The National Health Service

HL Deb 02 May 2001 vol 625 cc699-737

3.7 p.m.

Baroness Noakes rose to call attention to the state of morale in the National Health Service; and to move for Papers.

The noble Baroness said: My Lords, the state of morale in the NHS is of great concern. The NHS is a great institution in which I had the honour to serve for three years as Director of Finance and later as a member of its policy board. It is an essential part of the social and economic fabric of our land, but it is in crisis.

That crisis has no easy measurement. Most of the data that we have about the NHS are hard data. They tell us how many people have been treated; how many are waiting for treatment; how much money has been spent; how many new hospital schemes are under way; and how many staff are employed in the NHS. But crucially, those data do not tell us how the 1 million or so NHS staff feel. That feeling is critical to how well the NHS can deliver.

Anyone who has been involved in running any kind of organization—I imagine that will cover most, if not all, noble Lords here today—will know that people are the most important element. As the late Lord Sieff said: Ultimately, whatever the form of economic activity, it is people who count".

It is fair to say, although I derive no personal comfort from saying it, that four years ago many in the NHS welcomed the arrival of the Labour Government. They felt that the NHS would improve and that life for NHS staff would improve. They were wrong, and now more and more are saying so, although some are still too afraid to say so openly. The cumulative effect is of plummeting morale and dissatisfaction with the way that the NHS is being run.

A recent survey found that 84 per cent of nurses and doctors felt that stress levels were increasing in their jobs and that 10 per cent thought that stress might have resulted in clinical error. An increasing clinical error rate is truly frightening.

When we talk of morale we are not simply talking of the personal happiness of NHS staff or the latest fashion in HR initiatives. We are talking about a very real impact on patient care and that is why the current crisis in morale is so worrying.

I want to spend most of my time today talking about morale in various staff groups within the NHS. However, before I do that, I shall refer to one small group within it: community health councils. CHCs have done much valuable work for patients and carers over the past 30 years, particularly when the NHS made errors. But they were not perfect. The Government decided, without any consultation, to abolish them.

That decision caused much heartache and concern to the committed staff and volunteers in CHCs. For the past nine months, they have had to fight for their own survival while at the same time continuing their good work for patients. I know that morale in CHCs will have been lifted last week by your Lordships' wise decision to reject abolition in the Health and Social Care Bill—and we can only hope and pray that the Government will not inflict yet more pain on this group by seeking to reverse your Lordships' decision in another place.

The main experience of the NHS for most people is their general practitioner. Around 78 per cent of us saw a GP last year. If morale is poor among GPs, it can have devastating consequences for patient care. And morale certainly is poor. A recent survey for Doctor magazine showed that four out of five GPs would quit the NHS if they could, which is much higher than in any previous survey. Nine out of 10 thought that NHS reforms were lowering morale. More than two-thirds of GPs are now less likely to recommend a career as a GP than five years ago.

That seems extraordinary. Have we not frequently heard from the Government about their plans for general practice with the aim of improving everything from premises to the access times for patients? The NHS Plan proudly proclaimed a commitment for a further 2,000 GPs on top of the existing 36,000. But the GPs pointed out that the existing plans for new GPs already had 1,100 pencilled in; and the profession's own calculations showed that more than 10,000 new GPs were needed if the Government's various initiatives were to be delivered.

General practitioners believe that the Government are dragging their heels over the promised new contract. They are getting increasingly angry about this lack of progress. We saw that anger yesterday as some GPs even closed their doors to non-urgent cases. The BMA is balloting GPs. To date, all that GPs have had from the Government are some promises about freeing them from paperwork and various financial inducements, which were described by one despairing GP as "pathetic and insulting".

General practitioners genuinely want to deliver improved care to their patients. They want to increase the average time spent with each patient from the current level of eight minutes. But they can see only that clinical time will be squeezed further by central requirements. They worry that that will lead to dangerous medicine. That is why they would opt out if they could.

