the health service to play its part in creating an enterprise economy and a fair society.
The noble Baroness, Lady Cumberlege, talked about problems. I do not pretend that the NHS does not have its challenges and problems. Nor do I deny that many noble Lords have raised important issues, with which I shall attempt to deal. But first, perhaps I may turn to my noble friend Lord Winston. It is always a pleasure to hear him speak about the National Health Service.
I say to my noble friend that we have abolished the crude internal market and the absurd notion that there should be crude competition between hospitals and between doctors and nurses. We have replaced the internal market with a partnership approach. I say to my noble friends that it is right that primary care groups should play a key role in that. I make no apology to the House for that important role. Their input is crucial. But it is not an isolated input. It is informed by national priorities. It is aided by the whole process of developing health improvement programmes at local level, pulling primary care groups into the discussions with health authorities, providers and local authorities, and the development of long-term agreements rather than short-term contracts. That is surely the best way to make judgments about the best treatments to be offered to patients. All that must be underpinned by close dialogue between general practitioners and consultants.
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It is early days for primary care groups. However, one of the most pleasing indications of how they will succeed has been the development of the closest dialogue that has been known between GPs and consultants in the lifetime of the National Health Service. But, of course, we must build on that. I accept that the noble Earl, Lord Howe, and my noble friend Lord Winston expressed concerns that there are challenges for specialised services. I can tell my noble friend and the noble Earl that we have instructed regional officers to identify those trusts and services which have previously relied on extra-contractual referral income in order to fund some specialised services activity and make sure that arrangements are in place so that services will not be destabilised.
We are still in the middle of a developmental year in terms of Commissioning those services. However, we are satisfied that there is good evidence that health authorities and the regional specialised Commissioning groups are getting to grips with what needs to be done. I can assure my noble friend that we shall keep a very close watch on the process. I shall always be willing to discuss with my noble friend any problems that he identifies in that area.
I now turn to some of the other issues raised. I agree with the comments of the noble Lord, Lord Crickhowell, concerning mixed-sex wards. The Government are committed to their removal over the next few years, with most being removed by the end of 2002. I know that other Members of this House are keen for us to do that.
I accept the points raised by my noble friend Lady McIntosh and the wisdom she offered in encouraging the public to make the most appropriate use of the services that we offer. That is very much underpinned by the information that we can provide to the public, and which we want to provide, about the range of treatments on offer and the challenges and pressures that the service faces.
I warmed to the support expressed by the noble Lord, Lord Addington, for exercise and sport and the improvements that they can make to the nation's health. The noble Lord leads by example. Once again, in March, he will lead us all in the BT Swimathon charity event, in which many noble Lords enjoy taking part.
The noble Baroness, Lady Fookes, was right to raise the issue of dentistry. There are problems in some parts of the country as regards people gaining access to NHS dental services. We have launched a number of new initiatives, including "phone and go" access centres, and we shall shortly be publishing a new dental strategy designed to deal with many of those problems. I agree with the noble Baroness also about the problems of waste in the use and prescribing of medicines. We are keen to encourage improvements in the way in which medicines are used and see that they are not wasted.
My noble friend Lady Whitaker raised the important issue of mental illness. My noble friend will know that our national service framework was designed to ensure that we improved the status and

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provision of mental health services. We have provided £700 million of extra investment over a three-year programme. We also recognise the need to give priority to child and adolescent mental health services.
As to immunisation, I say to the noble Lord, Lord Astor of Hever, that we shall carefully monitor what happens this winter. Both the Chief Medical Officer and the Joint Committee on Immunisation will produce recommendations on the policy to be adopted next year.
Listening to this debate, noble Lords will recognise that the NHS has been under real pressure over the past few weeks. Sadly, some patients have not received the treatment that they deserve. It is also right to record that, thanks to the dedication and hard work of NHS staff both in recent weeks and throughout months of careful planning, including contributions from local authority social services departments, the NHS has coped well with very real extra demands and pressures. This is rot the story that we have read in the newspapers or heard from the myriad of commentators who have used these winter pressures as an excuse to denigrate the National Health Service. I very much agree with the comments of my noble friend Lord MacKenzie. The Herculean efforts on the part of NHS staff have had ill reward from those sections of the media who seem determined to undermine them and declare that the NHS has passed its sell-by date.
What is the reality? The Government have spent the past two years laying the foundations for modernisation, abolishing the internal market and starting the biggest hospital building programme in the history of the NHS. Of the 37 new hospitals that have been given the go-ahead, 31 are based on public/private partnership. In answer to the noble Baroness, Lady Cumberlege, and the noble Lord, Lord Biffen, we recognise the benefits of working with the private sector, particularly in the area of new developments such as the hospital modernisation programme.
We have also modernised casualty services so that every department that needs capital investment receives it. We are getting more doctors and nurses back into the NHS. I had hoped that the noble Lord, Lord Walton, would have acknowledged those efforts and the decision of the Government to increase the number of medical training places and develop three new centres of medical education. We have increased the number of nurses, not just those who have returned or are about to return, and the number of training places. Our efforts have also led to an encouraging increase in the number of young people who apply to become student nurses. The noble Viscount, Lord Bridgeman, drew attention to the necessary changes to be made to the nurse education curriculum. I accept the need to ensure that, alongside academic training, there is greater emphasis on practical training, and the debate which your Lordships had last week on this matter was very illuminating and informative.
The noble Baroness, Lady Cumberlege, warned us about the dangers of putting too much faith in structural change. Having lived through many
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structural changes in the NHS which the previous government initiated, I can only echo that warning. However, our emphasis is not on structural change for its own sake but on improvements in services. and in that we have the great support of our staff. Government and Ministers have a major role to play in developing the strategy under which the NHS should operate.
It is naïve to believe that the funding and overall strategic direction of our great National Health Service can ever be disengaged from the parliamentary process, but within the setting of a national service, with Ministers setting national priorities, there is considerable room for local NHS organisations to grow, develop and take ownership of the policies that they wish to see brought into play. Primary care groups and trusts are the visible indication of our wish to delegate decision-making to the level nearest the patient.
We are making improvements to the National Health Service. As an example, NHS Direct is part of the process of modernisation. That is a wholly new service which provides easy access to professional advice over the telephone or on the Net. As my noble friend Lord Prys-Davies emphasised, this is the kind of innovation that we are introducing to the health service. The service is very popular with patients; over 1 million calls have been received. In answer to my noble friend Lord Rea, the University of Sheffield has undertaken an assessment of NHS Direct and found that 97 per cent of callers are satisfied with the service received. It is important that primary care has links with NHS Direct. We have set up a primary care interface group which enables us to bring representatives of primary care together with those who run NHS Direct to talk about how the service can be developed and improved.
Step by step we shall build a faster service, but it will take 10 years to modernise the NHS, not least to train and recruit the extra doctors and nurses we need. As my noble friend Lord Davies reminded us, we are on target to hit our manifesto pledge to get waiting lists down by 100,000, but that was always just the start. In answer to the noble Lord, Lord Chadlington, we are determined to act on outpatient waiting lists and will treat one third of a million more outpatients this year.
We want to modernise all aspects of treatment in the NHS. Our next step is to modernise the services which deal with the biggest killers—cancer and coronary heart disease—as well as mental health. We are providing more money to give suspected cancer patients faster treatment and provide more operations for cardiac patients. While this brings about a revolution in hospital care, to complete it we must ensure that hospital services are fully integrated with the rest of the care system.
It may be that, given all the changes that have taken place in the NHS over the past decade, many hospital clinicians have felt rather left out. We must harness more effectively the enormous contribution that hospital doctors in particular make to patient care. That must take place in the context of a modern

