NHS Reform and Modernisation

HL Deb 22 March 2000 vol 611 cc323-40

6.6 p.m.

Baroness Jay of Paddington

My Lords, with the leave of the House I should like to repeat a Statement which is being made in another place by my right honourable friend the Prime Minister. The Statement is as follows:

Yesterday the Chancellor announced funding for the NHS, not just for the coming financial year but for the three years following. Taken together with this year—the first year of the current CSR—it means: the biggest sustained investment for the NHS (35 per cent real terms rise over five years); a real terms average increase of 6.1 per cent per year over the next four years. That is a rise of over double the average under the last government.

"Yes, there have been larger one-off rises, but never a rise sustained in this way. It means that by the year 2003–04, NHS spending will have risen to 7.6 per cent of GDP. That is a huge increase in any terms. In a period of predicted economic growth, it is unique. And it comes with an immediate injection this year of £2 billion extra for the UK, which includes the tobacco duty increase of £300 million.

"We have done this because we believe in the NHS. We never want to see it broken up, reduced to a rump service for those who cannot afford to pay for their healthcare. The NHS is a unifying force in this country and under me it will remain so. But here is the challenge to us in government and to all who work in the health service. Everybody knows that the NHS needed the new money announced yesterday. But everybody knows too that the NHS needs fundamental reform if it is to provide the standard of care people deserve in the 21st century.

"With the money must come the modernisation. A step change in resources must mean a step change in reform. In our schools, we now accept that though more investment is necessary, it is not sufficient. There is a real and often hard debate about standards, performance and reform. No one really believes that one without the other will work.

"Now is the time to raise the same debate in our National Health Service. So this afternoon I will set out the key challenges facing the NHS, the means by which we intend to tackle them and the methods for involving the people who work in the health service in this vital task.

"I say to our hard-working and dedicated staff in the NHS: you challenged us to come up with the money. We have done so. It was hard won and hard fought. There were many calls on it; many places it might have been spent. We rose to your challenge; now rise to ours. Work with us to make sure this money is spent well; make sure the NHS confronts the hard necessities of reform to improve the value we get for the money we spend.

"Some health authorities and trusts carry out four times more hip replacement operations than others. Why? How is it that some trusts can provide elective surgery for all their patients within six months while in others one in eight patients have to wait over 12 months? In some A&E departments non-urgent patients are treated within half an hour while in others there is a four or five-hour wait.

"There are trusts that see nearly 100 per cent of their outpatients within three months, while others only manage less than 60 per cent. The proportion of operations done as day cases varies from 75 per cent in some places to less than 30 per cent in others.

"There are around 5,000 elderly patients in hospital who do not need to be there because of complications between social services and hospitals over their care arrangements. Some hospitals employ twice as many nurses as others to staff critical care beds. Why is there a twofold difference in the cost of care between the best and the least efficient hospitals?

"Some hospitals manage without long trolley waits, while others have them on a regular basis. Patients can get a routine GP appointment within 24 hours in some surgeries but have to wait four or five days in others. The top 25 per cent of trusts use their consultants twice as productively as the bottom 25 per cent. There are huge variations in the proportion of patients at risk from heart disease who get the appropriate drugs to help to control their blood pressure and cholesterol.

"Nurses in some hospitals discharge patients from A&E and in others they do not. Some hospitals use physiotherapists to help to reduce waiting times for orthopaedic appointments, and others do not. Links between social services and GPs work well in some areas, but in others are virtually non-existent. Some medical teams are much better at preventing arid managing conditions, such as diabetes and asthma, than others.

"These are big issues. The reasons for the variation are sometimes complex. Some of these problems will be because of a shortage of staff and equipment. But some will be poor management; inefficient organisation. Some will arise out of outdated demarcations between professionals within the service. Some will be systems failures. Some will be professional failures. Each one of these must be confronted, analysed and solutions found.

"So these are the five challenges that I set for the health service. First, the partnership challenge: for all parts of the health system—GPs, hospitals and their consultants, primary care groups, social services and community health services—to work together to end bed blocking, reduce unnecessary hospital admissions and provide the right level of beds and services for each level of care.

"Secondly, the performance challenge: the challenge is to ensure that using information, incentives and inspection all trusts and primary care groups come up to the standard of the best; that we provide the right support and intervention for those who struggle to provide proper standards of care; and that the systems are in place to identify and root out poor clinical practice.

"As a first step towards meeting this challenge, the Secretary of State will later today give details of £660 million of the extra money for next year that will be allocated straightaway to health authorities, trusts and primary care groups. He will set out how the extra money will be coupled with new incentives to ensure that every pound provides value for money.

"Thirdly, the challenge for the professions: to strip out unnecessary demarcations, introduce more flexible training and working practices and ensure that doctors do not use time dealing with patients who could be treated safely by other healthcare staff.