The picture is no happier when we look at consultants. They were pretty satisfied with the Government's commitment in the NHS Plan to an extra 7,500 consultants by 2004, a rise of 30 per cent. Consultants think that that would be a good start to closing the gap with the rest of the EU, which has roughly double our rate of consultants. Consultants believe that our low consultant numbers are a major cause of our long waiting lists and stress within the consultant community.

However, the consultants were definitely not happy with the NHS Plan's proposal that new consultants should work for up to seven years exclusively in the NHS. Doctors do 12 or more years of hard work for low pay before they earn consultant status and the Government are now telling them that their ability to work privately will be severely constrained for a further seven years.

Even with the promised extra pay, consultants will not be paid well compared with their peers. Young doctors look at their university colleagues, now working in the City or in the professions, generally with less stress and earning far more money. Small wonder that many are considering whether it is worth it. If more quit, unfilled vacancies will continue to rise and the planned growth in the consultant population could very easily go negative.

The Government have belatedly started negotiations on the new contract. Just before that, consultants were, deeply frustrated and annoyed by the failure to make progress on negotiations".

If these negotiations do not bear fruit to the taste of consultants, they will be very dissatisfied. Behind them, the junior doctors, who work so hard with the aim of becoming consultants one day, will also lose heart. The NHS cannot afford this level of dissatisfaction.

No story of NHS morale would be complete without reference to the largest professional group—nurses. The NHS Plan set out a fairly modest increase of 20,000 nurses, on top of the existing 390,000. But there are 22,000 vacancies at present and an increasing number of our nurses are leaving to go abroad; there were more than 5,000 last year.

At the same time, we are becoming increasingly dependent on nurses from overseas. Twenty-five per cent of London's nurses are foreign. The Department of Health has even created a director with specific responsibility for recruiting nurses from abroad. My noble friend Lady Cumberlege put the spotlight on this last week during the Report stage of the Health and Social Care Bill. She described how we are simultaneously depleting the scarce skills base of countries with desperate healthcare needs, such as South Africa, while not even solving the problems of work pressures on our own hard-pressed nurses.

A recent survey of nurses in London, where vacancies are particularly acute, had eight out of 10 saying that the NHS was not a better place to work than two years ago. Most nurses do not feel that they are adequately paid. Many do part-time agency work, which is itself costly for the NHS, merely to survive. More than two-thirds of nurses received only an inflationary increase last year. The new cost-of-living supplement is not being paid to all nurses with high housing costs. This has done little for morale or recruitment.

At the same time, the Government are introducing modern matrons. This is yet another call on our over-stretched front-line nursing workforce without any additional resources being provided for implementation. Described by one commentator as "an evidence-free political wheeze", this is no substitute for policies which will make the NHS a better place for nurses.

Let me now turn to managers in the NHS. Over the past year or so we have seen a steady trickle of the most senior managers leaving the NHS. We have seen scapegoating on an unprecedented scale, with chief executives and even chairmen being forced to resign for little or no good reason. The newly appointed NHS HR director said, before his appointment, that the "heads must roll" approach is, seriously eroding the confidence of senior managers".

Targets and priorities rain down from on high and new initiatives arrive daily. The Government are introducing traffic lights which would see 25 per cent of all health bodies graded red, the bottom of the pile, set to be interfered with to an even greater degree. The books still do not balance without massive intervention, a process described by the NHS Confederation as "bruising".

Let me quote the words of one long-standing NHS manager: You are always being watched. But it is not just that. It's the number of people watching you—the regional office, the health authority, the primary care group not to mention the media and all the formal inspection bodies".

The Minister may well say that all that will change following the Damascene conversion we apparently witnessed last week when the Secretary of State for Health announced a new-found love of decentralisation. But this promises yet more reorganisation. My instinct is that the burdens on managers will be increased in the short term for little or no long-term gain. It is not surprising that managers are worried; the last thing they want is another reorganisation. Many managers already complain that they work a 10 to 12-hour day, sometimes six days a week, which is way beyond European Working Time Directive rules.