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healthcare system which moves away from the management of single health institutions and towards a concept where there is management of the clinical conditions that span the component NHS services from which patients receive care. That calls for an intermediate level which is fully networked into local hospital, community and primary care services.
I was interested in the contribution of the noble Lord, Lord Rotherwick. Over the past few weeks hospitals have been full of very elderly people with severe respiratory illness. Demographic trends suggest that those pressures will not change. What must change is how we deliver those services. For example, it is self-evident that we need more critical care beds. It is perhaps less evident, but no less true, that we need wholesale modernisation of the care process. In answer to the noble Baroness, Lady Thomas of Walliswood, that is one of the fundamental findings of the national beds inquiry which my right honourable friend the Secretary of State hopes to publish later this month. I am sorry that the noble Lord, Lord Clement-Jones, is not here to glean that information. The inquiry shows that in comparison with a number of other European countries the NHS is a relatively efficient user of beds with comparatively low bed numbers.
The inquiry reveals, however, that there is a wide variation in hospital bed usage between health authorities in the NHS. Interestingly, it has not shown any simple link between the number of acute beds, the management of emergencies and elective waiting times. All this points to the fact that we need to take a whole-system approach to our services. That approach, under any scenario, will require an increase in the number of beds in the system. I believe that the trend of a reduction in hospital beds over the past decade or more cannot keep pace with changing demography, additional activity and the new services that we envisage for the NHS. More on that later.
This is just the beginning. We want the whole patient experience to be transformed. Our vision is of an NHS where services are shaped around the convenience of patients, and—my noble friend Lord Harris was right—where decisions are shared between clinicians and patients.
That means embracing technology to provide faster services. It means direct booking of hospital appointments, shorter waiting times for treatment, more rehabilitation services, greater use of telemedicines, the Internet and NHS Direct to bring care closer to home. We have made a start on this vision. Now we are upping the pace of modernisation.
A number of noble Lords raised the point about what has often been described as the lottery of care, and the unacceptable variations in access to care from health authority to health authority. We are determined to end that lottery. For the first time in the history of the NHS we are setting clear national standards, through national service frameworks and the National Institute for Clinical Excellence. Perhaps I may say this to the noble Lord, Lord Forsyth. The work of NICE is not about rationing but about
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ensuring that the treatments provided in the NHS are the most effective. The work of NICE will enable us to speed up the introduction of such treatments in the future.
For the first time we are inspecting all parts of the health service, through the Commission for Health Improvement, to ensure that patients obtain the top class care they deserve. Of course—and I turn to my noble friend Lord Winston—the NHS modernisation programme needs cash. So when we look to NHS resources over the past few years it is interesting that many commentators said that the NHS needed 3 per cent growth a year to keep pace with demographic and technology changes. I say this to my noble friend Lord Winston and the noble Lord, Lord Walton. In the three years of the current Comprehensive Spending Review we have given more than that: an average of 4.9 per cent a year over the CSR period. We know that the NHS needs sustained investment. That is what it will receive. My right honourable friend the Prime Minister has said that. Indeed, as my noble friend Lady Ashton has testified, that extra money is being received by health authorities, enabling them to spend more money on developments in services. It is tempting to bandy figures with the noble Baroness, Lady Hogg. I suspect that we would not get far.
I turn to the more fundamental issues relating to future funding of the health service. The noble Lord, Lord Biffen, called for a health Select Committee. He drew attention to the various funding options on offer. Indeed, today we have heard several of those options. The noble Baroness, Lady Cumberlege, proposed a health insurance premium—essentially, I guess, a hypothecated tax. I am not convinced. Inevitably, it reduces government flexibility over public finances. I think that it is potentially more regressive.
Noble Lords: Oh!
Lord Hunt of Kings Heath: My Lords, noble Lords may say "Oh", but given the size of the budget for the NHS, and the proportion which relates to public finance as a whole, it is inevitable that government have to take decisions on funding which give them flexibility over the whole public finance field.
If we are talking of the hypothecation of the entire NHS budget, that inevitably makes the service more susceptible to economic downturn than the current financial arrangements. I agree with the noble Baroness when she said that undiluted private health insurance is not the answer. I had hoped that today's debate might have flushed out what Dr Liam Fox meant in his article in the Daily Telegraph today. He talks about encouraging greater use of private healthcare and wants incentives to be given to individuals and firms to use the private sector. What is difficult to work out is how one relates that to the other initiatives which the Opposition have announced—the patient guarantee and the tax guarantee. The question is whether he suggests that private health insurance is a way forward when the patients who would be forced

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to pay private health insurance under the patient guarantee and the tax guarantee are precisely those who can least afford to do so.
Baroness Hogg: My Lords, while we are flushing out ideas, the Minister has spoken for 24 minutes but has not mentioned the Prime Minister's new commitment. Can he give us the authorised version?
Lord Hunt of Kings Heath: My Lords, I did not think that I needed to comment on it because I thought what my right honourable friend the Prime Minister said was clear.
We have already increased spending around 5 per cent growth in real terms over this year and the next. By the end of the next health spending round, as a proportion of GDP the figure will be around 7 per cent. The Prime Minister made clear that we shall find the funds and are confident that we can sustain an increase in funding that allows us to match the EU average. Of course, detailed decisions on the additional moneys to be made available will be taken in the current spending review which will set spending plans up to the year 2003–2004. Growth in the NHS spend depends on the economy, our sound management of it, and ability to pay.
My noble friend Lord Davies put his finger on the point as regards private health insurance. The very people who need most care are those who are most at risk of ill health and they are the people least able to obtain it. The second reason that private health insurance is the wrong answer is that if one were to do as Dr Fox appears to suggest—to provide tax relief or subsidies to those private health insurances—one is diverting hundreds of millions of pounds which should be spent on the NHS into a huge cash hand-out in tax reliefs and subsidies. Not only would one reduce support for the NHS, and from those with private health insurance, undoubtedly one would risk a two-tier system. The NHS would be left as a safety net service for the poor. Experience in the US and Australia also suggests that tax incentives to encourage private healthcare will fuel the spiralling costs of insurance premiums.
The noble Earl, Lord Howe, and the noble Lord, Lord Lucas, considered social insurance a better runner. Having been in your Lordships' House for a little more than two years, it is probably the first time that I have heard noble Lords opposite look to France and Germany for inspiration. Germany's social insurance system is a heavy cost on employers. For instance, German employers have to pay about 7 per cent on top of the cost of each worker's salary for healthcare. In France, employers have to pay about 12 per cent on top of each worker's gross wage for health social insurance. We should be wary about going down that route. In many cases, it could have a negative impact on our economy and the competitiveness of our businesses. I do not think that we should go down those routes.
We should put our emphasis on the modernisation of the National Health Service. We should reject the idea that the NHS should shrink to cover emergencies
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only and give up on elective care such as hip replacements, hernias or cataracts. We should also reject the idea that the NHS should be reduced to a safety net service for the poor and marginalised. Improvements in healthcare will come through the National Health Service. It is only the NHS which combines efficiency with fairness, providing care on the basis of need and not ability to pay.
When the Second Reading of the NHS Bill which set up the NHS was debated in this Chamber, although in another place, 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 welt-being of the people of this country.
He was right then, and we are right now to take that Bevanite vision forward: to modernise the NHS to make it fit for the 21st century; and to fulfil our commitment to the people of this country.
8 p.m.
Baroness Cumberlege: My Lords, during 10 years in your Lordships' House I have learnt that the way to win gratitude is to bring these five-hour debates to a brisk conclusion. I shall be brief, but I want to make one comment. I am not surprised and have been enormously encouraged by the intellectual range, expertise, innovative suggestions and practical experience that your Lordships have shared with us tonight. It has not been a trivial bang-about. I have sensed that people have been listening. There has been a real search to analyse what is wrong with the NHS and to find new and better ways to rejuvenate it.
I thank the Minister for his masterly and careful summing up, but I am not sure that he picked up all the nuances that were put forward in the suggestions. I know the pressure on ministerial life and that there is a great temptation to say, "Phew, that's another night over". However, I hope that he will read Hansard carefully and try to tease out some of the suggestions that were made. There is a huge feeling of consensus in the Chamber tonight. We are willing the NHS to succeed, but we feel that it is a time of crisis and that there must be some new thinking.
I thank all noble Lords who took part in the debate and I beg to withdraw the Motion for Papers.
Motion for Papers, by leave, withdrawn.

Defence Medical Services
8.1 p.m.
Baroness Cox Baroness Cox rose to ask Her Majesty's Government whether the Defence Medical Services are able to provide appropriate healthcare for the Armed Forces now and in the event of future conflict.
The noble Baroness said: My Lords, a good medical care system is essential for the morale and physical well-being of the Armed Forces. They are prepared to