"Fourthly, the patient care challenge: for hospitals and primary care groups. It is to ensure that they all adopt best practice, design out delays and introduce convenient booking systems so that patients with the most serious conditions get treated quickly, and no one has to wait too long for an operation that he needs.

"Fifthly, the challenge on prevention: to balance spending on tackling the causes of ill health with treating illness, to develop a more systematic approach to treating people at risk from chronic diseases and to persuade more people to play their part in achieving better health by adopting a more healthy lifestyle.

"These are tough challenges. Together we need to find the answers. If excellence can happen in one part of the country, then I say why cannot it happen in all parts of the country. In the past two to three years, there has been substantial change and improvement. The internal market has gone; a record numbers of hospitals are being built; nurses are returning to the National Health Service; and there are more doctors in training. There are new services like NHS Direct; new standard procedures just published for cancer and heart treatment; casualty departments are being modernised; there is a new Commission for Health Improvement, an Ofsted for the NHS, charged with raising standards in all hospitals; and a new institute, NICE, to advise on the best treatments and drugs.

"But we know that this has not been enough; and too often the pressure of change has been made doubly painful by the pressure of scarce resources. Now we have a chance to put the money to work. I have set out the challenge, but I offer to meet it in partnership with those in the health service. In the next few months, the Secretary of State for Health and I will meet and talk with the people responsible for healthcare in every part of the country. We will consult the leaders of the professions and NHS organisations.

"For each of the five challenge areas, there will be a dedicated unit to examine the problems and come up with solutions. The unit will be jointly led by a health Minister and a key leader from within the health service. Because it is a national health service, I have invited the First Minister in Scotland and the First Secretary in Wales to join me in a UK-wide group of Ministers to develop and drive through the reform we devise.

"In addition, for England, a new Cabinet committee chaired by me will be established to agree and monitor the standards of service and improvements that people can expect by the end of the financial year 2003–04. Then, in July of this year, we will publish a detailed four-year action plan for the NHS: the improvements we seek, the change necessary to achieve them and the timetable for their delivery. It will not complete the journey of renewal for the NHS, but it will take us a long way towards our destination. It will take tough, often painful decisions about change to make progress. But I want all parts of the NHS to sign up to the plan, to feel ownership of it, to agree the priorities that we set out and to help us to deliver them. I want the country to unite around it.

"But I do not, and I will not, yield to those who believe that the NHS has had its day. It has not. A modernised NHS, not private medical insurance, is the future. The values of the NHS are every bit as relevant today as they were 50 years ago. But they have to be applied in a different way for a different age.

"The NHS is one of the great institutions that binds our country together. It is one of the great civilising achievements of the 20th century. It is our task, as the party which created the NHS, to renew it for the 21st century and to defeat the pessimists and the privatisers who would see it dismantled".

My Lords, that concludes the Statement.

6.16 p.m.

Lord Strathclyde

My Lords, perhaps I may begin by thanking the noble Baroness the Leader of the House for repeating that prime-ministerial Statement. It is an unusual Statement but not, I am sure, unprecedented. I should also like to say at the outset how much I welcome the intention to devote more resources to the health service. We on this side of the House support that aim. However, as is now well known, that was yesterday's announcement; indeed, the Chancellor of the Exchequer told us that yesterday afternoon.

In contrast, the Prime Minister's Statement today is, I have to say, a disappointment. It sounds as if the No. 10 policy unit has just given him a seminar on the problems that doctors and nurses of this country could have told him about for years. I am bound to ask: where has the Prime Minister been these past three years? He tells us that he is going—no doubt, trailing the cameras behind him—on a roadshow of discovery to every part of the country. I thought that he was supposed to be running the country.

We all believe that Britain needs additional healthcare capacity. But does not the fact that the Prime Minister has felt the need to intervene personally—and put his job on the line—show the utter incompetence of the Ministers who have been in charge of the NHS since the general election? Over most of the long life of the NHS is has been Conservative governments who have supported it, modernised it, built new hospitals and pioneered new treatments. Surely that ought to have been acknowledged in today's Statement. When the noble Baroness replies, perhaps she might show the Prime Minister the way in that respect.

One of the things that has bedevilled the NHS has been the tendency of politicians on the Left to play politics with it. Too often, when Conservatives were in power, those people belittled its achievements and seized with glee every one of its problems. We hear that the Prime Minister now expresses his anger with the media for reporting problems in the NHS. I did not sense that fury in 1995, 1996 or, indeed, in 1997 when the Prime Minister made his extraordinary remark that there were, only 24 hours to save the NHS". Since then not 24 hours have passed but almost three years. What has happened?