I could go on. There are some groups of NHS staff that I have been unable to cover this afternoon, but I am keen to hear the views of other noble Lords. Before I sit down, I remind your Lordships that a poor state of morale exists in the NHS despite the fact that winter pressures have been almost non-existent. We had no flu or similar epidemic, and almost all the statistics were benign. The workforce is not exhausted by a hard winter but by initiative overload, a failure to address recruitment and pay and, above all, a failure to listen to the concerns of people in the NHS. My Lords, I beg to move for Papers.

3.21 p.m.

Baroness Northover

My Lords, I welcome this debate on a very timely and topical subject and I thank the noble Baroness, Lady Noakes, for introducing it. I declare a kind of interest. On a daily basis I see evidence of the stress of working in the NHS. My husband is a surgeon at one of the London hospitals. I can assure noble Lords that his 80-hour week hardly makes for an easy life. Some flourish under such pressure, but for many the workload, stress and feeling that constraints simply prevent best practice destroy morale.

There is plenty of anecdotal evidence about morale in the NHS, but we now have the most systematic survey ever conducted of NHS staff at all levels. In 1999 the NHS Executive developed a human resources framework called Working Together as part of the Government's NHS national plan. Central to the plan were the objectives of increasing staff numbers and improving their working lives. All trusts were asked to conduct surveys of their staff. No doubt trusts groaned as they undertook yet another instruction from the centre, but, one hopes, with an understanding of its purpose. After all, the NHS is its staff, and it would be a negligent employer within any organisation, whether a huge public service or a business, who did not look to see whether his or her employees were happy, focused on their work and not about to leave.

The results of the surveys were reported to trust boards in the autumn of 2000. The views of almost 80,000 NHS personnel are recorded, which makes this the most comprehensive picture of NHS staff attitudes ever compiled. But no doubt noble Lords will be surprised and alarmed to hear that no analysis has been made of the material. No lessons could, therefore, be drawn from it had not my colleague in another place, Paul Burstow, taken it upon himself to carry out that analysis himself. Surely the Government could not have feared the results of the survey, could they? But the results are dynamite. "Stressed out and overworked" sums up the views of the 80,000 NHS staff. Fifty-two per cent of staff in the eastern region said that there were insufficient resources to do the job properly; 60 per cent of staff in the northern and Yorkshire region said that morale was not good in their trust; 71 per cent of staff in the West Midlands said they were not coping with work-related stress; 77 per cent of staff in the north west region said that they were not coping with their workload, and so on. These surveys are a snapshot of the views of NHS staff and will not make pleasant reading—should be get round to it—for the Minister.

Another appalling indicator of low morale and stress is the suicide rate. I was horrified to discover that the suicide rates among doctors is twice the national average, and among nurses it is almost four times that. There are many within the health service who find their work very rewarding, but it is clear that for more and more staff the mounting pressures increase stress, diminish the sense of satisfaction and undermine morale, and we ignore that at our peril.

Why is the position as it is? Endless bureaucratic changes, a feeling that staff are not in control and that the wrong decisions are being made, long hours, low pay, long waiting lists and dissatisfied patients have all contributed to this sense. But the key factor time and again is simply lack of staff. Take an operating theatre not too far from here last Thursday. It could have been any Thursday, or any weekday. The list had been set up: two major cases were to be followed by a few minor ones. The first case took longer than expected because complications arose, which is common enough. Therefore, the list could not be completed on time. The nurses pointed out that there would be no one to replace them when they finished their shift and the list must be curtailed. The surgeon and his team would have liked to continue to operate on the cancer patient, who was ready and waiting, but there were not enough nurses to do that. Therefore, it was the surgeon who had to explain the position to the anxious patient and her relatives. Thus, the doctor is pitted against the nurse and the patient against both, and all go home angry and upset.

Why has this happened? It is a supreme irony—or maybe evidence of a change of heart—that this debate is today led by the Conservatives. The Tories cut the number of nurse training places in the late 1980s and early 1990s. The number of nurses recruited fell from 37,000 in 1983 to only 6,000 in 1995, and the number of doctors in training also declined. We are now paying the price for that. Low pay and high stress levels mean that many nurses leave the service, and 62 per cent spend hours in excess of those for which they are contracted. Forty-two per cent of nurses have caring responsibilities, which is not a matter that is being satisfactorily addressed.

