HL Deb 27 July 2000 vol 616 cc585-604

3.43 p.m.

Baroness Jay of Paddington

My Lords, with permission I should like to repeat a Statement being made in another place by my right honourable friend the Prime Minister. The Statement is on the health service and is as follows:

"The NHS was the greatest achievement of the post-war Labour Government. It was based on one solid founding principle: that healthcare should be given on the basis of a person's need not his wealth. Some objected to that principle then. Some would like us to abandon it today. But this side of the House will never abandon what was one of the greatest civilising acts of emancipation this century has ever known. Our task is instead to provide both the money and the reform to make the NHS and its founding principle live on and prosper in the 21st century.

"As to investment, in March we took a profound decision as a government. We had sorted out the public finances. Debt service payments were down. Spending on unemployment benefits was down. It was the tough decisions we took on the economy that gave us the opportunity to make an historic commitment to the NHS—an average real terms increase in spending of 6 per cent. Over five years the NHS will grow by a third in real terms, the largest ever sustained increase in its funding.

"The plan shows, first, how that money will make up for years of under-investment. Over the next four years, it will provide 7,500 more consultants, a rise of 30 per cent; 2,000 extra GPs; 450 more GP trainees and more to come after that; in time 1,000 more medical training places each year—on top of the 1,000 already announced—a 40 per cent increase since 1997, and more than 20,000 extra qualified nurses, to add to the 10,000 extra already in post making 30,000 in total.

"For decades the NHS has failed to invest sufficiently in modern building and equipment. The plan will mean 3,000 GP premises modernised and 500 new one-stop primary care centres, 250 new scanners for cancer and other illnesses, modern IT systems in every hospital and GP surgery, 100 new hospital schemes in the next 10 years; and 7,000 more hospital beds in hospitals and intermediate care including the first rise in acute hospital beds in 30 years.

"This is only possible because we are making this historic investment in the NHS. Caring better for NHS staff will mean better care for NHS patients. That is why this plan sets out new facilities for staff, starting with 100 on-site nurseries; and money for training for all staff not just the professions but the support staff as well. Our task is not just to tackle years of under-funding but years of low morale too.

"We know money alone is not the solution. Over the past few months, myself and my right honourable friend the Secretary of State—to whose work I pay tribute today in drawing up the plan—have had scores of meetings with NHS staff and professionals, visited hospitals and GPs and spoken to providers and users of the NHS. Because the issue of funding has been alleviated, at long last people have been able to lift their heads and look at the system in which they operate.

"The NHS staff are magnificent. They are the greatest asset the service has. They are the basis of the trust British people put in the NHS. But in truth they have been, often still are, working flat out in a system that is still organised as it was in the 1940s, when today patients and staff expect and demand a wholly different type of service for the new world in which we live.

"What amazes me is that this is the first time that Government have looked long and hard at all aspects of the NHS: the absurd demarcations between staff that keep patients waiting; the splits between social services and the NHS that make life misery for many elderly people; the consultants' contract unchanged since 1948; the issue of private practice and NHS work left unresolved; GPs' contracts being based too much on quantity not quality; and a stand-off between the private sector and the NHS that is not in the interests of NHS patients. All difficult issues, all a relic from 1948. All addressed in this plan.

"In this plan, each of these issues is faced up to and fundamental reform proposed. The aim is clear: to redesign the NHS system around the needs of the patient.

"First, the role of nurses will be radically enlarged and old barriers to modern working removed. A qualified nurse has had at least three years' training. It is wrong that in many places nurses are unable to make and receive referrals, admit and discharge patients, order tests, run clinics and prescribe drugs. In future these old rules will be swept aside and nurses in every hospital will have that opportunity.

"Secondly, in respect of GPs, the vast majority do a superb job. They are highly respected and rightly so and we should never allow publicity given to the few exceptions to undermine the excellence of the GPs' reputation. But the GPs' contract again is outdated and inflexible. GPs can do more, even some work presently undertaken by consultants, and should have far more freedom in how they use the money they have. Over time, without compulsion but with clear incentives, we aim to move GPS on to a new system of contractual arrangements—the Personal Medical Service contract—which will reward doctors on the basis of quality of care as well as numbers of patients and will give them within it far greater flexibility to innovate and change. There will be more salaried doctors. This will be the most significant change to the way GPs operate since 1948 and can literally transform primary care in this country.

"Consultants do an extraordinary job for the NHS. Their expertise and immense skill are key to the future of the NHS. That is why we are increasing consultant numbers by a third and giving leading clinicians a greater role in the setting of national standards. But the consultant contract has remained largely unchanged since 1948. And though most consultants work extremely hard for the NHS beyond their contractual commitments, there is no proper management of their time. So for the first time we will make sure that all consultants have proper job plans setting out their key objectives, tasks and responsibilities. Consultants will also have their performance regularly reviewed.

"But most of all, we want to reward those who make most commitment to the NHS. First, to encourage high standards of performance and the use of the new national service frameworks. In this case, the consultants, along with others, will have access to the new £500 million performance fund which will give extra money to those meeting the highest standards of service.

"Secondly, we will merge the existing distinction awards and discretionary points schemes and increase the funding of them. By 2004, we will increase the number of consultants in receipt of a superannuable bonus from under one half of all consultants at present to around two-thirds and double the proportion of consultants who receive annual bonuses of £5,000 or more.