Pensioners with lifelong savings—people who, once again, were neglected in yesterday's Budget—have lost tax relief on health insurance. The numbers of people on waiting lists of over a year have risen when patients were promised they would fall. A new scandal has emerged of the doubling of waiting lists for the waiting list: 248,000 more than in May 1997, as a direct result of health Ministers distorting clinical priorities in 1997 and 1998 with their flawed waiting list initiative that has been roundly condemned by the BMA and every reputable medical body in this country. As the Daily Mail revealed this week, some 160,000 people are being forced to spend their savings to get life-saving and life-enhancing operations because the waiting lists for the waiting list are too long.

We have seen a transfer of choice away from the GPs, to whom we had given it, back to bureaucracy. Millions of pounds have been wasted on further bureaucratic tampering while problems on the wards have mounted. So much for "24 hours to save the NHS"; it is more like three locust years while the Government have fiddled and unmet demand for care has steadily grown. Now the Prime Minister comes forward with a Statement that lectures the NHS on its shortcomings. He tells us that he has discovered places where management is not as good as it should be. But who put it there? Was it not the Labour Party's mayoral candidate for London?

Is it not a classic comment on this Government that when the noble Lord, Lord Winston—I am delighted to see he is present—who knows the realities of the NHS, said that there were problems, he was privately bullied and publicly humiliated? But when, a few weeks later, the all-powerful focus groups revealed rising anger in the Labour heartlands about the failure of the Government's health promises, the Prime Minister panicked into action. I do not wish to embarrass the noble Lord, Lord Winston, but perhaps the Prime Minister should listen to the experienced people in his party a little more, and to the flatterers and spin doctors a little less.

What does today's Statement amount to? There is a promise by the Prime Minister to go on a roadshow and to set up new Civil Service units and Cabinet committees. And then what? He is to "prepare an action plan". When the Prime Minister talks of roadshows, units, Cabinet committees and action plans, have we not been here before with a roadshow on social security reform, a new Cabinet committee, "thinking the unthinkable"—remember that?—and delivering nothing? The public will not bear a repeat of that fiasco.

Does the noble Baroness agree—I hope that she does—that if the additional money is to be spent properly, that spending must be properly managed? It is a substantial increase in funding. Does she accept that you will no: get good management if you persist with the appointment of second-hand politicians to run the NHS? Has the noble Baroness had time to read the Fritchie report? It shows a record of unparalleled cronyism and political favouritism in the NHS since 1997. The report finds that of 343 councillors appointed to run the NHS since May 1997, over 80 per cent have been from the Labour Party; just 10 per cent have been Liberal Democrats; and 6 per cent have been Conservative. The Commissioner for Public Appointments comments that the appointments process has been politicised in a systematic way". I may be wrong, but was not the noble Baroness herself part of that system? Does she accept that when public money on this scale is about to be committed to the NHS, political cronyism on this scale has to stop? I hope that the noble Baroness will give an unequivocal undertaking that the Government will accept the Fritchie report's key recommendations.

Yesterday, extra resources were announced for the health service. That was welcome. Today I am sorry to say that we are taken little further by a Statement that lectures the NHS on its shortcomings. We shall watch, supportively but sceptically, to see how wisely this extra money is spent. How much say, for instance, will the clinicians, the doctors and the nurses, who understand so well the problems of care, have in the way it is spent? How much, above all—this will be the test—will go to direct patient care?

After three years of waiting for a year of delivery that never actually comes, we are all entitled to be sceptical, not just us, as a political party, but also people outside the House. This is a government who tax more but deliver less. In this Budget they are again taxing more. Let us hope for the sake of the patients of Britain that this time, for once, they will actually deliver.

6.24 p.m.

Lord Rodgers of Quarry Bank

My Lords, on behalf of these Benches I greatly welcome and thank the noble Baroness the Leader of the House for repeating the Statement made in another place by the Prime Minister, although at this hour it is inevitably to a rather thin House with fewer than 30 noble Lords present.

In so far as I here is to be more money for the National Health Service, we welcome that without reserve. To that extent we certainly welcome the Chancellor of the Exchequer's Statement yesterday, and to that extent—although I wish to qualify my approval—we welcome what the Prime Minister said today.

It is a matter of regret that the needs of the health service were not recognised earlier. To that extent we have had three wasted years because it was plain for everyone to see that the National Health Service had been in decline for at least a decade. We must also note that welcome though the prospect for the next four years is, it is only part of the way towards the Prime Minister's aspiration—if that is what it still is—to achieve levels of spending in terms of GDP comparable to those within the European Union. Although I mention those two reservations at this stage, it is good news. The money is good news and it would be wrong to pretend otherwise.