We shall not keep these nurses unless we address their needs, and we shall not replace them if we do not train them. We believe that we need 27,500 more nurses, 4,500 more doctors and 10,500 more professionals allied to medicine, and we have that costed. The real answer to the problem of morale is to have a proper commitment to the NHS. Only by doing that will the investment in the staff take place which is so essential. Let us call for papers but, more than that, let us call for action.

3.28 p.m.

Lord Haskel

My Lords, I have no connection with the NHS apart from being a patient from time to time. The noble Baroness asks about the state of morale. I believe that in such a vast organisation which employs over 1 million people a generalisation about the state of morale is quite meaningless. A generalisation may be unfair to the thousands of skilled and hard-working people who are dedicated and committed to the NHS. When the noble Baroness spoke about different groups—GPs, consultants, nurses and managers—she was perhaps getting to the core of the problem. However, morale is a matter for even smaller units than that. Within an organisation morale varies from part to part and goes up and down.

For example, morale must be high in a hospital where a new treatment that has been tried results in unexpected improvements in patients' health. Equally, morale will be low in the hospital where an injection was administered incorrectly into the spinal cord of a patient resulting in death. Therefore, a vast generalisation about morale is quite meaningless. Morale concerns the smaller parts of an organisation. But that is not to say that there is no value in high morale; there certainly is.

Of course people matter. High morale produces better performance; people work more cheerfully and are more helpful. The hope is that that is transmitted to patients who will get better. So I agree that it is important to create circumstances where morale flourishes. But that is not solely in the hands of the Government; it is also in the hands of health managers, health professionals, doctors, and, indeed, the patients. I am sure that when Lord Morris of Castle Morris came to your Lordships' House from his hospital bed especially to thank and compliment the nurses at the Midlands Cancer Unit who treated him, morale there went up. To make sure that there was no mistake, noble Lords may remember that he read his hospital details off his wrist band. Sadly I learnt that he died yesterday.

Morale is under pressure in the NHS because the organisation is under pressure of change; change for the better. So it is a pity that the noble Baroness is challenging and putting on the defensive those who want to make the change rather than those who want to preserve the status quo. There are three changes taking place; one by the Government, one by patients and one by science. All are taking place simultaneously.

First, the change from the internal market. The Government are right to move from a service where doctors and hospitals were in competition with each other to a service encouraging collaboration and the setting of high standards. The noble Baroness has plenty of experience in business. She knows how difficult and hard it is to introduce customer care. There is a world of difference between providing what management thinks the customer wants and providing what the customer actually wants. One has to listen to one's customers to find out what they want and not just talk to them. Then one has to find the money, the staff and the facilities to provide it while sacrificing one's own sectional interests. The NHS and the Government are getting on with the matter. I hope that my noble friend the Minister will give us the details.

Secondly, there is the change in the public's attitude towards the medical profession. Today patients are better informed about medicine; indeed, they can challenge doctors, not only by finding out about illness from the Internet, but also because of the emerging relationship between illness and lifestyle. A cardiologist, as well as being skilled at heart transplantation, must also know about exercise and good diet and discuss it with someone who perhaps knows just as much. Patients with such diseases as rheumatoid arthritis now want to know whether the reason for their suffering is genetic or environmental.

Nowadays all professions are more stressed, not only doctors. Since the public stopped being deferential towards professions, ever-increasing demands are being made on them. That means that their effectiveness and efficiency have to be open to public scrutiny and measurement. That is always a stressful experience which can raise or lower morale.

That leads me to the third change. With new science, expectations are increasing; 100 per cent success is expected. Of course that is impossible. There are always risks. Doctors are struggling to find better and more open ways of communicating risks and the limitations of knowledge. But the naming, shaming and blaming culture that we have today only adds to the stress on doctors. It also affects morale.

All these are very complicated changes which are happening simultaneously. They have to be managed. Inevitably, managing changes of this kind means that there is more centralisation, bottom-up reporting, top-down guidelines, budgeting, bureaucracy and paperwork.