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risk life and health and suffer separation from their families. They deserve to know that they can rely on the best possible healthcare.
In recent years, they have proved again and again that they are willing to make these sacrifices: in Northern Ireland; in the Gulf and Falkland wars; in Bosnia and in Kosovo. But the current state of the DMS can be seen as a betrayal of their trust. As we have this debate tonight, I believe that France is opening its 15th military hospital, while we are closing our last. Admiral Brigstocke's paper, reported in The Times on 24th January, stated:
"I learned on Friday that the £1.5 million which the Surgeon-General's Department had ear-marked for use across the three services had to be taken as an in-year savings measure. There are soldiers and sailors whose careers are being held back, and in some cases who are being invalided out of the Navy because they cannot get treatment".
I am therefore grateful to have the opportunity to put on record some of the problems besetting the DMS. And I am deeply grateful to all noble Lords who will be speaking tonight. I hope that the Minister will be able to reassure us that the crisis in the DMS, which may soon become a catastrophe, is being addressed urgently and effectively. And I hope that this reassurance will be conveyed to the men and women in the DMS and their families in order to raise morale, to stem the haemorrhage of personnel and to begin a resuscitation process before it is too late and we are carrying out a post-mortem.
The issues include problems of retention of senior staff who cannot quickly be replaced by the current recruitment drive, and closure of facilities which cannot quickly be reopened in the event of an influx of casualties. Closure of military hospitals and transfer to an already overburdened NHS means that military personnel cannot receive the treatment they need when they need it. Career opportunities for medical, nursing and paramedical personnel are severely truncated, adversely affecting morale and commitment. Premature voluntary retirements (PVRs) result, with a backlash on those still in service, who find themselves working for longer hours than civilian counterparts, often for lower salaries. Their loyalty is being tested beyond endurance and many more are contemplating leaving. The downward spiral is continuing with disastrous consequences.
Perhaps I may give a few examples. First, RH Haslar, the UK's only remaining military hospital, has been scheduled for closure. A stay of execution has been granted, but staff know that they are on death row and the implications for morale are obvious. Also, soon after the new intensive care unit at Haslar was opened at great cost and with great pride, the decision was made to transfer it to Queen Alexandra Hospital.
Is that coherent planning? If it were appropriate to have an ICU for the DMS at Haslar, why the change so soon afterwards? If it was not appropriate, why the massive expenditure and triumphalist opening? Little has changed by way of demographic trends or service needs. The reversal of policy represents a gross waste of money for the taxpayers and a confusion of policy extremely detrimental for DMS personnel.
My second example refers to the costly transfer of the Royal Defence Medical College from the well-established and easily accessible centre in Millbank to Gosport. Now another relocation, this time to Birmingham, is being mooted, costing some £140 million. These apparently ill-thought-out moves conjure up a bizarre picture of a kind of Walt Disney procession of DMS personnel marching from London to Gosport and then turning round and marching off to Birmingham, except that the numbers in the procession are dwindling and morale is much lower than in the real Disneyland.
The third issue concerns transfer of DMS facilities and staff to an NHS which is already overburdened and unable to cope with crises such as the recent flu epidemic, even in peace time. Civilian patients with malignant disease have had operations postponed, with life-threatening consequences. How can such an overburdened NHS cope with an influx of military casualties? Last August, I asked a Question on staff shortages at the QA Hospital, about to take over intensive care facilities from Haslar. The Minister's reply detailed some of the staffing problems already besetting the hospital. This is the overburdened NHS into which our DMS are being transferred while, as I already mentioned, France is opening a brand new military hospital—its 15th.
Have any other NATO countries closed all their military hospitals and are relying entirely on civilian hospitals? Furthermore, what has happened to other military hospitals, such as the RAF hospital at Wroughton? It had been a splendid state-of-the-art hospital. It has been closed and become derelict. With no air conditioning, high-tech operating theatres are contaminated with fungus and mould. The Government are talking about building an array of new hospitals. Why not use those already built, which have already cost a great deal of money and which are now going to waste?
The fourth issue relates to pay and conditions of service. I shall deal first with pay. Although basic salaries are broadly comparable to civilian counterparts, those for senior personnel, such as qualified GPs and consultants, do not take into account opportunities in civilian practice to earn additional NHS fees and/or to earn from private practice. While new merit awards are welcome, they benefit only a few. And the much-heralded 1999 pay award is, after tax, only 0.6 per cent higher than the NHS pay award. It is hard for military personnel to resist the temptation to take PVR. This temptation is increased by seeing colleagues of comparable age in civilian practice having a much better quality of life. Overstretch in the DMS often results in long hours on duty, perhaps working one in two nights and weekends, with separation from families and stress for all concerned.
These problems are compounded by truncated career prospects. Last summer, I asked the Government how promotion rates for medical officers in the Royal Navy compared with those for regular officers. The Minister's reply confirmed the average

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length of time for promotion from commander to captain for nor-medical personnel is 6.7 years, compared with 11.3 years for medical officers.
The Government have offered moderately enhanced salaries to compensate for relatively slow promotion. This misses the point. Your Lordships will be aware of the significance or rank in service life and a little more salary is not compensation for delay in recognition of service and equality of status with peers. Also, delay in promotion has ad verse effects on pensions.
It is no wonder that there has been a mass exodus from the DMS. Dr Ferguson, Chairman of the BMA's Armed Forces Committee, stated:
"It is particularly disturbing that figures for some hospital specialties most critical for the DMS's ability to support service operations (anaesthetics, orthopaedic surgery, burns and plastic surgery, accident and emergency medicine) are more than 50 per cent below requirements".
Perhaps I may ask the Minister, by way of example, how many RAF consultant physicians and how many uniformed Royal Navy consultant orthopaedic surgeons are now in post, compared with the numbers who should be in post according to a full complement? Secondly, are reports true that our DMS capability is so inadequate that the UK could not have mounted a land campaign in Kosovo, if we had wished to do so, because there are only enough DMS staff for 1.5 field hospitals and such a campaign would have required 5 to 7 hospitals? Also the deployment would have caused even further reductions in already overstretched DMS facilities in the UK, such as naval bases and air stations, which must still continue to operate.
No amount of recruitment of young medical personnel can fill the vacuum created by the loss of experienced clinicians in the provision of patient care or in the training of junior colleagues. I suspect that we may hear from the Minister glowing accounts of the proposed new centre for defence medicine. This prestigious centre may serve a useful role as a centre of excellence. However, it cannot solve the grave and diverse problems besetting a DMS now verging on catastrophe.
One positive suggestion has been made by leading representatives of the medical profession such as Dame Turner Warwick, who have proposed the establishment of an inter-collegiate faculty of defence medicine to complement the proposed centre. Such a faculty, with tripartite representation of the MoD, the Department of Health and the medical and nursing professions, could be a valuable resource for addressing current crises and longer term policies.
As I conclude, I am sorry to have been so negative. However, many Members of your Lordships' House have been expressing grave concerns over the problems of the DMS for a long time. Successive governments have failed to address those concerns. Now time is running out. DCS 15 has been predictably disastrous. Perhaps I may ask the Minister who has been or should be called to account for such gross errors of judgment.
I look forward to hearing from the Minister how the Government propose to stem the flow of medical personnel, restore the morale of those who have not
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yet left, rebuild infrastructure and replenish facilities to recreate a DMS worthy of our Armed Forces. We proudly and rightly believe that they are the best in the world and as such they deserve the best medical services in the world. These they certainly do not now have. That is a challenge. For the sake of the nation, I hope that the Government will be able to rise to it.
8.11 p.m.
Lord Craig of Radley: My Lords, I welcome this opportunity which the noble Baroness, Lady Cox, has given the House to debate the Defence Medical Services. I warmly congratulate the noble Baroness on her trenchant remarks and many probing questions.
Last spring, I had indications that there could be a considerable number of servicemen and women who were not available for duties due to delays in being seen by consultants and receiving treatment. In four Questions for Written Answer tabled last May, I sought information on the number of personnel of each of the three services who were unfit for duty, who were waiting for secondary care medical treatment, and what percentage of personnel who required medical care in the NHS were having to be treated in turn with non-service patients. The answers I received, some weeks later, were that the Ministry of Defence did not maintain central records of the number of service personnel who were unfit for duty while awaiting secondary care medical treatment; a surprising admission when the shortage of service manpower is already so acute.
I was informed that all service personnel requiring secondary medical care in a National Health Service hospital were placed on the hospital consultant's waiting list and were then treated in turn with other NHS patients on the basis of clinical need. This is a very disturbing attitude from the point of view of the Armed Forces. I Learned that there are financial incentives in Ministry of Defence contracts with NHS trusts to encourage a trust to meet critical operational priority targets set by the Defence Secondary Care Agency; but there does not seem to be any way that the Armed Forces can be guaranteed universal fast-track medical treatment within the NHS. The attitude seems to be that service personnel must be treated along with civilian patients on an equal footing.
I do not think that any of this is satisfactory for the services. My view seems to be reinforced by the remarks attributed in recent newspaper articles to Admiral Brigstocke, a recently retired Second Sea Lord and Chief of Naval Personnel. Regardless of the precise accuracy of the figures which the admiral mentioned—these will change from day to day—his fundamental point was that the Defence Medical Services were in a parlous state. Relying on the National Health Service was not proving to be a satisfactory solution.
Service training is not cheap. When it comes to fast jet aircrew, the costs to reach front-line requirements are today measured in millions of pounds. The effective operational flying life of the fully trained airman or woman is completed in perhaps three or