I ask the noble Baroness a question concerning what might be called the public spending context. It is not clear to me—but this may be my shortcoming—how the announcement yesterday fits in with the comprehensive spending review. Will it mean in any respect robbing Peter to pay Paul? Have other spending Ministers been told that there will be no more money for them? Clearly, the announcement appears to pre-empt a large slice of the Government's spending for the next four years. It is fair to assume that there will be losers. It would be helpful to know who they may be; otherwise, in due course, we shall have to probe to find out.

We shall also look for double counting. I shall not repeat the rather disgraceful story of what the Government have sought to do. I do not think that it is the first choice of Ministers, but they have been urged to adopt that course—and not to their long-term advantage. We hope that there will be no -window dressing". I mean by that easy measures of apparent, short-term success which hide long-term failures. What we want to see are clinical priorities and not political priorities, although I have to say to the noble Lord, Lord Strathclyde, that political priorities did not begin in 1997. We can see them a long time before that.

However, I agree with the noble Lord, Lord Strathclyde, that if the Government are to be trusted on putting clinical priorities before political priorities and we are to have a highly competent service spending more money wisely and well, the Government must clear up the messy and indefensible situation affecting public appointments to NHS trusts and health authorities. My noble friend Lord Clement-Jones tabled a prescient, pertinent and revealing Starred Question last week on that subject. However, I do not think that it more than partially prepared us for the most remarkable and damning report of Dame Rennie Fritchie, published today. Again, I have to say that when the noble Lord, Lord Strathclyde, rather boldly refers to it, it is something of a pot calling the kettle black because this has been long-standing practice. But the fact that it is long-standing practice does not mean that it is not time for a change. I tentatively and nervously suggest that here is a case for an appointments commission. However, I shall not set out the principles upon which it should work.

I do not want to be ungracious to the Prime Minister although I and others are not impressed by his Statement. If the noble Baroness had made her own Statement, I believe that it would have been a great deal more rigorous and substantial, even if she had chosen to make it at all. Almost all the contents are concerned with administration, not with policy. The questions—there are 15 of them within the Prime Minister's Statement—sound more like a research programme, which could have been undertaken a long time ago, than a process of decision-making. On the basis of the Statement there is something to be said for giving all of the money to the King's Fund to come up with the answers which would enable the remaining money to be better spent.

Then again, those of us with experience of government will have allowed ourselves a hollow laugh at the proposal for a new Cabinet committee. It takes us back to the world of Harold Wilson and a long way from the world of new Labour, as we understood it. Our doubts are strengthened by references to dedicated units for this or that. I have never understood what a dedicated unit is; I simply do not believe in them. The five challenges are pure public relations or elementary management gimmicks. They get us nowhere, and we should recognise them for what they are.

The Statement is pretty empty and would have been better avoided. It is either an attempt to catch tomorrow's headlines—headlines for a second day of an important announcement—or, dare I say it, to prevent the Chancellor getting away with all the credit.

I simply ask the noble Baroness—it may be a rhetorical question—whether the money is aimed more at the administrative challenges set out by the Prime Minister. Or are we to believe that some will be left for improving treatment within the health service?

I have one further question of substance. I hope that the noble Baroness will forgive me if it was dealt with by the Secretary of State, Alan Milburn, in a further Statement in the other place. It concerns the existing policy targets. There are a number of targets in regard to cancer treatment, heart disease, mental health and other illnesses—they are reasonable targets; I do not dispute them—but are we to assume that the new resources will be devoted to these targets and that these targets still stand. Or are they to be widened?

I appreciate it is unrealistic to expect the Leader of the House to deal today with these and many other questions about the details of how the money will be spent. I hope very much—it is an obvious request—that we shall have a debate at an early date so that all sides of the House can examine more fully these very important developments.

6.32 p.m.

Baroness Jay of Paddington

My Lords, I am grateful to both noble Lords for their broad welcome for the additional resources. As to the final point of the noble Lord, Lord Rodgers, about opportunities to discuss these far-reaching and important proposals, he will understand that that is a matter for the usual channels. I am sure, however, as always in matters concerning the health service, that your Lordships will contribute authoritatively and interestingly as the debate proceeds and as the understandings we have about the targets to be developed in the new national health plan become more clear.

I should say to the noble Lord, Lord Strathclyde, that I am absolutely delighted that he welcomes so full-heartedly the additional resources for the National Health Service. I had understood, from looking at the comments of his right honourable friend Mr. Portillo before yesterday's Statement, that the Conservative Party believed that there was a choice in this country between making public sector investments and cutting taxes. Mr Portillo said only a few days ago, I think on 12th March, that he would recommend that the Chancellor cut taxes rather than improve public spending. None the less, I am delighted that that position seems to have changed. I am sure that the Conservative Party's conversion to this major extension of public expenditure will be welcomed by all sides.