I believe that the initial stage has been passed. The grip is being loosened. Step by step, difficulties and problems are being attacked. Two Budgets have promised more money for staff and better facilities. More doctors and technicians are being trained and more nurses recruited. Today there was a scheme announced to recruit more midwives. As these initiatives begin to take effect and as the grip loosens, morale will improve in every surgery, hospital and laboratory. As patients, we, too, can help morale by being better informed and more discriminating and understanding users of the health service; making a fuss when we experience negligence and errors but also acknowledging good work and high standards; and being realistic about our demands of what a public health service can deliver.

3.35 p.m.

Baroness Eccles of Moulton

My Lords, I start by thanking the noble Baroness, Lady Noakes, for introducing the debate. I have contracted a common cold. I have no need to go to the doctor, but I hope that my voice will hold out.

I had connections with the health service in west London for many years, but I no longer have to declare a direct interest. I too should like to use change as my theme, not in order to defend the status quo, but more to explain the impact that change has on the health service and some of the ways that it affects doctors and managers. I do not mention nurses and other related professions specifically, but many of my comments apply equally to them.

I start with organisational change. Each time the management of the health service is reorganised, there is a loss in human terms. That is not compensated for by projected cash savings, which are seldom realised anyway. Changes to the structure make managers worry about their future job prospects. That makes it difficult for them to give their full attention to the job in hand. A degree of stability and continuity is essential if people are to feel secure enough to give their best.

Organisational change can be justified only if in the medium to long term it provides an improved framework to support and enable the front line. Reshaping management for the sake of it can exacerbate rather than address deep-seated problems. The unease is increased by the assertion that there are too many managers. How many times have we heard that said? How does that equate with the plea from doctors to be relieved of the increasing load of form filling and red tape? To believe that the health service can be run efficiently without adequate, competent and valued management is fantasy.

Another aspect of change that is worth mentioning is the speed of technological advance. As we know, that makes possible more sophisticated diagnosis and treatment, but it tends to move ahead of an adequate supply of staff trained and experienced in the use of new techniques. Also investment in sufficient modern equipment will inevitably lag behind. The increasing number of new drugs and the complexities surrounding their introduction and use place yet another burden on the profession. Working out which patients' needs are greatest, and trying to assess outcomes, gives rise to dilemmas that are both practical and ethical. Distorting comment in the media, not always refuted by government, does not help.

Another aspect of change is behavioural change. That is perhaps the hardest to define, but it is relevant in this context. In general, society's respect for people in the professions has declined in recent years and health professionals are no exception. To attempt to analyse the causes of this decline would be a subject in itself, but I shall spend a moment looking at the effects that it has on consultants and GPs.

Because ill-health can cause pain and disability and because we all die in the end, we would like to place doctors on a pedestal of infallibility. That puts them in a unique and impossible position. Realistically we know this. But each patient wants to believe that the doctor in charge of their case has sufficient knowledge and skill to provide the best care available. Nowadays, with patients having access to far more information than ever before—both individual and general through the Internet and other sources—the relationship is changing and doctors have to be prepared to be more closely questioned or even challenged during a consultation, and to discuss the case with the patient in more detail than ever before. Those who previously thought explanation unnecessary can no longer remain aloof. These new relationships will be difficult and painful for those doctors who are not skilled in talking to their patients, but the old ways are becoming unacceptable.

When a service is having to contend with rapid and sometimes confusing change, strong and supportive leadership is essential. Sadly, there are times when the Government have failed in that respect. They have been known to seize the opportunity provided by damaging media stories to castigate the profession, and doctors are held up as examples of the forces of conservatism which have no place in our "modernized Britain". When the Government realise that they have gone too far, that the sense of being undermined and of being held in low esteem felt by doctors will rebound on them, and that public opinion is shifting in support of doctors, they change their tune and praise the profession for the valuable contribution that it makes to society.

The Government have also allowed public expectations to be raised far above achievable levels. We are told of the extra billions going into the health service, which themselves can be misleading owing to a tendency by the Government to double count. They also announce additional funds as if they will be spent today and with instant effect, whereas in fact there is always a time-lag. Furthermore, funds alone cannot achieve stated objectives. In primary care, for instance, skilled staff and accessible high quality premises cannot be produced out of a hat. As a result, disgruntled patients hold doctors to account for failing to deliver what they have been led to expect.