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four tours. Other individuals will have specialist skills of which the services are critically short. The loss of availability of aircrew and key specialists can seriously affect the operational readiness of front-line units or lead to the overcommitment of others. It has often been said that medical support should be treated as an element of front-line capability because of its direct contribution to the health and availability of front-line personnel. It wants to be readily at hand and fully resourced.
I believe that the run-down of the Defence Medical Services over a very long period of years has now reached a point where much more drastic measures are called for; measures which need not be expensive and which could even yield savings to the defence budget. If personnel "waiting time" for treatment could be cut back to days rather than remain at weeks, months or even years, there would be considerable increases in operational availability. That would be very welcome given that recently the commitments of the Armed Forces have been so high. Furthermore, there could be a saving in defence resources. Indeed, part of this saving could be directed to treatment of service personnel in the private health sector.
As Chairman of Council for the King Edward VII's Hospital for Officers (Sister Agnes'), which has had a close association with the Armed Forces over the past 100 years, I can assure your Lordships that we have all the necessary facilities required to get individuals back speedily to fully effective duty. The same can, of course, be said for many other hospitals in the private sector. I hope that the Government will not dismiss such a solution on grounds of principled objection to the use of the private health sector. Indeed, it could help to alleviate some of the overloading on National Health Service facilities to the overall benefit of the community.
Have the Government taken a long, hard look at the overall cost-effectiveness of the Ministry of Defence turning to the private healthcare sector to speed up the treatment and return to duty of our very valuable front-line aircrew and other key personnel? I hope that we shall learn tonight that this approach, if it is not already in place, will be studied and adopted. It cannot be resolved by the Ministry of Defence alone. This has to be tackled on a broader front by the Government. Surely this problem is an excellent candidate for a positive demonstration of joined-up government.
8.18 p.m.
Baroness Park of Monmouth: My Lords, the Strategic Defence Review was published in July 1998, over 19 months ago. By then it was well known that thanks to the monstrous depredation of Front Line First, the Defence Medical Services were collapsing. In the SDR debate of 8th July 1998, the Minister rightly referred to the, "hollowed out" and "demoralised Defence Medical Services", and pledged to make new money and personnel available to "revitalise them". He promised a great many things. One of those was that 200 specialists and other medical staff would be
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recruited to the Defence Medical Services "within about three years". He expected to be spending an "additional £40 million a year" on those services.
When I asked the noble Baroness, Lady Symons, in the debate on the Queen's Speech last November—17 months later—where were the hospital ships, one promised as a matter of urgency, I received a written reply which, while both full and helpful in responding to the issues I had raised, said that the MoD specification for the vessels was currently being developed and was expected to be completed early this year; namely, in 2000. The requirement would then be passed to the Defence Procurement Agency, where an implementation scheme had already been formed. The in-service date remained April 2005. Therefore, a project described as a matter of urgency in 1998 is expected to take seven years. Is it so high-tech that the MoD needs seven years to test all the equipment; or could it be that either the Defence Medical Services have been told that there is no money for the project or that it has been put on hold more or less indefinitely?
The Government must recognise that, like housing and education, access to good medical care for the Armed Forces now serving out of the UK in large numbers is a basic requirement. Recently we have committed ourselves to further UN operations anywhere, any time. What use then will there be in blueprints for a hospital ship? That is one of the easier things that have been promised.
Some good things have been achieved, although I fear that they are quite small. The Defence Secondary Care Agency is now headed by a serving officer, who understands the needs of the forces. That is a great advance. At Frimley MDHU, although there is still no mess and virtually no opportunity for the tri-service staff to work in a military environment, plans at least are inching forward for a fitness centre and the upgrading of some of the living quarters.
However, there are two major threats to the survival of the Defence Medical Services: the desperate and continuing shortage of doctors and nurses. To no one's surprise, the latter are defecting to the NHS. After all, they are obliged to do a great deal of NHS work, but without the overtime that the NHS nurses receive. All too often the patients for whom they care are NHS patients, including geriatrics, and they work in conditions very far from the military environment with its opportunities for adventure training, travel and other challenges for which they joined. Retention can scarcely be helped by the fact that, unless things have changed, the review of nurses' pay by the Armed Forces Pay Review Body is not due to report until 2002. By that time, the outcome of the review may be largely academic as far as the nurses are concerned.
I hope that the Minister will be able to tell us how many nurses, consultants and other medical personnel respectively asked for premature voluntary retirement in the years 1998–2000. Last year the Defence Committee was told that five consultants who served at Haslar had asked for PVR on hearing that Haslar was to close. On that occasion the British Medical Association quoted a Ministry of Defence statement of

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25th March 1999 that there were then 265 fewer consultants than there were posts to be filled. What is the present shortfall? What serious incentives to join or to stay are being offered? Has the pensions issue been more flexibly resolved?
I turn briefly to the future of Haslar, which the noble Baroness, Lady Cox, has already dealt with in considerable detail. However, it is worth repeating some of the issues. In 1998–99 the annual operating cost of Haslar was £49 million. The net saving to the defence budget from the closure of Haslar was expected to be £14 million per annum after allowing for the creation of a centre for defence medicine and a new MDHU at Portsmouth. That is a paltry sum. Incidentally, I should like to know how much it would cost per annum to run a comparable NHS hospital.
The centre of defence medicine was to consist of one ward and four consultants. However, as well as being a centre of expertise, it was thought that it might be a reception unit for patients who were aero-medically evacuated to the UK in peacetime. Like the MDHUs, it would, of course, be associated with an NHS institution. There Fore, no doubt its beds also would be open to pre-emption by the NHS. We need to know from the Minister, as do the service families who increasingly are anxious about the proposed closure, what provision has been made in all those plans for the repatriation and accommodation of families from abroad? Provision for that exists at Haslar, but there is no such provision at the MDHUs and, presumably, none at the centre.
The BMA has expressed considerable concern that the closure at Haslar will, in its view, seriously damage the Defence Medical Services' ability to train doctors, particularly for operational military medicine. It is scandalous that, as reported recently, young men in the Navy have not been able to receive the orthopaedic and other treatment which they need to allow them to return to service, and that the effectiveness of that service has been reduced correspondingly. Moreover, a surgeon in an MDHU attempted to clear six beds for much-needed orthopaedic operations but had to cancel them because the NHS wanted and took the beds. Are we not allowing the NHS tail to wag the MDHU dog for, I am sorry to say, largely financial reasons? Surely the DMS exist in peacetime primarily to enable the injured to be returned to fitness and to their service duties promptly? The noble and gallant Lord, Lord Craig made the point that that, curiously enough, would save money.
Does the MoD really want to add yet one more anxiety for service families by closing Haslar, without which there is no planned provision for family repatriation? In the very useful letter, which I have already quoted, the Minister told me that Haslar will not close until the MDHU at the Queen Alexandra Hospital is ready. That was not expected "for several years". Meanwhile, however, is the MoD producing any statement to meet the anxieties of the families and to say to them, with some degree of fairness, what the alternative arrangements will be?
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Another aspect of health provision for the services which once would have been a part of the contribution made by the four service hospitals is the needs of families. Given the immensely valuable services which the MDHUs deliver to the NHS, why is it not possible for the MoD to negotiate a binding agreement applicable throughout the country on the issue of NHS waiting lists? That question has often been raised by the families. Again and again, a family on posting will just have reached the head of a list at hospital A, only to have to start again at the bottom at hospital B. That is a most stressful process, not helped by statements from at least one NHS hospital that Army families have less priority than civilians since they are not, after all, regular local residents and are owed no consideration.
Through the Task Force, the Army Families Federation has pressed for a guarantee that a "credit" be given to ensure that no one waits for more than a maximum total of 18 months in a continuous process between two or even three hospitals. Surely that is not unreasonable, and it is the least that the services should be able to expect as a quid pro quo for the major contribution which service doctors and nurses make daily in the MDHUs in taking on some of the NHS load—in my view, far too big a contribution.
The House has just debated the state of the NHS. The health of our soldiers, sailors and airmen deserves equal consideration and equally effective financial support. Failure to fund that seriously and effectively will be one more reason for failure to retain our forces. Our soldiers and their families, too, are members of the human race.
8.26 p.m.
Lord Carver: My Lords, we are all extremely grateful to the noble Baroness, Lady Cox, for having raised this important issue. No one who has read the excellent report of the Defence Select Committee in another place on the Defence Medical Services, published at the end of October last year, can have any doubt in their minds that the Defence Medical Services are in a state of crisis. There are enormous difficulties to be faced and grave doubts about whether they can be solved.
I want to concentrate, first, on the question of the hospital at Haslar. I declare a personal interest because I live near Portsmouth and over the past 15 years I have been a regular out-patient and, for a very short time for a small operation, an in-patient. Over that time, Haslar has been "mucked about", as has the whole of the Defence Medical Services, but perhaps more than any other part of the defence service. I have seen it as a completely naval hospital and as a hospital being transformed into a joint service hospital with the concept that it would remain the one joint-service hospital. I have seen that hope removed and now there is a great deal of uncertainty about the future.
The report from the Defence Select Committee gave a great deal of attention to the whole question of whether or not there should be a core service hospital. The committee studied and argued the matter with