"Thirdly, we offer the consultants a deal. From now on, once someone is newly qualified, then for the first few years of their service they will be contracted to work exclusively for the NHS. Again, these will be the most substantial changes to consultants' contracts since 1948.

"The next major reform is to remedy the incredible situation where at one time thousands of older people are in the wrong place for their needs; stuck in hospital when they could be better cared for in their own homes. So for the first time, social services and the NHS will in every area use pooled budgets and new arrangements which ensure they work together for the good of the patient. And where local councils and primary care trusts want to go further and merge into one organisation we will enable them to do so, creating new care trusts that will deliver one-stop care with an entirely unified budget. Where partnerships persistently fail to deliver, we will require local health and social services to join together in a new care trust.

"I would like to thank Sir Stewart Sutherland, who chaired the Royal Commission for Long Term Care, and the other members who sat on it. A full response to the commission's report is published alongside the Health Plan.

"Today we are correcting a major injustice in the system. The NHS provides nursing care free of charge for people living in their own home or in hospital. But until now nursing provided in a nursing home has been charged for. This will now change. From October 2001, subject to parliamentary approval, nursing care in nursing homes will be treated as nursing care elsewhere in the NHS; free at the point of use.

"In addition, we are investing in a major expansion of intermediate care, prevention and rehabilitation services for the elderly. By 2004 spending on new services and facilities will rise to £900 million a year. Also, as the commission proposed, we will expand respite care for services benefiting 75,000 carers and those they care for.

"This package amounts to an extra £1.4 billion per year for older people, more investment than the Royal Commission itself called for.

"Next, there is a series of reforms aimed at preventing ill-health and improving the nation's health, including measures to reduce smoking and improve diet.

"Central to this are measures to reduce health inequalities. The truth is that there are gaps between the health of the poorest and the better off in our society which are completely unacceptable in a modern Britain. And it is children who pay the biggest price. That is why programmes like Sure Start, like the enhanced maternity grants, increased child benefit and the New Deal for Communities are so vital and why we should fight so hard to protect them against those who would abolish them.

"Next, we will reform the treatment of the most serious illnesses such as cancer and heart disease. Up until now, there have been no national standards and patchy treatment. Some get drugs, others do not. Some are seen quickly, others are not. For each of the main conditions, there will be a national framework of standards which will lay down minimum standards of access and care to which patients should be entitled. For cancer, for example, this means maximum waiting times covering not just referral to diagnosis but also diagnosis to treatment; a big expansion in cancer screening and cancer specialists; and an end to the postcode lottery in prescribing cancer drugs. Four hundred thousand patients every year will benefit from new equipment for diagnosing and treating cancer. For coronary heart disease there will be an extra £230 million a year by 2004; a 50 per cent increase in cardiologists; and shorter waits for heart operations.

"These national service frameworks will reflect a fundamental change in the relationship between central government and the local NHS. The centre will do what it must do: set standards; monitor performance; support modernisation; put in place a proper system of inspection; and, where necessary, correct failure. The new Commission for Health Improvement will inspect and report on hospitals, primary care groups and primary care trusts. This information, like Ofsted on schools, will be available to the public. If necessary, the worst performing trusts will have new management put in. The 3,000 non-executive board members of trusts and health authorities will not in future be appointed by the Secretary of State but by an independent appointments commission. There will be a new independent panel to advise the Secretary of State on proposed reorganisations of local hospitals and health services.

"There will be maximum devolution of power to local health professionals. Primary care groups will over time move to being primary care trusts offering minor surgery, physiotherapy and diagnostic tests and minor operations in the local primary care centre. And for all PCTs, health authorities and hospital trusts there will be a new system—what is called "earned autonomy"—which will radically reduce the amount of central intervention where performance is high. Patients put their trust in frontline doctors. So do we.

"The best performers will be given greater freedom and flexibility and all will get access to additional funds tied to clear outcomes in performance.

"This will include a new framework, a concordat, with the private sector. There should be and will be no barrier to partnership with the private sector where appropriate, as the PFI hospital building programme shows. Where the facilities of the private sector can improve care or help fill gaps in capacity, we should use it. But let me make one thing clear. We will never permit people to be forced out of the NHS for non-urgent care. That would destroy the NHS. Where the private sector is used, it will be fully within the NHS service-free at the point of use to the patient.

"We also examined in detail alternative methods of funding the NHS. We concluded that the proposals of some to expand healthcare through tax incentives for private health insurance were massively inefficient and took vital resources out of the NHS and that moving entirely to a continental European type of social insurance system, while less inequitable than many other suggested alternatives, would cost an extra £1,000 to £1,500 per employee per annum. We also estimated that through the NHS, administrative costs are hugely reduced compared with other systems. We were therefore confirmed in our view that modernisation of the NHS was what was required not its dismantling.

"At the heart of these reforms is the idea of re-designing the system round the patient. Too often, whatever the quality of actual care, the patient is catered for in dirty wards, rundown premises with standards of food and basic amenities far below what would be tolerable in other services. Part of the reforms outlined go to remedy this situation. Clean wards and better hospital food will become central to trusts' work, with new resources to back it up. This will get under way now. By 2002, 95 per cent of mixed sex wards will have gone. NHS Direct will be available in all parts of the country. In time, we aim to have the ability to link all parts of the system through technology so one call will put the patient immediately to the right place.