Both noble Lords referred to how the Statement seemed to be concerned more with administration than with the development of clinical care and the organisation of medicine. It is important to understand—I can say this having been a Minister in the Department of Health at the very beginning of this Government—that it was not until the Government started to look at the variations in performance which the Prime Minister, quite rightly, spoke at some length about today, that there was any system in place within the health service for benchmarking the comparative performances of individual trusts and individual health authorities. It was in order to establish this basic tool of management that a great deal of the preliminary work was done. If the questions to which my right honourable friend referred today about the variations in performance of different hospitals and different professional bodies in the health service had been asked in 1997, it would have been very difficult to answer them in the precise terms that he used today. Noble Lords should not under-estimate the importance of achieving the position where we can now address those variations and make decisions about the distribution of resources, which are obviously part of that issue.

Both noble Lords referred to the question of whether this settlement—which is important, both in the context of long-term management planning and the distribution of resources on a fair and improved but targeted basis—has distorted the already outlined plans for the second comprehensive spending review. The House is aware that my right honourable friend the Chancellor of Exchequer yesterday announced an extra £1 billion for education, and other amounts for transport and other high priorities within the Government's present policy objectives. Of course, the comprehensive spending review in its detail will be carried out with all the other spending departments during the next few months, but I do not think that anything that has been said—or anything that may be read into the implications of the Statement as it relates to the health service—should be read across as an indication that decisions have been made about other public sector expenditure.

On specifics, the noble Lord, Lord Strathclyde, referred to the discussion about waiting lists. I am sure that the noble Lord will be pleased to hear that the health department regards itself as being completely on target to fulfil the election pledge on waiting lists. The department and the chief executive of the health service have acknowledged that there has been what one might describe as a blip in that path upwards or downwards, whichever way one wants to look at it, in the past few months for reasons which were only too familiar to your Lordships when we discussed the problems of winter pressures. The question of outpatients is something to which the Government wish to give attention in this new planning period and in the light of this additional new money.

I suspect that noble Lords may have a slightly pessimistic view. Right across the health service, it is the case that 75 per cent of patients are seen within the patient's charter target of 13 weeks. No one pretends that we are all content with that target—of course it should be improved—but if one says that three-quarters of patients are seen within the existing target, at least we should not be too gloomy about existing standards.

Noble Lords were slightly dismissive of the plan set out by the Prime Minister to act on benchmarked information to lake projects forward in the context of the new spending arrangements. I thought my right honourable friend was rather precise on that issue. He described what indeed was an administrative process—and therefore perhaps not particularly exciting— but he was fairly clear about the way in which he hopes to move forward on a consensual basis involving the health service, the professions, the different parts of the United Kingdom—he referred to consultations with Scotland and with Wales—in order to achieve a consistent and coherent new plan which would be available and ready by July this year. That would then of course be planned out in the context of the longer term spending agreements announced today. This gives the health service a very important breathing space and a capacity to plan on the basis of knowledge of what the future spend will be. That makes it more coherent from the clinical as well as the administrative point of view.

The noble Lord, Lord Rodgers, asked whether the present clinical targets would stand. It is my understanding that they will, particularly those which have been developed within the new national service frameworks and the clinical priorities which have been agreed on cancer and heart disease. I am sure that the additional money will enable new national service frameworks and new national targets to be set in specific clinical areas. Clearly, those targets already agreed—which were in themselves quite ambitious—will be held to. I suspect that clinicians will be more confident in their ability to deliver them within the new financial context.

Both noble Lords referred to quality of management within the health service—I suspect, both the professional quality of management and that which is deployed by those who sit on health authorities and NHS trusts. They referred also to the report delivered today by Dame Rennie Fritchie. I do not know whether either noble Lord realised— the announcement was made only today—that my right honourable friend the Secretary of State for Health, Mr Milburn, announced that he was considering fundamental changes in the NHS appointments process in response to Dame Rennie's report. Most importantly, he said that the first point he wished to examine was responsibility for appointing hospital trusts and primary group trusts; namely, non-executive board members being devolved to local health authorities rather than those duties being undertaken by Ministers. That means that the process would be brought much closer to the local community and, presumably, that ministerial oversight would be removed.

I think it fair to point out again that headlines regarding the way in which appointments have been seen as political—even if that has not actually been the case—have been uncomfortable for all political parties. We are talking about a small proportion of Labour Party councillors being appointed since 1997. I understand that they constitute 20 per cent of the total number of appointments. Having been involved in the appointments process at an earlier stage and knowing that there are literally thousands of appointments—the total for which Ministers are responsible is 3,000—a figure of some 250 appointed councillors should not necessarily be exaggerated, although, given what my right honourable friend has said about an overhaul of the appointments system, I hope that some of the concerns about appointments made from all sides of the political process will be ameliorated.