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great care. I am afraid that I must accept the conclusion which it reached reluctantly that a core hospital for the services, as a service hospital only, is not a going concern for the future.
However, the report also highlighted and gave great emphasis to the relationship of the run-down of Haslar with the establishment of the Centre for Defence Medicine. It expressed severe doubts, as I myself have, about whether the Defence Medical Services as they stand can manage the combination of the run-down of Haslar with the establishment of the Centre for Defence Medicine at Birmingham.
When the Minister replies, will he tell the House what "MD" stands for in "MDHU"? The Defence Select Committee report refers to it as a military district hospital unit and the Defence White Paper, a few months later, referred to it as a Ministry of Defence hospital unit. I should be grateful to know what it really stands for.
The report assumed that the MDHU at the Queen Alexandra Hospital at Cosham, or, at any rate, one in the Portsmouth area, would have been set up by 2002, but the most recent Defence White Paper, which has already been quoted, forecast that the Centre for Defence Medicine will open at the University Hospital in Birmingham in April 2001—not a very long time away—but that the MDHU at the Queen Alexandra Hospital at Cosham is dependent on the development of that hospital under the PFI which is expected to take several years. We are assured that Haslar will not be closed until that MDHU is up and running.
The Queen Alexandra Hospital, Cosham, is a very good hospital but it is under great pressure now. It is absorbing patients not only from Haslar but from St Marys. From the point of view of somebody at Haslar, that last statement—that it will take several years—means more uncertainty, and probable continual run-down which will not be compensated for by the employment of civilians, who are already employed in considerable numbers at Haslar. It will inevitably mean a further large number of resignations, particularly in important specialties.
The result of that will be that the dire warnings in this Defence Select Committee report that the Defence Medical Services will not be able to handle that whole process may well come true.
This report deals in considerable detail and in a very balanced way with the problems posed in the MDHUs, to which reference has already been made. It is of vital importance to ensure that those MDHUs function properly and in a way that is satisfactory to the NHS hospitals, the service personnel in them, and to the service community which the MDHU serves. I am not satisfied that that is so at present. Some are undoubtedly better than others—for example, the MDHU at Colchester does not ever seem to have had any great problems. That is a really high priority issue.
The whole question of reservists and the TA hospitals is of very great importance. Because of the difficulties of the regular element of the Defence Medical Services, any major military operations are
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bound to have to call on the TA hospitals and the reservists, both volunteer and regular, who are in the National Health Service. I do not believe that at present that is a satisfactory situation at all. The report deals with that to a certain extent. It is a very high priority issue.
What does the Ministry of Defence propose to do about all that? First, without doubt, it should cancel the application of the infamous 3 per cent savings imposed by the Strategic Defence Review. It was infamous in all areas, but its application to the Defence Medical Services is scandalous—and I should not say anything but that.
What this problem deserves is something like the action which the noble Lord, Lord Carrington, took when he was Secretary of State for Defence in relation to procurement in the Ministry of Defence, which was in a mess. He called in Derek Rayner of Marks & Spencer, later Lord Rayner, and said, "Now, you look into this; tell me what is needed; and then I will put you in charge of putting it right". I believe that the Defence Medical Services need somebody like that. They need somebody of high standing in the medical world to come from outside and not, I hope, to produce a lot more changes. What is needed now is to accept the changes that have been proposed but to make certain that they work. Only by infusing the Defence Medical Services with that sort of spirit will it be possible to retain the essential people who are leaving at present, not quite in droves but in a steady trickle.
8.35 p.m.
Lord Swinfen: My Lords, like other noble Lords, I am extremely pleased that my noble friend has asked this Question this evening, for those serving in the Defence Medical Services are very concerned that they will not be able to cope in the event of conflict. They are concerned also that not enough is being done to put that right. It is an appalling situation.
At Question Time on 2nd December, I asked the noble Lord, Lord Burlison, who is to answer the debate this evening, what was the establishment in the Defence Medical Services of medical consultants. He did not know but he promised to write to me with the answer. However, last month, as I had heard nothing, I tabled a Question for Written Answer and I received the Answer from him yesterday. He told me that on 1st December 1999, there were 174 accredited medical consultants in post against an operational requirement of 443. That is a shortfall of 269 which, if my arithmetic is correct, is well over 50 per cent. That is certainly not a satisfactory position.
Also, when the Minister replies, will he please tell the House how many of those 174 who are still in post have applied for premature voluntary retirement? After they have retired, how many consultant orthopaedic surgeons will still be serving and what is the operational requirement for orthopaedic surgeons? Likewise, what are the operational requirements for anaesthetists, burns and plastic surgeons and accident and emergency consultants?

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Again, what will be the position when those currently seeking premature voluntary retirement have left the services? As I understand it, those are the major consultancies required close up to the field of battle.
Will the Minister also tell the House how the number of regular service consultants today, and after those applying for PVR have left, compares with the number serving just before it was announced in December 1998 that the Royal Hospital, Haslar, was to close? It is my belief that that announcement shattered the morale of many in the Defence Medical Services and was a major cause of the current rot.
It is quite obvious that those ghastly deficiencies need to be made up. How many orthopaedic and general surgical registrars are there in training in the Defence Medical Services? How many of the other specialties which I have mentioned in my speech are in post and in training at present?
I understand that last year's targeted recruitment campaign—which cost, I am told, £100,000—resulted in no medical recruits and just a handful of nursing recruits. That was money wasted. It was certainly not well spent.
How can the hospital cadre of the Defence Medical Services be expected to survive without a flagship tri-service hospital of sufficient size to train and retain a surgical and anaesthetic cadre capable of taking care of service personnel in peace and war? The effective disintegration of the service hospitals dealt a lethal blow to the morale of hospital service doctors who ask, "Why should I stay?". Further, the loss of institutional memory which resulted from the haemorrhaging of senior hospital doctors will have a catastrophic effect the next time we go to war for real. Some predict a second Crimea with old lessons being re-learnt at the expense of making mistakes in managing war-injured casualties, which means losing and crippling our servicemen.
I understand that ships in the Royal Navy that carry a consultant surgeon as part of their complement do have one, but that that surgeon rotates, par roulement, about every six weeks. In my view that cannot help to build up the necessary esprit de corps and confidence among the crew.
I am also told that the 100-bed primary casualty receiving ship, the RFA "Argos", can be manned at present for short exercises. However, can the Minister, when replying to the debate, assure the House that both the RFA "Argos" and the new 200-bed hospital ship currently being procured will be fully manned in the event of conflict? In order to operate effectively, our Armed Forces need to know that they will be properly cared for if wounded in action. As a nation, we have a duty to provide that medical care.
8.41 p.m.
Lord Bramall: My Lords, in this interesting and timely debate, for which we are grateful to the noble Baroness, Lady Cox, we have usefully heard both justifiable criticism and constructive suggestions. I am sure there is more to come. I agree with everything said by my noble and gallant friend Lord Carver.
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However, I hope that in answering, even if it is not his department, the Minister will find an opportunity to admit or at least recognise that the medical plan hatched by the central staff to the Ministry of Defence under intense Treasury pressure in the context of the defence costs study, better known as Front Line First, was probably one of the most disastrous initiatives ever to emanate from that department. It was made all the worse because far from such criticism being in hindsight, repeated warnings had been given in advance, directly to Ministers in your Lordships' House and in another place, that major mistakes were about to be made. They were warned that the consequences to the medical services, secondary care of service personnel and operational sustainability would be very serious indeed, as has now proved to be the case.
The root of the trouble was that too many core hospitals; that is, military hospitals, which were the cornerstone of the medical services in terms of professional incentives, motivation of specialists and the ability to expand for operational emergencies, were done away with; five out of six, if I recall correctly. As mentioned by my noble and gallant friend Lord Carver, the only one left is Haslar. That is now under threat of closure, and was probably in the wrong place, as many warned at the time.
As pointed out by the noble Baroness, Lady Park, that knocked the stuffing out of the medical services with the disastrous manning consequences this Government has now inherited. The Ministry of Defence, still in pursuit of yet more savings, with the term "Front Line First" pushing in the direction of support areas 'but what is the front line? Certainly the medical services should be considered as such' passed the buck of secondary care to the National Health Service, which had many problems of its own.
It did that by grafting on to National Health hospitals—some, I have to say, of varying quality— small medical and surgical teams from the medical services who, though promised it, never achieved the status of having their own wing around which morale could be built up.
There is certainly nothing wrong with Armed Forces doctors and specialists having a greater contact with civilian practitioners and patients. That occurred increasingly in military hospitals and has many advantages. However, such rushing in to complete integration meant that many of the military staff found themselves in geriatric wards. They were swept up in all the problems of the National Health Service. The result, predictably, was that specialists left. The loss of surgeons and anaesthetists was particularly serious to any operational commitment. The waiting list for appointments for service personnel became longer and longer. As pointed out by the Second Sea Lord, that had a serious effect on manning and, therefore, on the operational availability of battalions, ships and aircraft.