"By 2005, booked appointments will take the place of old waiting lists. As a first big step towards this, all hospitals will by April 2001 be using booking for two of their major conditions. By 2003–04, two-thirds of all appointments will be pre-booked.

"By 2004, there will be an end to long waits in accident and emergency and people will get an appointment with a GP within a maximum of 48 hours. Plus, if an operation is cancelled on the day it is due to take place, other than for medical reasons, patients will get another one within 28 days or have their treatment funded somewhere else.

"Patients will also have more say and more choice with a patient advocate and forum in every hospital to give patients immediate help with sorting out their complaints and a voice in how the hospital is run.

"Over time, these changes, plus the money and staff, will allow waiting to come down substantially. By 2005, the maximum waiting time for an outpatient appointment will be three months and for an in-patient six months, rather than the present 18 months with urgent cases being seen the most rapidly. Average waiting times will, as a result, also come down from seven weeks to five weeks for outpatients and from three months to seven weeks for operations. That means reduced waiting times for all conditions—not only some. And our eventual objective, provided that we recruit the staff and that the NHS makes the reforms, is to reduce the maximum waiting time for any stage of treatment to three months by end of 2008.

"Many other proposals for change are set out in the plan. It will mean, over time, a very radical change in the NHS. But I emphasise to the country that it will take time. Some changes will be fast; others are crucially dependent on new investment in staff and facilities. Staff are crucial to this process. Uniquely, the principles that underpin the plan command the wide support of professions and staff across the NHS, as will be seen from the signatures to these principles at the start of the plan.

"But there is another cause for optimism. At every level of the NHS there are already examples where change and reform have made a difference. We know that the plan is achievable because somewhere in the NHS it is being achieved. The challenge has been to remove the outdated practices and perverse incentives that have prevented the best from becoming the norm. And I make this clear to NHS staff: we shall continue with the same system of co-operative working and partnership that has characterised the past four months. This is the beginning and not the end of that process.

"The challenge is to make the NHS once again the healthcare system that the world most envies. Now, with the money being invested, the reforms can follow. Therefore, we can proclaim loud and clear that the idea of decent healthcare, based not on one's wealth or position but on one's need and suffering, is not an old-fashioned principle that has had its day but is, rather, a timeless principle that this generation has found the courage to reinvigorate for the modern world. I commend the plan to the House".

My Lords, that concludes the Statement.

4.1 p.m.

Lord Strathclyde

My Lords, I am most grateful to the noble Baroness for repeating the Statement made earlier today by the Prime Minister. As the House knows well, over the course of the past few weeks, the noble Baroness and I have dealt with a number of such Statements emanating from the Prime Minister. I have to say that this is the first one of any real substance. Compared to the banalities of the annual report or even the one about the G8 Summit earlier this week, this Statement is very much worth dealing with.

Of course, that is why the Prime Minister elbowed aside the Secretary of State and decided to make the Statement himself. Therefore, I express my sympathy to the noble Lord, Lord Hunt of Kings Heath. The House has come to appreciate his deep knowledge of healthcare and I am sorry that he did not have the opportunity to make the Statement today.

In essence—and I know that the noble Baroness will forgive me for saying this—much of the Statement atones for and, indeed, repudiates the policies pursued in the first years of this Government, for which the noble Baroness herself bears some responsibility. In that sense, it is particularly appropriate that she should be making the Statement this afternoon in this House. This must also be one of those eye-catching areas, referred to in the infamous leaked memo, with which the Prime Minister wanted to be associated as closely as possible.

The Statement deals with our most important national service. The last Conservative government gave the NHS record levels of support and the next Conservative government will do the same. We have made clear that we shall match whatever spending the Government commit to the support of healthcare in Britain. Therefore, the debate is not about how much we shall spend but about how it will be spent. We are becoming familiar enough with this Government to know that we shall need to study the small print with great care before we can reach a final conclusion on that.

Is it not extraordinary that this Statement was not the Statement made three years ago? During the election the Prime Minister said that there were 24 hours to save the NHS. Since then we have seen three wasted years in which many of the best initiatives of the last government have been torn up for narrow political reasons and precious little else has been done. One has only to look at the present day realities. Waiting lists to see a consultant are up by 154,000; 80 per cent of health authorities report that more patients are waiting over a year for their operations; the number of heart bypass operations has fallen for the first time in 25 years; and, as the Prime Minister's Statement acknowledged, morale among staff in the service is exceptionally low.

As we now know, the Prime Minister's closest adviser has written: TB has not delivered. He said he would improve the NHS but instead things have got worse". Quite! Therefore, we must all think that this Statement marks a new beginning—a real break away from the course plotted in 1997 and 1998—and, so far as it does, it will have our strong support.