To end on a brighter note, some good things have happened without which the pressure on competent GPs would have been even greater. Primary care groups have benefited practices that are single handed or very small. They have reduced isolation and provided mutual support and performance scrutiny. GPs themselves are now more critical of their weaker members and cases being reported to the GMC have increased in number and are being acted on more speedily. Out-of-hours co-operatives have helped a great deal and, looking back, many GPs in demanding urban areas wonder how they survived being on call round the clock. Now they can plan their time between work and home in a more reasonable way.

The vast majority of people working in the health service are loyal and committed. They need to be working in an organisation which will support and encourage them and give them enough space to get on with the job.

3.43 p.m.

Baroness Walmsley

My Lords, I thank the noble Baroness, Lady Noakes, for introducing this debate. I agree with her that what is important about the poor morale in the NHS is its devastating effect on patient care.

We have heard from my noble friend Lady Northover the hard evidence of the chronic state of morale. However, I have gathered some anecdotal evidence by talking to health professionals working at the cutting edge—not all of them surgeons! They were unanimous in their claim that morale in the health service is at an all-time low. That is not just because they are overworked and underpaid but because they believe that the shortage of staff and resources limits their ability to care for patients. Health service workers are some of the most conscientious in the workforce. It matters to them that they are unable to do the job as well as they know they could. For Britain to have reached a position where large numbers of GPs are threatening to resign in 12 months is a clear indicator that something is very wrong.

That is not the only indicator. Look at the outcomes—for example, the cancer survival rates for the UK compared with other European countries and the US. We have the worst survival rates for every single common cancer of every single major organ. I know that it is not just a matter of money, but is it a coincidence that these outcomes correlate with spending? The UK spends less and more people die prematurely. That is a terrifying fact.

The first port of call for most people is their GP, who, according to the BMA, is facing a crisis of morale. A recent survey conducted across the country by the Liberal Democrats has shown a worrying level of dissatisfaction with the length of time patients have to wait to see their doctor. Half of those surveyed said they had to wait between two and five days for an appointment and 19 per cent had to wait longer than that. I recently had to wait nearly two weeks myself. No wonder people are dissatisfied and doctors are worried.

Delegation is not the answer because there are not enough practice nurses and district nurses either. They too are demoralised. One district nurse I spoke to told me that morale is at an all-time low because Department of Health officials do not listen to the people on the ground. She and her colleagues believe that money is not being spent in the right way—on patient care. People do not think problems through properly and nurses have to waste time as a consequence For example, computers are provided, but not in the right place, at the district nurse's base. She then has to go somewhere else to input her data, wasting time that could have been spent visiting patients. Hard-pressed district nurses cannot spend time during visits doing that vital bit of health education that can avoid problems in the future. This is short-sighted and not really cost-effective in the long term.

No wonder the suicide rates for doctors and nurses have been so high for the past 10 years. Lurking beneath these figures is a level of stress which, even where it does not lead to suicide, compromises the health of the staff involved and their efficiency in dealing with patients. We need more doctors and more nurses and certainly not privatisation of the health service.

Another area where anecdotes abound is dental services. Everybody knows how difficult it is to find an NHS dentist and as a consequence many people go without dental treatment. The previous administration gave grants to dentists to improve their surgeries as long as they agreed to take NHS patients for five years. Just as this scheme was beginning to work, along came the Labour Government and changed it. Now we have NHS dental access centres, which are a sort of A&E for teeth. They may work, but there is a danger of their perpetuating the two-tier dental service that we now have.

Part of the demoralisation is caused by foot dragging and poor decision-making. One example of that is cervical cancer screening. Despite having one of the most comprehensive screening programmes in the world, with 85 per cent coverage, the UK has among the worst death rates from cervical cancer in western Europe, with over 1,300 women dying every year. Yet the condition is 100 per cent treatable if detected early.