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I take the point made by my noble and gallant friend Lord Craig: waiting in a long queue may be highly inconvenient for civilians but for service personnel it means a loss of operational capability. Such "hand in glove" with the National Health Service is still not working as well as it should. The Government are doing their best to correct the shortage of specialists. However, as stated by my noble and gallant friend Lord Carver, the services have had to rely disproportionately, indeed almost exclusively, on the reserve forces for their field hospitals and field ambulances in the event of significant operations occurring in support of our bullish foreign policy.
However, the reserve forces from the medical point of view is the health service, which has its own manning shortages. The release of those people cannot be relied upon in anything but the most major emergencies. As has been said, if the Kosovo operation had degenerated into a two-sided shooting war with serious casualties, which undoubtedly would have occurred, the medical services could have found themselves quite unable to cope because everything has deteriorated so much since the time of the Gulf War.
Now, the Government must put that right if the utility of our forces as a force for good in the world, about which the Government are always boasting, is not to be compromised. A starting point must not be to just tinker around with the management structure and this and that committee. It should first be admitted that the MoD got it all wrong. Then, as and when more doctors, specialists and manpower generally become available, the Government must start to put back some of the things which have been removed. That will require major resources, so that, among other things. specialists can be paid the sort of salaries which would attract and retain able people, as would be done in the marketplace.
There must also either be a new core hospital or Haslar should be reprieved. If we have gone too far down that road and the people are not available, we must build up proper wings of the National Health Service hospitals instead of the very unsatisfactory arrangement which exists at present. The centre of excellence, if given some bed spaces, could turn itself into a core hospital. That must be brought into action as soon as possible.
It is important to build up medical reserves, as is being done, to some extent. However, although an immense help, that is no substitute for a hard core of regulars who are available to train others and for active service at the drop of a hat, come what may.
I hope that the Government, with their heart so much in the right place over defence, will prove that they are better than the previous government at keeping the Treasury at bay. Their good intentions could then be backed by those extra resources, undoubtedly more than have been so far budgeted for, which are needed to put right this very serious state of affairs. However, because of past mistakes, that can no longer be done "on the cheap".
8.50 p.m.
Lord Wallace of Saltaire: My Lords, I, too, have read the report of the Defence Select Committee in another place. I have also read a helpful BMA briefing and wish to echo strongly the sentiments expressed by successive speakers in this debate.
The Defence Medical Services are at a low point; they are close to falling below the critical mass needed to rebuild. If one is going to maintain an effective Defence Medical Service, urgent action needs to be taken to review the levels of staffing; to reverse low morale and to give a sense of a core activity and core commitment back to the service.
We have had a drift downhill over the past 10 years. I agree with the noble and gallant Lord, Lord Bramall, that Front Line First was a classic mistake. It cut the logistical tail without which it is not possible to project forces on a sustainable basis. That, of course, was a failure of the previous government. The failure of our current Government has been to reverse that decline. They have at last conducted a Strategic Defence Review which should have considered not just the need for long-range strategic transport, but also the need for a full logistical tariff, including a defence medical dimension.
Clearly, further investment is needed; that is to say, more money. I am sure the noble Earl, Lord Attlee, will comment on this. I listened on the "Today" programme this morning to the new Conservative Shadow Chancellor promising yet again that he would cut taxes. I merely wish to ask: if one is going to provide this sort of increased investment, how will it be done while squeezing other expenditure further?
What do we need? One starts from the Strategic Defence Review and asks what this Government need and want to do with defence policy? It is really rather ambitious. Someone remarked earlier today that our current Government have a very activist foreign policy in terms of future deployment of forces abroad, partly in the service of defence diplomacy—one of the new themes of the Department for International Development—and partly in terms of the Government's European Defence Initiative. I know that at the European Council in Helsinki in December—very much on the initiative of the British Government—Members of the European Union agreed that we would constitute within the next three years a military force of 60,000 people, of which a quarter is likely to be provided by the British. That is to be sustainable at a distance from Europe for up to one year. There was nothing in the detail that I read relating to the medical dimension. There was a lot about strategic air lifts and strategic sea re-supply. But again, if one wants a sustainable force, the medical dimension is important.
One may say, as indeed the British have said in some of the discussions, that the British will provide most of the spearhead elements of this integrated European defence initiative and others will provide more of the logistical back-up. I remember at the time of the Gulf War that a large number of European countries fell over themselves to offer field hospitals, because that

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was easier to offer than well-trained front-line troops. But even if we accept that others provide more of that sort of tail, clearly the British will need to have sufficient British capacity to cope with our immediate forces.
How do we supply that? As has already been remarked, here there is a clear link with the earlier debate today. One cannot at the same time rebuild the Defence Medical Services in competition with an under-funded and over-stretched National Health Service. Yet again, joined-up government requires one to think about those two things together. At the moment—it is well set out in the front-line documents to which I have referred—the weaknesses of each increase those of the other. There is rivalry over qualified staff; there is resistance from National Health Service trusts to the potential compulsory call-up of reserves, and thus to encouraging their staff to join the reserves.
If we want to rebuild core Defence Medical Services, there are clearly a number of things which need to be done soon. Better pay has to be part of that. There must be greater incentives to stay on, and concern about pensions for those who will retire earlier than they would retire from the National Health Service. It is an unavoidable part of any rescue package. There must be sufficient core facilities to provide a continuing sense of identity, not being swamped by the National Health Service. As the noble and gallant Lord, Lord Bramall, said, we need a Centre for Defence Medicine which is large enough and separate enough to have a clear military ethos. We need to have MDHUs—whatever that stands for and I have no doubt the noble Lord, Lord Burlison, will enlighten us on that question—which are sufficiently large and sufficiently autonomous to have a sense that they are not simply some small part of an over-stretched NHS hospital.
There needs to be a training margin. In everything that I have read it is clear that that training margin has been lost, and once it is lost it is difficult to rebuild. It is also difficult to retain existing staff. There needs to be a clear sense—I am not entirely sure what the Defence Secondary Care Agency is—of distinction between primary care operations and secondary care in terms of back-up. The secondary care must be particularly concerned with provision and training in specialisms in military medicine.
This is a question of priorities within the defence budget as well as of the overall size of the budget. The Strategic Defence Review set out some ambitious objectives. Her Majesty's Government, in the European Defence Initiative, in many ways are being even more ambitious. If there is not enough money in the budget, then Her Majesty's Government should not pretend to be so ambitious.
8.56 p.m.
Earl Attlee: My Lords, I am extremely grateful to my noble friend Lady Cox for tabling this Unstarred Question. Before saying anything substantive, I remind the House that I have an interest.
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My noble friend explained the problem with her usual clarity. I do not propose to revise the points of my noble friend or other noble Lords. I do not take issue with anything said so far tonight. Even the noble Lord, Lord Wallace of Saltaire, holds similar views to myself.
Last week I took part in an Unstarred Question debate. I do not believe that the noble Baroness, Lady Symons, replied to any of my helpful questions about depleted uranium ammunition; I cannot think why. So I hope that the Minister will be more forthcoming tonight. Of course, he may not be able to answer all my points, but the ones which he does not, I shall retable as Written PQs.
Anyone who follows defence matters will be well aware that DCS 15 was not a perfectly developed policy. Well over three years ago, when I was still on the Cross Benches, I was on an All-Party Defence Study Group visit to the Defence Secondary Care Agency. It was a nightmare visit. We immediately became aware of the substantial problems that we all now know about, and applied pressure on the Minister, both in the House and outside. What is interesting is that this Government's policy is not markedly changed, despite all the criticisms. We still have MDHUs and the agency structure. However, the Government have taken the policy further and decided to close the last service hospital—the Royal Hospital at Haslar. My noble friend Lord Swinfen talked about the effect on morale that that decision brought about. It is to be replaced by an MDHU nearby and a Centre for Defence Medicine. But Haslar is becoming run-down before the CDM is up and running. The noble and gallant Lord, Lord Carver, touched on the challenges involved.
Moreover, morale and retention in the DMS, if anything, is even worse. The Government have had this problem for nearly three years and have known about it for much longer than that. Is it not the case that in three years they have not made much of a dent in the problem? Surely if the DMS personnel were confident in the Government's plans, the loss of staff could have been stemmed, or even reversed.
During the previous debate, the Minister, the noble Lord, Lord Hunt of Kings Heath, proudly talked about how the NHS had attracted staff back to it. Why cannot the MoD do this with the DMS? Is the Government's plan for the DMS the final answer, the final solution to the problem? Can the Minister assure the House that the CDM will be up and running by April 2001? It appears to be a challenging target; nearly as much so as the efficiency targets that are causing the MoD so much difficulty.
It is clear from the contributions tonight that the problems of the DMS are largely to do with personnel. Unfortunately, the DMS has to compete with the NHS for staff. Worse still, it competes for the same specialties, as was noted by several noble Lords. There are particular problems with anaesthetists and orthopaedic surgeons. Perhaps when the Minister answers a question posed by my noble friend Lady Cox about orthopaedic surgeons he could say how many