We welcome, for example, the help given to older people in nursing homes—a measure that we had been calling for. We congratulate Professor Sutherland and the Royal Commission, who are the real authors of this proposal. However, will the noble Baroness explain where the boundaries are drawn between personal care, for which the NHS will not pay, and nursing care, for which it now will? For example, how much care for an Alzheimer's disease patient is classed as personal care and how much as nursing care? Will bathing or feeding a dementia patient be personal and paid for, as the Royal Commission suggested, or will it be disallowed as nursing care? Has a decision been taken by Her Majesty's Government on where the line will be drawn?

We welcome other aspects of this Statement. We welcome the additional responsibilities given to nurses. Professionals, such as pharmacists, nurses and members of the professions supplementary to medicine, have long been under-used in the NHS. We welcome the renewed commitments to care for serious conditions, such as cancer and heart disease. We welcome the additional resources for healthcare. And we hope that the money is used wisely and that better patient care will be the result.

However, the Prime Minister seemed unclear about his attitude to the private sector. On the one hand, he extends a ban on trained consultants working in the private sector; on the other, he talks of co-operation in treating patients. Is it not about time that the Government got over their schizophrenia with regard to private health and acknowledged and embraced it as part of our national resource, to be used wherever it is of service to NHS patients, always free, of course, at the point of use? Bluntly, can the noble Baroness tell us unequivocally this afternoon that she welcomes the existence of the private sector in health in this country?

Now that there is no argument about lack of resources, will the Government restore GPs' freedom, abolished last year, to send patients to the hospital of their choice? And will the noble Baroness tell the House whether the waiting list initiative remains a core of the Government's policy on health? And when the Prime Minister declares an end to what he calls the "postcode lottery for drug prescribing", can the noble Baroness confirm that that will apply to the prescription of drugs for patients of chronic conditions, such as, specifically, MS?

We shall wait to see how the plan works. If it is to work, it will do so only because of the skill and dedication of the hundreds of thousands of people who work in the NHS. We on this side of the House share in paying our tribute to them. However, if I have one nagging worry about this Statement and about this policy, it is that the Government trust them too little in some respects and trust centralisation too much.

The Government abandoned local initiatives when they scrapped GP fundholding and the autonomy of NHS trusts. Yet many of the best initiatives in the NHS have come from local innovation. I hope that the noble Baroness can confirm that it is not the Government's aspiration to move to an entirely salaried GP service. I hope, too, that she can confirm that, in centralising GP and consultant contracts, they will not lose their personal concern for the individual patient and freedom of action that has always characterised the best in healthcare.

This afternoon, the Prime Minister, and the noble Baroness in this House, made an important statement of intent. It requires examination and further debate. Therefore, I hope that the noble Baroness will be able to indicate her approval—if not definitely conclude that it will happen—for a debate to take place in this House when we return in the autumn so that the Statement can be properly judged. It is very important that this House, particularly with the great expertise that exists within it, should be allowed to take a view.

4.9 p.m.

Lord Rodgers of Quarry Bank

My Lords, on behalf of these Benches, I, too, thank the noble Baroness for repeating the Statement made elsewhere by the Prime Minister. I agree with the noble Lord, Lord Strathclyde, in only one major respect: it is a pity that this Statement was not made two or three years ago. History will say that the great error was that the Chancellor committed himself to the spending plans that he inherited. Over the past two or three years, the National Health Service has deteriorated as a result of inadequate spending.

However, the tone of my remarks, which I hope will be echoed elsewhere, is that the Statement and the plan deserve a generous welcome. It is the best statement of policy that I have seen from this Government. I hope that it will receive wide support. We are all in the business of politics and I fully understand that there will be argument about the detail. It will be the duty of this House and another place to monitor the progress of the plan. I shall return to that point. Having said that, however, I hope that there will be a genuine attempt to find a consensus among all parties that will enable the national health service staff at every level to get on with the job.

I note that the noble Lord, Lord Strathclyde, effectively gave an undertaking on the quantum—in other words, he said that the Conservatives would not spend less—but he went on to imply that there might be major changes in the direction of the spending. Of course, one cannot deny the right of any opposition party to think of alternative ways of spending, but it would be a great mistake on this occasion to look for reasons to disagree with the proposals, rather than reasons to go along with them. Agreement will give the National Health Service the stability that it requires.

Of course, we can argue about the past. For a quarter of a century, from 1948, we believed that our national health service was the best in the world. We were living on sentiment, because no government did enough to give it a proper future. In the end, it was limping and falling behind. Then there was another quarter of a century of positive neglect. I do not want to argue about who was responsible. Political parties did not give the necessary leadership in saying that it is impossible to maintain the quality of the National Health Service that the nation requires unless the costs are met. Those costs ultimately fall on the taxpayer and on no one else. It would have been far better if we had been honest about that throughout that long period.

I say that because successive governments have fiddled with management and structure to avoid the central issue. However justified some of the changes may have been, as are further changes now, there is no escaping the fact that the National Health Service cannot be put on a proper basis and meet its agreed objective without the resources being made available to it. I ask for consistency over a considerable period of time in the availability of resources, and some consistency in objectives and the means of delivering them.

Let us recognise that mistakes will be made. Some priorities may change. That is the nature of medicine. There will be advances and events in medicine and technology that we shall need to take account of. However, within that framework, there will still be a great deal of room for giving the NHS support on all sides. I hope that that will be done.