As someone who was involved in this process as a health Minister early in this Government's term of office, I would say that one must not be over-sensitive on this matter. It was important for the Government—as it was when reforms were made by the previous administration—that those who sat on local hospital boards and were members of local health authorities genuinely believed in, and were concerned about, the way in which the government of the day sought to organise the healthcare system. As a Minister, I was pleased that people came forward for selection feeling that the health service was being focused on in a rather different way after the 1997 election. But we should also remember that all those appointments were made through the process set up by the previous Commissioner for Public Appointments.

I was pleased and flattered by the remark of the noble Lord, Lord Rodgers, that had I been making the Statement, as it were, ab initio it would have been more rigorous and substantial than the one that I repeated. However, the noble Lord, Lord Strathclyde, seemed to place some of the blame as he saw it on existing government Ministers for the disorganisation in the health system as it now stands. I am happy to plead guilty to being in that position two years ago, although the noble Lord, Lord Rodgers, has said that I would have been more rigorous today, but I cannot accept that on behalf of my noble friend Lord Hunt.

Lord Strathclyde

My Lords, I was not referring to the noble Baroness the Leader of the House. My main target was Mr Frank Dobson.

6.43 p.m.

Baroness Carnegy of Lour

My Lords, perhaps I may put one or two rather detailed points to the noble Baroness. Like my noble friend, I very much welcome the infusion of money. I take it that the £2 billion includes Scotland and Wales. First, does the £2 billion include the big increases in wages and salaries that have already been awarded recently? Does it also include the outcome of the review of long-term care which is under way? If that is the case, it indicates that the whole sum will not be available for the reforms with which the Statement is concerned.

On the question of Scotland and Wales, the noble Baroness mentioned the First Minister of the Scottish Parliament and the First Secretary in Wales as taking part in the group that will make the final decisions. Do the five challenges set out in the Statement that are being put to the health service by the Prime Minister apply to health authorities in Scotland and Wales as well? Will the four-year plan that is to be agreed apply to Scotland and Wales? If so, when will the Scots Parliament have a say in this matter? The health service is a devolved matter for Scotland, as it is for Wales.

Baroness Jay of Paddington

My Lords, the noble Baroness's final point is entirely relevant. Health matters are devolved to Scotland and to Wales. I think what my right honourable friend was indicating in referring to the consultations that he intended to have with the First Minister and the First Secretary in Wales, was that the National Health Service is a UK institution. Of course, the funding is somewhat different. The arrangements even for administration and management within Scotland and Wales are slightly different. However, the aspirations for achieving the challenges and for meeting the targets set out are ones which I am sure both he and the Secretary of State for Health in England and Wales would regard as particularly important for the whole of the unified system.

It is important that we have a more consensual approach to reaching the targets, as I hope the Statement made clear. The reference was made in the context of bringing in the professions, presumably from different parts of the United Kingdom, as well as those responsible for administration. Clearly, although the overall settlement is UK-wide, there will be differences in the way in which resources are deployed. In Scotland, those will be matters for the Scottish Parliament, as the noble Baroness rightly said.

Wages and salaries fall to be met out of the overall budgets, but the figures given are for real terms growth. As the noble Baroness will know, they are susceptible to the outcomes of the independent wages and salaries review boards which are referred to the Government for the year in question. The real terms growth is over the entire UK and the whole economy, but, as I say, individual budgets will be deployed by the Scottish Executive in the way that it chooses.

Baroness Carnegy of Lour

My Lords, just to be quite sure, will the four-year plan apply to Scotland?

Baroness Jay of Paddington

My Lords, if I have failed to answer the noble Baroness's questions I shall be delighted to answer her in writing.

Lord Winston

My Lords, I am grateful for the solicitude of the noble Lord the Leader of the Opposition. I hope it continues until the end of my question to the Lord Privy Seal.

Is my noble friend aware that, judging from what I saw this morning in my own hospital trust, which I believe is representative, the Budget announcement has led to a real enthusiasm which I have not seen for a long time in the health service. It will clearly do a huge amount for morale. In particular, it will do a great deal for those hospitals in inner-city areas in deprived parts of the country.

My noble friend the Lord Privy Seal mentioned bench-marking. She, above all, is well aware that one of the problems in relation to disease is that its quality and severity, and indeed the stage of any disease, often depend on a whole range of factors, such as poverty, education and environment. One of the problems with performance indicators and bench-marking is that it is difficult to compare trust with trust across different parts of the country. I know that the Government are aware of that and that they have it fully in mind. A simple league table is clearly not the answer.

One of the problems in the health service is that, as a result of a very long period of neglect, the fabric has been run down. Consequently, one major investment that has been lacking is in information technology. Information technology would do a great deal to provide useful comparators in the health service which could lead to a better assessment of performance. Perhaps my noble friend will comment briefly on whether part of the extra money might be spent on examining how we can best gather information within the health service.