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with the DMS are fit and available for operations. There is no point in having specialists on strength in the United Kingdom but not fit for operations. My understanding is that there are no traumatologists in the DMS. Is this the case? If so, is the Minister content with that?
Noble Lords have identified two problems: pay and conditions of service. My noble friend Lady Cox raised the point that DMS staff do not have an easily exercised opportunity of engaging in private practice which could increase their earnings considerably. But on top of relatively poor salaries, the conditions of service life are not as good as they once were.
Furthermore, with the appetite of this Government for engaging in operations, there is no end in sight to the problems of overstretch. The noble Lord, Lord Wallace of Saltaire, said that the Government were "ambitious"; I think that he used the word more than once. Military personnel need to undertake military training in order to be able to survive in the field. They also expect opportunities to undertake sport and adventure training. But this is proving very hard to achieve in the DMS. This is a vicious circle and the Minister will have to explain to your Lordships tonight how that circle is to be broken.
The Minister will point out that setting levels of pay is a task for the Armed Forces Pay Review Body. He is, of course, correct. The Minister will at least send out positive signals by telling the House tonight that future pay awards will not be staggered. The Minister may respond to the point of the noble and gallant Lord, Lord Carver, on the state of our reserves. As the noble and gallant Lord explained, there are anxieties there as well. Because of the overstretch in the Regular Army, clinicians are reluctant to join the Territorial Army due to the fear of being called up for operations and, thus, damaging their own careers.
The noble and gallant Lord, Lord Craig of Radley, raised the issue of servicemen waiting for appointments with consultants. He explained how important it was for servicemen to be treated rapidly. Does the Minister recognise the need to treat servicemen rapidly in order to keep them at their peak of physical fitness?
On a related point, given that 5,000 personnel are unfit for operations, can the Minister explain why funding to cut orthopaedic waiting lists for military personnel has been cut?
If it were not for the need to be able to conduct operations away from the home base, the problems faced by the Government would be much simpler. Much has been said about what would have happened if Kosovo became what I call a "hot operation". It may not quite have been intensive warfare, but it certainly involved significant engagement and, sadly, numerous casualties. The noble and gallant Lord, Lord Bramall, and my noble friend Lord Swinfen covered this point. Hopefully, the casualties would be from the opposition, but they would still have to be properly treated and to our own standards of healthcare. We have a frightening ability to inflict casualties on an
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opponent, but we would have to treat them as well. What I would like the Minister to tell us tonight—I shall not let him sit down until he does so—is what is the largest army formation that we can deploy with full medical cover for "hot operations". Is it true that we can support only one armoured brigade? Could we support a full armoured division if we called out the Territorial Army to complete the order of battle? What can the Minister tell us about our current capability?
This debate has quite properly focused on personnel issues; but there are also equipment issues. First, what are the plans for hospital ships? As my noble friend Lord Swinfen asked, would it be possible to man them?
The second issue concerns casualty evacuations. Many noble Lords may fondly believe that every serious casualty will be evacuated by helicopter. This is certainly the case with our current operations. We have only a limited number of helicopters, and in a "hot operation" demand soon could outstrip capacity. The Army has numerous tracked armoured ambulances called the FV432 Armoured Personnel Carrier. Is it correct that they are over 30 years old and that spare parts are difficult to come by? Are they able to keep up with the modern Warrior armoured fighting vehicles during manoeuvre warfare? Do the radios with which they are fitted actually work? It is no use having armoured ambulances if the commanders cannot direct them to casualties.
We have been discussing very serious problems. I do not see how the Minister is going to convince noble Lords that this Government have made any better progress than did their predecessor.
9.5 p.m.
Lord Burlison: My Lords, I am aware that the noble Baroness, Lady Cox, takes a deep interest in the DMS. She has made known her concerns most effectively during the course of this debate. I join noble Lords in thanking her for the opportunity to debate this important issue this evening. I hope to respond to most of the points that have been raised tonight. However, if there are any issues that I do not address in the detail that they deserve, I shall certainly respond in writing to the noble Lords concerned.
I should like to start by reiterating the Government's commitment to ensuring that our Armed Forces have the medical support that they need. I am sure that noble Lords would wish to join me in paying tribute to the manner in which the Armed Forces carry out their tasks, both at home and abroad, often under very difficult circumstances. Of course, they must have the very best possible medical care. It is my view that this is being provided by members of the Defence Medical Services.
It is undeniable that the DMS faces a number of problems. The Government have long recognised this and have set about rectifying the situation. The Strategic Defence Review, which the Government initiated on coming to office, identified shortages both in medical manpower and in equipment.
As your Lordships are aware, the Government made an additional £140 million available to the DMS as a result of the Strategic Defence Review. The money

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is for additional medical equipment and personnel. The £140 million is for the four years from 1998 to 2002. It is the Government's intention to maintain increased expenditure in subsequent years.
As noble Lords have recognised, the main problem facing the DMS is a shortage of manpower, and specifically the retention of trained personnel. The current shortfall of doctors is running at about 28 per cent and the shortfall in respect of nurses stands at some 42 per cent. Despite these shortages, I should like to emphasise that the DMS has, to date, met all of its operational commitments. I recognise that this is due in no small way to the dedication of those who serve in the DMS.
I am particularly mindful of the turbulence caused to medical personnel who experience frequent operational deployments due to shortages in their specialty. In order to reduce the frequency of deployments for consultants, our national hospital at Sipovo, in Bosnia, became a multinational facility in May 1999, which means that manning is now shared with allies. This arrangement is working well and has saved a number of United Kingdom medical posts. We are exploring the possibility of a similar arrangement in Kosovo.
The deployment of reservists on a voluntary basis in the Balkans is also helping to reduce overstretch among regular medical personnel. There are currently some 60 medical reservists serving in the Balkans who volunteered their services. This is useful experience for them and, of course, we welcome the contribution that they make.
The noble Baroness, Lady Cox, asked whether the DMS is able to provide appropriate healthcare for the Armed Forces in the event of future conflict. Depending on the scale of any possible additional operational commitments, the call up of medical reservists might be necessary. Defence policy has always been based on the call up of reserves to supplement regular personnel when necessary. The need to call up reserves, including medical reserves, is kept under review as part of contingency planning.
The Strategic Defence Review placed an increased emphasis on the use of volunteer reserves and, in particular, increased the number of reserves in the Territorial Army to support the Army medical services. This increase comprises 2000 personnel, of whom over 600 are medical reserves, with the remainder being drivers and other general support personnel.
A major Territorial Army recruiting campaign for medical reserves was launched in September 1999. The initial response has been encouraging and around a thousand enquiries have been received. It is not yet clear how many people will eventually join, but this is a very promising start.
As I mentioned earlier, an additional £140 million was made available to the Defence Medical Services following the Strategic Defence Review. Among the measures being taken to enhance the operational capability of the DMS is the provision of two 200-bed primary casualty receiving ships, the increased
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readiness of 800 TA field hospital beds, the formation of three new ambulance squadrons and an extra air evacuation flight.
As I have already acknowledged, retention of experienced personnel is the main problem facing the Defence Medical Services. The re-structuring of the services that took place following Defence Costs Study 15 in 1994 damaged morale and resulted in many medical personnel deciding to leave prematurely. It will inevitably take some time to restore manning levels in the DMS.
There are no quick or easy solutions to the problem, as it takes three years to train nurses and up to 12 years to train consultants. Recruitment into training is generally satisfactory and the number of medical cadetships and nurse training places has been increased. Recruitment of direct entry qualified doctors is difficult, however, and work is in hand to identify the barriers to such recruitment and, where possible, to take steps to remove them.
A key element of the new strategy for the Defence Medical Services which we announced in December 1998 was the creation of a Centre for Defence Medicine in association with a National Health Service centre of excellence. As your Lordships are aware—and has been mentioned during the course of the debate—the University Hospital Birmingham NHS Trust has been selected as the host for the Centre for Defence Medicine. The centre is to have an important academic role undertaking medical training and research, as well as providing clinical services and acting as the professional focus for the Defence Medical Services. The trust has provided good proposals which offer a firm foundation for the successful development of the centre. We believe that this new venture offers an exciting vision for the future and will encourage recruitment and retention in the Defence Medical Services.
The noble Baroness, Lady Cox, and the noble and gallant Lord, Lord Craig of Radley, mentioned the leaked letter from the former Sea Lord. No funding was programmed by the Ministry of Defence to reduce waiting lists for service personnel in the current financial year. The possibility of making funds available to pay for additional treatment to reduce waiting lists was considered. In the event this was not possible within the programmed budget. The possibility of action to reduce waiting lists, including orthopaedic waiting lists, in the next financial year is being pursued by the Ministry of Defence.
I refer to the point that was raised of NATO nations with military hospitals. The noble Baroness, Lady Cox, said that France had opened its fifteenth military hospital and asked whether any NATO nations do not have separate military hospitals but rely on partnerships with civilian hospitals. I understand that although the French have opened a new military hospital they have reduced the number of military hospitals from 20 some three years ago to nine now. Some other NATO nations besides the United Kingdom do not have separate military hospitals, for example, Canada, the Netherlands, Denmark and Norway.