No one should seek to restore the past and move back to 1948, more than half a century ago. I take it from what the noble Lord, Lord Strathclyde, has said that the principles set out in the Statement are endorsed on all sides. Those objectives—that need, not wealth should determine the availability of healthcare and that that care should be the very best—should be common to us all. They are repeated at the end of the Statement, with reference to the poorest and the better-off. It is shaming that the poorest in this country have a worse standard of healthcare than those who are comfortably off and know where to go to get considerably better care. We must apply ourselves to that issue. That means that a great deal more must be done in the areas of most need.

It might be said that we find it easy to support the plan because, for the most part, it is consistent with Liberal Democrat policies. However, even if it were not, we should try very hard to examine each issue on its merits and see whether we can support the plan.

I have two points to make. The first is on long-term care—an issue that is familiar to the Leader of the House and on which I agree with the noble Lord, Lord Strathclyde. We believe that the Royal Commission's majority report was right: we should not separate nursing from personal and social care. More to the point, we do not believe that the policy will work. That is one of the proposals in the plan that, in the end, will come unstitched.

The second point that needs to be looked at carefully is the role and effectiveness of public/private partnerships. We should remain sceptical about their effectiveness and about whether they are the best and cheapest way of getting the money required for the investment on which I hope that we are agreed.

Apart from sharing the view of the noble Lord, Lord Strathclyde, that an early debate would be welcome, despite our heavy programme, my only question for the noble Baroness is how the Government intend to monitor and audit the process that they have begun today. We all want it to succeed. How can we ensure that it does and how will progress be reported to Parliament?

4.16 p.m.

Baroness Jay of Paddington

My Lords, I am grateful to both noble Lords for their welcome for the Statement. In a sense, the noble Lord, Lord Strathclyde, made his own point by saying that it was a Statement of substance. The noble Lord, Lord Rodgers, went further, saying that it was the best policy programme put forward by the Government since the election. I endorse the point made by the noble Lord, Lord Strathclyde, about the knowledge and understanding of my noble friend, Lord Hunt of Kings Heath, but with all due respect to my noble friend, the serious and substantive nature of the policy statement makes it worthy of the Prime Minister's involvement.

Both noble Lords have to some extent ignored the opening paragraphs of the Statement, which deal with the economic situation and the reasons why the Government are coming forward with the Statement now. As we have said many times, including at the time of the recent Comprehensive Spending Review proposals, the Government have now enabled this level of public investment in the health service, which was agreed at the time of the Budget, by achieving a stable economic platform.

The past four months have been spent in a collaborative process, as was mentioned in the Statement, with members of the professions, members of the public, members of the voluntary sector and people representing NHS staff, to produce this comprehensive plan. It has been brought forward now rather than in 1997 because of the state of the economy that we inherited, in which 42 per cent of public expenditure went on financing debt and on social security payments. We have changed that to the extent that the figure is now 17 per cent. That has enabled a real-terms rate of investment in the health service of 6 per cent a year, making it possible for us to make substantive and important changes.

The questions of detail about GP contracts and the way in which consultants and others are employed are relevant, but the point about the relationship with the private sector is clearly set out in the Statement and in the detail of the report. The Government have said that where there is extra capacity in the private sector that can enable health service patients to be treated quickly and appropriately, particularly at times when the health service is under pressure, such as in the winter months, that extra capacity should be used.

The noble Lord, Lord Strathclyde, used the word "schizophrenia". There is nothing split-minded about the question of the private healthcare industry and the concerns that the Government have about consultants. I think that most people will understand that that is a pragmatic approach to using the resources of the private healthcare system within the overall healthcare economy. On the other hand, if one considers the enormous expenses invested by the taxpayers to train doctors in the health service and take them on beyond undergraduate education to the point at which they achieve consultant appointments, it seems to me perfectly legitimate to say that they should then invest their time for a period of years exclusively in the health service. If they then have opportunities to take on private practice, that is something which they can in turn enjoy. But the concept of a return on the taxpayers' investment in this extremely long and complicated training, in the form of a reinvestment of their very high skills into the health service, is generally acceptable to both members of the public and to the medical profession itself.

The noble Lord, Lord Strathclyde, asked about issues related to prescribing and individual types of disease and medical conditions to which these would apply. Of course, under the national service frameworks and the development of the National Institute of Clinical Excellence and its work on recommending ways in which treatment should be applied in every part of the country, all conditions will over time be able to achieve this uniform part of treatment and care. One of the criticisms most vociferously expressed by patients all over the country is that their expectations of what they will receive in one particular postcode will not be the same as in another. The development of these national service frameworks will, of course, lead to much greater stability and uniformity of treatment and care in that way.

The noble Lord, Lord Rodgers, asked me how these new standards will be monitored. That is a rather complicated question, which I am delighted to answer in précis. However, it is a question to which we may usefully return. The current measures of performance are contained within the so-called performance assessment framework. These will be extended, because they presently apply basically to health authorities and it is thought appropriate that they should be extended to all NHS trusts, which would, of course, include all district general hospitals as well as primary care trusts. That system will therefore be extended.