Baroness Jay of Paddington

My Lords, I am very grateful for my noble friend's reaction and for his comments about the enthusiasm that he finds in his trust. Having known my noble friend very well over many years, I know that he speaks from a completely independent and objective assessment and reports accurately his experience in his own trust. I simply tell the House that it is reflected in a conversation in which I was involved this morning in Ipswich, in a non-inner city area, where a Conservative county councillor, who is also the chairman of the local health authority, was equally enthusiastic about the infusion of extra funds. As the Prime Minister and the Chancellor of the Exchequer have said, I hope that this will be seen as a nationwide enthusiasm. I certainly hope, to echo my noble friend's remarks, that it will raise morale and performance right across the health service.

My noble friend is, of course, absolutely right about the complexities of simple target setting within the NHS. He mentioned the social issues of poverty, education, and the environment which tend to affect the severity of disease and the problems which bring people to hospitals and to see their GPs at different stages of disease. I am sure that he will be aware that a great deal of work is being done in the Department of Health both to look at those complicated issues in the statistical sense, and, more importantly, to address the broader issues of ill health, so that there will be a better prevention programme as well as a public health programme which will back up the health service issues.

The question of IT is, of course, a priority for NHS expenditure. I know that there is a major commitment in the health service and in the Department of Health to taking forward the IT strategy which was developed two years ago. This will ensure that the exchange of information necessary to assist in the management of disease, and the practical advantages to patients of booked appointments, is spread as widely and as quickly as possible.

Lord Clement-Jones

My Lords, I too welcome the additional funds announced yesterday and today. I believe that they have the potential to make a real difference to the NHS in the years to come. Perhaps I may ask the Leader of the House two questions. First, the Prime Minister in his Statement highlighted a consultation process with people responsible for healthcare in every part of the country. Will this be about how the additional funding is to be spent in this year, as well as in the following years? If so, the Secretary of State's speech today seems to conflict with that. He referred to allocations being made, and specifically one of £650 million, and he seems already to have decided what the expenditure should be. There appears to be a lack of clarity in that respect. Perhaps I may ask whether this consultation exercise will be a genuine button—up process or a top-down process, which seems to have characterised quite a great deal of the Government's expenditure to date. I am sure that we all want to sere the four-year action plan, to which the Prime Minister referred, genuinely owned by those who work in the NHS. But if there is no adequate consultation, it will not be.

Secondly, perhaps I may follow up the question asked by my noble friend Lord Rodgers about the status of the Comprehensive Spending Review, about which there appears to be a lack of clarity. Has the Department of Health's total budget for this and the following four years now been set? If so, can the Minister, the noble Lord, Lord Hunt of Kings Heath, indicate very soon the decisions that will be made on the Children (Leaving Care) Bill rather than waiting until the Comprehensive Spending Review?

Baroness Jay of Paddington

My Lords, my noble friend Lord Hunt of Kings Heath, who is seated behind me, says that the answer to the noble Lord's final question is "no".

With regard to the broader point, as I hope that I made clear to the noble Lord, Lord Rodgers, the four-year spending agreement is not, as the noble Lord, Lord Clement-Jones said, related to the Department of Health's spending. It is related to NHS spending. However, that is the agreed programme.

With regard to the question of the consultation process, my understanding is that the allocation of the £600-odd million referred to in the Secretary of State's additional Statement this afternoon relates to the extra £2 billion which will be made available at the beginning of this immediate financial year. The consultation process on the new national strategy, if that is what we wish to call it, which is to take place over the next few months, will be about putting the plans for the health service in a broader, longer-term context. As I said in reply to the two noble Lords who spoke from the Front Benches, the hope is that this agreed spending over the four-year period will enable proper planning and understanding of agreed targets to be the subject of consultation over that longer period of time.

Lord Peston

My Lords, in welcoming the Statements of my right honourable friend the Chancellor of the Exchequer yesterday and my right honourable friend the Prime Minister today, is my noble friend as puzzled as I am by the extent to which the Official Opposition are waxing so strongly about the fact that more Labour councillors than Tory councillors were appointed to these bodies? Does she recall that during their 18 years in power, the Conservatives were absolute past masters of the politicisation of all forms of public appointment? Was it not from their side, from a very good friend of mine whom I particularly respect, that we heard the Statement, "We would not knowingly appoint a Labour Party member to any public appointment"? We have nothing to learn from them, as my noble friend agreed.

Further, is my noble friend as puzzled as I am by the question from the Leader of the Liberal Democrats with regard to the three-year delay? Does she agree that my right honourable friend the Chancellor of the Exchequer is the first Labour Chancellor in history to make absolutely certain that he had the economy on a sound basis and the public finances fully under control before spending the money? I stand second to no one in wishing that it would not take quite so long. But is she aware that at least those of us on our Benches who know a little about economics believe that my right honourable friend was entirely right to ensure that the funds were first in place before committing them, and that what we really ought to be saying is, "Thank goodness that the funds are there now, and we are committing them to this top priority of the NHS"?