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A number of noble Lords mentioned the updating of the intensive care unit at Haslar—
Lord Wallace of Saltaire: My Lords, while we are discussing NATO nations, I hope that the Minister can help me on this matter. The United Kingdom has committed itself to providing a substantial proportion of the new European rapid reaction force. In view of what he said about multi-national hospitals in Kosovo and Bosnia, is it assumed that the defence medical dimension for the British contribution to that force will be provided from within Britain, or is it assumed that it will be provided in part by other NATO nations?
Lord Burlison: My Lords, I thank the noble Lord for making that point. I hope to give him a specific answer before I have finished replying to the debate.
I return to the point made by the noble Baroness, Lady Cox, and noble Lords in relation to the Haslar hospital. The noble Baroness referred specifically to the new intensive care unit at Haslar and suggested that money had been wasted because intensive care services were subsequently transferred to the Queen Elizabeth Hospital at Portsmouth. The intensive care facilities at Haslar were updated late in 1995, as no doubt the noble Baroness and noble Lords are aware. Before the hospital became a tri-service facility, the reconfiguration of the intensive care services became necessary in 1999 as a result of low throughput of patients combined with a shortage of service manpower.
As regards a possible move to the Royal Defence Medical College from Fort Blockhouse, the Ministry of Defence stated in the future strategy of the Defence Medical Services that ideally the Royal Defence College would be integrated with the new Centre for Defence Medicine. This issue is being examined as part of the work of the Centre for Defence Medicine. The financial cost of such a move has not yet been assessed but it is not expected to amount to anywhere near the figure that I believe was in the mind of the noble Baroness. I am informed that those personnel at the college who visited the University Hospital Birmingham Trust are enthusiastic about the college moving there. Many of us can appreciate the reasons for that enthusiasm.
As to the point raised by the noble Baroness about the use of former service hospitals, such as the Princess Alexandra Hospital at RAF Wroughton and others, there are no plans to reopen former service hospitals at either the Wroughton, Halton or Aldershot sites. The hospitals did not provide sufficient patients or the variety of cases needed to train medical personnel for their operational duties or to obtain the necessary training accreditation of the Royal Colleges. The Wroughton site was sold in January, while the A & E wing of the Cambridge military hospital is being used by the Frimley Park Hospital Trust.
The issue of Royal Air Force consultant physicians and Royal Navy orthopaedic consultants was raised by a number of noble Lords, who asked how many Royal
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Air Force consultant physicians and Royal Navy orthopaedic consultants are in post as at 1st February compared with the number required. There were five Royal Navy orthopaedic consultants against a requirement of 10; at the same date, there were six Royal Air Force consultant physicians against a requirement of six, with a further three filling command and staff posts.
Lord Swinfen: My Lords, I was not specific as to the Royal Navy and the Royal Air Force; I was asking about the Defence Medical Services as a whole.
Lord Burlison: My Lords, I shall respond to the point of the noble Lord, Lord Swinfen, a little later. I was answering a point raised by the noble Baroness about those two areas. I realise that the noble Lord's point went a little further.
As to the point raised in relation to the Centre for Defence Medicine, we plan to have the initial agreement in place for the host trust by 1st April 2000. Detailed discussions are now well under way. The Centre for Defence Medicine is to open by 2001. The rate of development from then on will be by agreement with the University Hospital Birmingham Trust. At the same time, it will meet the requirements of the Defence Medical Services. The Centre for Defence Medicine will open with approximately 100 personnel, including administrative support, on 1st April 2001. It is expected to grow over the next five to 10 years at a rate, and to an optimum size, jointly agreed by the MoD and the trust involved. Detailed planning to ensure the appropriate provision of the manpower to the Centre for Defence Medicine and other Defence Medical Services commitments are currently in hand.
The noble Lord, Lord Swinfen, made reference to the figures. I appreciate that his point is well made. The retention of manpower is vitally important in this area. At 1st December, the total strength of the regular Defence Medical Services was 6,174 against a requirement of 8,530—and that is where the 28 per cent shortfall that I mentioned earlier comes in. Between December 1998 and November 1999, a total of 25 medical officers submitted applications for premature voluntary retirement. Of the 25, 19 were specialists and six were GPs. As of 1st December 1999, the total strength of medical officers was 865, including all trainees, against a post-SDR requirement of 1,201. That represents a shortfall of 28 per cent. Twenty-five applications for premature, voluntary retirement represent 4.6 per cent of the total strength.
I may not have covered all the points raised in the debate. I know that I have not covered the point raised by the noble Lord, Lord Swinfen, on the traumatologists. That issue is rather complex and I should like to write to the noble Lord. The noble Lord, Lord Wallace of Saltaire, felt that the training margin has been lost. All noble Lords have concerns on that issue. But I hope that from what I have said tonight with regard to the Centre for Defence Medicine and the Ministry of Defence hospital units, the training margin in the future may well be protected and, indeed, enhanced. We are on a much better course in that respect at the moment.

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The noble and gallant Lord, Lord Bramall, asked about reserves. He mentioned that the reserves were indeed, in the main, National Health Service reserves. That is accepted and, with that in mind, the MoD is in constant dialogue with the National Health Service. I am pleased to say that the relationship between the National Health Service and, indeed, the MoD, is at its best. A number of liaison groups and committees have been set up to discuss matters of common interest, such as personnel issues, operational planning and the application to the Defence Medical Services of developments in civilian medical practice.
The noble Lord, Lord Wallace, and other noble Lords referred to wages within the Defence Medical Services. The re-organisation of the Defence Medical Services in recent years has meant that medical personnel of the three services now work more closely together. Different terms of service created some problems and have become a source of discontent. Rationalised terms of service for medical and dental officers have been agreed and proposed pay spines based on the terms of service have recently been submitted to the Armed Forces Pay Review Body for agreement in principle. Rationalised terms of service for nurses have been agreed in principle also.
The noble and gallant Lord, Lord Carver, asked about the Ministry of Defence hospital units. They are working well, providing an excellent clinical environment and representing good 'value for money. It is clear that the majority of younger medical officers value the training opportunities created by the patient volume in the case mix provided by the MoD hospital units.
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I have been warned that I have run out of time. I have not been able to cover a number of points.
Earl Attlee: My Lords, my noble friend's Question referred to the event of future conflict. Will the Minister say whether we can support an armoured brigade in operations without calling out the TA?
Lord Burlison: My Lords, it would not be appropriate for me to answer that query with a quick reply. But it is a fair question. Some time needs to be spent on it, which is not available to me tonight. However, I will respond to that point and I thank the noble Earl, Lord Attlee, for raising the issue.
The noble Earl asked about the present availability of operational deployment. It is not possible to say how many medical personnel are required to support a particular size of force. It depends on whether the force is employed in war fighting or peacekeeping operations and with whom the UK forces might be deployed. I know that that is only a brief answer to what was a perfectly valid question from the noble Earl.
The Government acknowledge that there is no quick solution to the manpower problems facing the Defence Medical Services. Nevertheless, the Government believe that the measures being taken as a result of the Strategic Defence Review, combined with our new strategy for the Defence Medical Services, provide the basis for ensuring that the Armed Forces continue to receive the high quality medical support they both need and deserve.
House adjourned at twenty-nine minutes before ten o'clock.