As I said in the Statement, it will be monitored by the Commission for Health Improvement, and the Audit Commission will work with the Commission for Health Improvement to achieve that monitoring. We hope that in time this will result in a progression to a situation in which the very best of NHS practice, which certainly occurs in many parts of the country, can be extended throughout the whole of the system. One sadness about the NHS at the moment is that there are often pockets of extraordinarily good practice that are not spread around throughout the system. Monitoring by an organisation such as the Commission for Health Improvement, working on the basis of the system which I previously described, with national service frameworks in place to enable particular standards of care and treatment to be expected and provided by all hospitals and general practitioners, should enable proper benchmarking and proper dissemination of good standards throughout the system.

A number of questions were asked about the details of the organisation, including the questions relating to prescribing to which I have referred. Overall, the answer to the question of the noble Lord, Lord Strathclyde, about prescribing is "yes".

With regard to the question about the relationship between personal care and nursing services, the issue of agreeing how one defines a service that is delivered under the nursing care arrangement and one which, as the noble Lord rightly said, could possibly be described as personal care, has always been a grey area. What has now been rather sensibly decided is that, instead of trying to demarcate between different services, it should be understood that all care provided by a registered nurse should be eligible for the free treatment arrangements. That defines it more by way of the person who is giving the care rather than by some artificially demarcated system of services, and I know that the Government and the health service together feel that that is a more useful way in which to approach it.

I was glad that the noble Lord, Lord Rodgers, spoke as he did about the overall and universal way in which we hope that this will be taken forward to improve healthcare and to improve the situation in which we have gross inequalities in standards of health in various parts of our community. In my view, one of the most hopeful and inspiring parts of the report is that which contains the signatures right at the beginning of this document. They cover everybody who is involved in the provision of healthcare and the leaders of health services in this country, all of whom have put their signatures to this document, which very clearly sets out the core principles and the NHS mission statement, to use that inelegant word, which lie behind the health service and which will continue to represent its values in the modern setting of the 21st century. They range from the President of the Royal College of Physicians to chief executives and chairpersons of individual, voluntary organisations. That creates a universal accord for the virtue of continuing, delivering, promoting and improving publicly-funded healthcare in this country, which I am sure the vast majority of our citizens want and expect.

Noble Lords

Hear, hear!

4.26 p.m.

Baroness Gardner of Parkes

My Lords, on a day when we have heard much about improvements to the health service, can the noble Leader of the House assure us that, in the abolition of postcode prescribing, NICE will not result in a levelling down rather than a levelling up? In particular, can she comment on the imminent announcement of the multiple sclerosis Beta Interferon NICE decision? Can she assure me that that will not be slipped out quietly in the shadow of this report?

Baroness Jay of Paddington

My Lords, I am afraid I cannot comment on the noble Baroness's final point. As I understand it, the Government have not yet received this. Therefore, I am not in a position to comment on it.

On the noble Baroness's overall point regarding levelling down, of course that will not be the case. The whole point of the national clinical frameworks, as devised and set out by the National Institute for Clinical Excellence, is precisely to incorporate both clinical excellence and cost-effectiveness when considering the matter of prescribing.

Lord Patel

My Lords, I thank the noble Baroness the Leader of the House for repeating the Statement made by the Prime Minister. I also welcome the commitment now demonstrated by the Government to making the NHS responsive to the needs of patients and helping NHS staff to deliver the care. These are radical reforms, and I support much of what is contained in the plan.

Consultant and specialist registrar expansion is most welcome. We know from today's Question Time that more consultants are needed in the service. However, I should like to ask the noble Baroness if a stop will now be put to the current round of reductions of specialist registrars in training that is recommended in respect of some of the specialities. If a stop is not put to it, there will be difficulty in filling consultant expansion.

I also welcome the recommendation in the plan for the funding of specialist registrars from central funds. The current arrangement of 50 per cent of the funding coming from postgraduate deeds and 50 per cent from the trust is not working satisfactorily. Many specialist registrar posts are not currently being filled.

In relation to specialist registrar training, I was, as the current chairman of the Specialist Training Authority, a little surprised to read the proposal to establish a medical education standards board to replace the current Specialist Training Authority and the Joint Committee on Postgraduate Education in General Practice. Nevertheless, although I welcome the proposal to establish a board with a wider representation from the professions, the NHS and the lay public, I hope that the Minister will agree that an opportunity will be provided to those currently responsible for running the two competent authorities on postgraduate medical education to take part.

Baroness Jay of Paddington

My Lords, I am grateful to the noble Lord, Lord Patel, for his authoritative thinking about some of these issues. As he will be aware, all the concerns about registrar training and training for particular specialties are being looked at by the overall workforce planning initiative of the NHS. As I understand it from the document, it is proposed that there should be 1,000 more specialist registrars by 2004 and those will be targeting key specialties. That will obviously deliver a further acceleration in the number of consultants later in the decade.

As I said in the Statement, one of the advantages which those who have written the Statement and worked on it in government have experienced is the enormously co-operative and collaborative part played by the medical profession and the different specialists who have taken part in developing that plan. As I also said when repeating the Statement, the Government regard that as the beginning, not the end, of that process. It is our intention that this matter should be taken forward on a collaborative basis.

Lord Clement-Jones

My Lords, those of us who hold at heart the best interests of the NHS and, indeed, do not believe that private medicine is the route for its salvation will support the broad thrust of the plan before us today. There will be some disappointment, however, in terms of the treatment of older people, as my noble friend indicated, and the failure to accept the recommendations on personal care.