Baroness Jay of Paddington

My Lords, I entirely agree with my noble friend politically and, of course, as always, I defer to his expertise in the broad economic field.

With regard to the question of whether or not this Government have anything to learn from the present Opposition party about appointments to public bodies, before the noble Lord from the Opposition Front Bench rises to his feet, I must point out that I was a member of a health authority under the previous administration. It would be completely churlish and inaccurate of me to deny that fact. However, I agree with my noble friend that a number of appointments were fairly extensively made on a political basis during those 18 years. In addition, however, we in this House quite clearly learned in our debate on the House of Lords Bill—although I hate to raise this subject again—that "independent", when it refers to public appointments at local level and particularly when it applies to certain areas of the country, often means "Conservative". But let us not dwell on that particular part of our collective past.

With regard to my noble friend's judgment about the overall macro-economic position, he is, of course, right that my right honourable friend the Chancellor of the Exchequer was determined, as he very clearly demonstrated in the Budget Statement yesterday, to get the finances of the country in good order to provide a good platform for growth of the public sector, and I am very glad that noble Lords all round the House have now recognised what a generous settlement this is.

Baroness Masham of Ikon

My Lords, I thought that it was getting a little party political. Does the Leader of the House agree with me that the Statement was rather disappointing in that it did not mention the consumer, the patient? Does she also agree that the consumer should take part in management? More and more professionals are coming in who have their jobs at stake and their careers at heart.

Does the noble Baroness also agree that it is a little disappointing that no mention was made of infection control? This is becoming a big problem. Patients are becoming frightened of going into hospital, and we now have a report that 5,000 patients per year die from infection. Would she therefore include the question of infection control in the health agenda?

Baroness Jay of Paddington

My Lords, I entirely agree with the noble Baroness that patients should be involved in the process of consultation. I suspect that it was only the limitations of time which prevented this matter from being explicitly developed under one of the challenges referred to by my right honourable friend. The noble Baroness will be aware that for the first time the Government have instituted an annual patient survey and a large number of patient representative appointments have been made to individual boards and trusts, particularly in the area of primary care. But the noble Baroness is absolutely right that patients must be involved in consultation and the development of plans.

As to infection control, the noble Baroness will be aware that there is now strong guidance in place to deal with this very serious issue. I agree that this matter must be taken seriously. This is perhaps precisely the kind of detailed issue which the consultation period on the new national strategy will include.

Lord Shaw of Northstead

My Lords, I too welcome the Statement. The Statement says that a modernised National Health Service is the future, with which I also agree, but much reform is needed. In looking ahead, do the Government reject out of hand any method of raising funds other than general taxation to meet the needs of the National Health Service: the private sector, insurance or any other means? Can the alternatives be looked at, or are they forbidden ground?

Baroness Jay of Paddington

My Lords, in so far as the noble Lord makes a rather universalist challenge by referring to "forbidden ground", the answer is yes. The Government believe that public sector funding of the kind announced yesterday by my right honourable friend, together with the plan developed by my right honourable friend the Prime Minister this afternoon, is the appropriate way to run a universal health service free at the point of need. That is the fundamental principle of the health service from which we have never diverged, and do not intend to diverge at this moment.

Baroness Hooper

My Lords, does the noble Baroness recall that during the passage through your Lordships' House in 1989 of legislation to reform the National Health Service an amendment was moved and accepted by the then government which led to the appointment of a director of research for the NHS whose primary function was to look at the delivery of services within the NHS? Rather than set up a plethora of new bodies, committees and consultation processes, can the noble Baroness assure the House that the work conducted by the various directors of research over the past 10 years, and/or the suggestion of the noble Lord, Lord Rodgers, that the King's Fund research facilities should be utilised, will be fully taken into account?

Baroness Jay of Paddington

My Lords, I do not recall the particular amendment to which the noble Baroness refers; I was not in your Lordships' House in 1989. I was, however, one of the first lay members of the Central Research and Development Council for the NHS which, presumably, was set up as a result of that amendment. I have been quite closely involved in the work of that body since its inception. My understanding of that body and the Director of Research and Development for the NHS has always been that the determining factor is research into services rather than their delivery. That may be a rather grey area but there is a slight distinction, certainly in terms of the projects in which I was involved when I served on the council. There is to be a new research and development strategy within the NHS which will embrace some of the topics included in the Statement of my right honourable friend about the challenges of modernisation to be published next week. I agree with the noble Baroness that the work of the Research and Development Unit within the DoH, although slightly different from some of the aspects of reform which the Government are anxious to pursue, is very relevant to the general process.