The Pap smear is the current test used for screening. Introduced in the 1940s, it has been very successful in reducing deaths from cervical cancer. However, the Pap smear does not test for the cause of the disease. It tests for the symptoms by examining a sample of cells taken from the surface of the cervix. Screeners review several hundred samples a day and spend only a few minutes examining each slide. Many abnormal cells can go undetected. I know this very well because when I left university, my first job was at the Christie Hospital, Manchester, a centre of excellence for cancer treatment and research. I was a cytologist screening cervical swears, looking down a microscope al] day. It was a very difficult job that required immense concentration for long periods. No wonder this kind of screening has only around 70 per cent accuracy. Having done the job, it is very obvious to me NA, by that is. Human beings simply cannot be 100 per cent sure that every cell on a slide is healthy. Besides, a smear could have been taken from an area away from the lesion.

However, there are three other tests, all of which have potential to be a great deal more accurate and save money as well as lives. High-risk types of a virus known as the human papilloma virus or HPV have been shown to be present in 99.7 per cent of cervical cancers. There is a DNA test that can detect high-risk, cancer-causing types of HPV with 95 per cent accuracy. Unlike the Pap test, HPV testing is predictive and thus can detect and track the cause of the disease. Many people, including the readers of Cosmopolitan magazine, would like to see the HPV test introduced as part of the national screening programme. A petition carried out by Councillor Patsy Calton, in Cheadle, Cheshire, near where I live, brought an unprecedented level of support for adding this test to the screening programme.

The National Screening Advisory Committee recommended in September 1999 that a pilot be carried out, but it was not until February last year that a decision was made to carry out a year's pilot. That did not start until last summer. In the meantime, although the screening programme saves thousands of lives, 1,300 women could die. In 1996–97, 200.000 women in the UK had a borderline smear result and 100,000 were referred for examination, at a cost to the NHS of£26 million—money that could have been spent on more doctors and more nurses. In the end, only 4,000 women were diagnosed with invasive cervical cancer that year. Those figures reveal the inefficiencies in the current system and yet the Government have dragged their feet over introducing a more efficient, well researched and cost-effective scheme which would also avoid the terrible anxiety undergone by patients who are called back for further tests.

It is that kind of situation that really gets to NHS staff and adversely affects recruitment and retention. Can the Minister say when the results of the HPV pilot scheme will be known and how soon action could be taken? Casting wider than that, I should like to know what the Government are doing to ensure that other demoralising inefficiencies of this kind do not persist in the NHS.

3.50 p.m.

Baroness Masham of Ilton

My Lords, I thank the noble Baroness, Lady Noakes, for her timely debate. As the Minister knows, in November I had a most unfortunate accident when, at the Parliamentary Dog Show, my Great Dane decided to protect me from a pug dog which had come too close. I landed on my knees, fracturing my legs in five places. My treatment involved three hospitals.

The good morale of patients is as important as good staff morale. I received excellent support from many noble Lords, as well as some lovely flowers and cards. I thank especially the Minister for his support.

The first hospital, in which I spent five days, was the Chelsea and Westminster. I found that in general the morale there was rather good. As a patient, I was pleased with the telephone system in the hospital. Every patient had a telephone which took telephone cards, which they could buy if they wanted to use the telephone. In other hospitals where no such system is in place, so many patients have a frustrating time trying to use trolleys, which take up valuable staff time. I recommend this service.

After five days of having my legs in plaster in a general hospital, and being a paraplegic, I became concerned as conflicting views were held on how to treat me. My usual bodily functions were incredibly difficult to perform as none of the nurses knew how to cope with a paraplegic. It would have been quite easy, had they listened to the patient.

I was fortunate to be able to go to the spinal unit at Stoke Mandeville hospital where I received the nursing care that I needed. Even more important, however, was the medical treatment. When my plaster casts were removed, I had two black heels from the pressure caused by the plasters. Having explained about pressure to the Chelsea and Westminster, I cannot stress how important it is for patients to be treated in specialised units, where their different needs will be understood. Otherwise things go wrong and morale can fall to rock bottom.