There is one particular issue in addition to that in terms of the limits on means testing for those entitled to accommodation costs in nursing and residential homes. Will the noble Baroness comment on that? There is also a considerable gap in terms of the treatment of those in hospices. There seems to be no mention of palliative or terminal care. That is an essential part of our health and social care. I wonder why that particular gap should exist.

Baroness Jay of Paddington

My Lords, the noble Lord, Lord Clement-Jones, invites me to repeat what I said in reply to the two noble Lords who spoke first. The Government are making an unprecedented new investment over the next three years in improving old people's services by making them more responsive and more fairly funded. The Government's investment will cover the costs of the Royal Commission's recommendations and there is no shortfall in the proposals which the Government have made against those made by the Royal Commission. But the Government have decided that making personal care universally free is not the best use of those resources.

I shall have to write to the noble Lord on the question of hospices. I too am not familiar with any detailed recommendations on that work but I recognise its importance. If there are proposals in the report which I have not yet read about or ancillary proposals, I shall write to the noble Lord.

Lord Ashley of Stoke

My Lords, is my noble friend aware that the Government deserve warmest congratulations on a highly constructive and tremendously impressive set of proposals? She must have been very proud to announce them. They are great.

I have just one reservation. Is my noble friend aware that there is a great deal of anxiety among certain disabled people about charging for personal care, mentioned earlier? In point of fact, there is no real difference between nursing care and personal care because people need that personal care because of their sickness or disability. There is no real difference whatever. Will the Government reconsider that point?

Baroness Jay of Paddington

My Lords, I am grateful to my noble friend for his first comments. I was very proud to be able to repeat the Statement. As the noble Lord, Lord Strathclyde, said, I realise that I have walked into a situation which should properly be for the noble Lord, Lord Hunt, given the enormous amount of work which he has done in this field in the past two years. It is a great privilege for me because, as the Statement said, this is part of the fundamental principles of a civilised society: to try to make the reforms of the health service work in the way which this outline report will now do when it is developed in detail. The Government's reputation will last on this for many generations.

On the point about charging people, I must repeat to my noble friend the point which I made to the noble Lord, Lord Clement-Jones. The Government decided that while making a major investment in the care of old people, which goes beyond that recommended by the Royal Commission, it was not the best use of resources to try to demarcate in the way which I hoped I explained earlier between the types of care being offered, one category being personal care and the other being nursing care.

I know that that is not entirely satisfactory and may be difficult to implement on the ground. But if we identify those services which are offered free as those being offered by registered nurses in whatever environment and surroundings they offer those services, then that is a major step forward which I know my noble friend will welcome.

Lord Renton

My Lords, I too hope that these proposals will succeed. There is one proposal which I do not think the noble Baroness mentioned but which was mentioned on television this morning; namely, that newly qualified consultants employed within the National Health Service should for the first seven years not take private patients. If that is not the proposal, that is splendid.

Baroness Jay of Paddington

My Lords, the reason that I shook my head is that perhaps the noble Lord, Lord Renton, was not here when I gave a very detailed answer to that point when it was raised on an earlier question. I shall be delighted to repeat it. It seems that I am invited not to repeat it.

Lord Renton

My Lords, I am grateful to the noble Baroness for that assurance.

Baroness Jay of Paddington

My Lords, I think that the noble Lord has misunderstood on both occasions. The point I was making was that I had answered the questions about the way in which consultants would be asked to work only for the health service immediately after they qualified. I was not responding to the point that the television programme was inaccurate. As far as the noble Lord described it, the television programme was accurate.

Baroness Greengross

My Lords, I welcome the plans and the report and I thank the noble Baroness for repeating the Statement. I want to make two points.

Noble Lords

Order, order!

Baroness Greengross

My Lords, I am sorry, I want to ask two questions. I welcome the fact that nursing care—looking after old people—will now be free at the point of delivery, wherever the person is. But could not that be defined sufficiently broadly to encompass care which needs to be given or supervised by a fully qualified nurse? As the numbers of old people increase, there will have to be some instances of delegation to people who are not fully state registered. We do not fall into little boxes, particularly as we age. Many people suffering from multiple pathologies get weaker and stronger as they are cared for during treatment and rehabilitation.

The other point is about children. The RCN, among other bodies, has pointed to the urgent need for children and young people to have an explicitly key focus at all levels of health policy.

Baroness Jay of Paddington

My Lords, the Government agree with the point which the noble Baroness has just made about the need for a special focus on children and young people's services.

On the previous point, I fear that I am becoming repetitive. I can only repeat what I said to my noble friend Lord Ashley and the noble Lord, Lord Clement-Jones. Perhaps the noble Baroness will refer to paragraph 2.9 on page 11 of the report which states: In the future, the NHS will meet the costs of registered nurse time spent on providing, delegating or supervising care in any setting. This is a wider definition of nursing care than proposed in the note of dissent to the Royal Commission report which suggested that it should include those tasks which only a registered nurse could undertake".

Baroness Cumberlege

My Lords, the debate has focussed on care of the elderly. Have maternity services been considered at all? The Statement said that for each of the main conditions there will be a national framework of standards. The National Service Framework for Mental Health has been successful. In the debate that took place with members of staff in the National Health Service, were maternity services rated as a high priority in the order of national frameworks that will be established?

I welcome the idea of care trusts, where local councils and primary care trusts merge. Will those be new organisations? If not, where will the corporate governance, the accountability, lie?

Baroness Jay of Paddington

My Lords, I do not believe that maternity services as such are contained in the national plan. I am afraid that I cannot tell the noble Baroness what private discussions were held with National Health Service staff. My suspicion is that if National Health Service staff had wanted to focus on those services and had wanted to advocate them with great vigour, they would have been contained in the plan. That is not to say that they did not advocate something that it is worth while looking at, but it was not something that emerged as a major national priority. That is probably because, on the whole, maternity services are rather good.

The next national service framework, as the noble Baroness may be aware, will be in relation to older people. The Government have not made a decision about the national service framework to be developed after that. It probably would be useful if other priorities were set out and perhaps in that context maternity services would be included.

I understand that one way of looking at the care trusts—this may be familiar to the noble Baroness with her great knowledge of the organisation of health and social care in the United Kingdom—relates to the way in which social care and health boards are organised; for example, in Northern Ireland there is an integrated provision of services and governance seems to be satisfactory.

Lord Bruce of Donington

My Lords, this afternoon is a very moving occasion for me. I sat in this House, which was then the House of Commons, while the entire National Health Service Bill was passed. I congratulate Her Majesty's Government on the way in which the plan and programme, which I have now read, have been put before the House. I also congratulate the Opposition on the honourable part that they have played this afternoon in sustaining the Government who will need all the help they can get from all quarters of the country in order that the plan may be achieved. What Aneurin Bevan started in 1948 now has the strong probability of being furthered to the good of the country as a whole.

Lord Jacobs

My Lords, I strongly welcome the Statement, particularly the significant increase in expenditure of more than a third over the next few years. However, I do not agree with the comments that National Health Service expenditure should have been greatly increased three years ago because, when the Government came into power, there was a deficit of £28 billion. Nevertheless, the Government have had three years to consider these proposals. Included in the proposals is an increase of 7,000 in the number of doctors. Will the Government and the noble Baroness consider what the public should be told about the fact that it will take between five and seven years to train 7,000 new doctors and, therefore, they must not expect quick results under these new plans?

Baroness Jay of Paddington

My Lords, I am grateful to the noble Lord, Lord Jacobs. I believe that I said in the Statement that such matters must be related to the time for training and the time for improving the labour force, if one can describe it that way, of the health service in all professions and in all healthcare areas. We are building on a situation where already more doctors and nurses are in training and more doctors and nurses are being recruited into the health service than three years ago. The additional number that has been announced this afternoon is based on a position that is already strong.

Lord Glenarthur

My Lords, the noble Baroness referred in the Statement to 100 new hospital schemes over the next 10 years. Are they to be funded under the PFI initiative or centrally? In relation to her reference to run-down premises—I draw on my own experience as a chairman of an NHS trust in London for several years—can she tell the House whether the system of capital allocations will be changed to allow those that may have to last for 10 years or more to be suitably built, rebuilt, added to, or adapted in a way that meets the aspirations to which the Statement refers?

Baroness Jay of Paddington

My Lords, the expansion of buildings and facilities, to which the noble Lord rightly draws attention, will be achieved by a combination of the schemes that are exclusively PFI and other methods of funding. I am sure that the noble Lord will welcome the fact that within the plan, although not within the Statement, was the fact that this autumn £30 million will be given to hospitals to clean up wards and so on—in other words, to have a spring clean in October.

Lord Winston

My Lords, the whole nation will be deeply grateful to the Government for the increased spending on the health service, for their focus on the fabric of the health service and for their focus on, and, above all, their support for, the staff of the health service. It is greatly cheering to hear the noble Lord, Lord Rodgers, make the point that this should not be a political football and that we should try to find an accord on all sides so that we can establish the best way of managing the health service.

Perhaps I may make a specialised plea for one group of patients who are rather neglected, who are subject to the postcode lottery and who, in many cases, are subject to inordinate waiting lists and a great unevenness of practice. Given the Government's commitment to family values and the importance of the family, can my noble friend the Leader of the House give us some assurance that people with reproductive difficulties will be better catered for in the forthcoming health service?

Baroness Jay of Paddington

My Lords, I am grateful to my noble friend for his support for the plan overall. On his special pleading point for his own specialty, which we understand, I am sure that he realises that some of the arrangements that are being made for the commissioning of specialist services should iron out the problems that he has described to your Lordships' House relating to "postcode treatment" of people who have particular problems. That is something that could be addressed by a national service framework and, as in the case of maternity services mentioned by the noble Baroness, Lady Cumberlege, this could be a good candid ate for future work in that area.

I am grateful to my noble friend for making the point that this must be a collaborative effort by everyone involved in healthcare. I recommend to the entire House the statement of principles at the beginning of the plan which sets out, in the most sensible and clear way, the basis on which the plan will be taken forward. As I said originally in answer to another question, it is signed by all those who have a particular responsibility for delivering healthcare, not only on a non-political basis, but also on a professional and a patient-centred basis. We all hope to achieve that.