My heels are only just healing, after a period of six months. Because of osteoporotic bones, I had external fixators instead of plaster casts put on my legs. I am grateful to the Russians for inventing this procedure. It was a quick way of getting soldiers back to the front lines. While I was in Stoke Mandeville, the Government announced that they were going to give a masterchef the job of improving hospital food. That would be a boost to patient morale. Can I ask the Minister whether this statement was just spin, or is it going to happen? It would be interesting to receive a progress report on this matter. I am sure that better food would raise morale.

Another statement was made saying that matrons were going to be put on the wards again. Having someone in place whom people could rely on, seeing that hospitals were clean and that someone was taking overall responsibility would provide another boost to morale—as long as the people appointed have the level of ability needed. The spinal unit at Stoke Mandeville is crying out for a good senior nursing officer who would be dynamic and thus attract the much-needed capable nurses which the hospital urgently needs. Stoke Mandeville is now under new management. I hope that it will move forward and give patients the specialist healthcare that they need. When all the interested parties work together, good morale will follow.

I have noticed that many consultants are now coming up to the age of retirement. The shortage of doctors is of great concern to patients. In hospitals, good consultants who can become effective team leaders and who can become expert in specialties win the respect and trust of patients. They can provide the biggest boost to morale in the health service, but unless there is good leadership, the standards will fall and so will morale.

There are many keen young doctors, some from the Commonwealth countries such as South Africa, who are queuing up to be accepted on a training rotation. It seems that there are not enough surgical trainers. Universities appear to be understaffed. What can the Government do to release this blockage? Until 1997, a trained surgeon could come over to Britain to work, but after that time, the ruling was changed. I am told that the relentless pressure is making many surgeons retire early from the new National Health Service. I shall quote one surgeon who said to me that: It is now no longer good enough to do your best". To make available specialist training for people coming from the colonies would be one way of opening the door to more specialists, thus raising morale. It is important that we have dedicated, keen young people who can speak English well and who can become experts in the many fields of medicine which at this time are very short of doctors and surgeons. Yet it is impossible for some of them to secure training. This seems to be a problem which should be a priority for the Government to rectify.

All governments seem to want to change the National Health Service. There has been so much change, which can be bad for morale. We have heard of many cases of dilapidated wards filled with sad, elderly people who need feeding and some TLC in their difficult lives. Good people would volunteer to help in this kind of work if the leadership was forthcoming. Good management, close to patients, will raise morale and lessen growing frustration and low morale due to the ever-growing patient population, paperwork and pressures throughout the NHS.

I have a moment in which to say how sorry I was to hear of the death of Lord Morris of Castle Morris. I am sure that he would have spoken in support of nurses in the debate today. The whole House will miss him.

3.58 p.m.

Lord Rea:

My Lords, about one-and-a-half hours ago, just before I came to your Lordships' House, I had my speech nicely prepared on a lap-top computer. I was about to print it out when the whole thing disappeared. Noble Lords will have to listen to some rather more disjointed remarks than perhaps is usual.

Since I retired from front-line duties in the National Health Service, like the noble Baroness, I have gained more experience as a consumer than as a provider. However, I keep in touch with what is going on in the health service because I have a son who is a consultant oncologist, along with a daughter and a niece who are both nurses. Furthermore, I keep in contact with my professional colleagues.

What is morale? According to Chambers, It is the, condition or degree of confidence, optimism or strength of purpose in a person or group". When one looks at individual health workers in the National Health Service, they appear to have those qualities to a great degree, in particular when they start out. Most summon up that kind of spirit whenever they are treating patients. People who have had any experience of the health service have no complaints to make about those who work in it.

It is the system which gets you down. Morale is eroded in a work situation where there is an excessive workload, especially if it consists of tasks set by someone over whom the individual concerned—perhaps a nurse or a doctor—has no control. Of course, health workers get a great deal of intrinsic satisfaction from their jobs—that is why they are able to tolerate a much higher workload and more unsociable hours than people in most other professions—but their tolerance can be over-stretched by pressure to carry out tasks which perhaps could be carried out equally as well by people with lesser training, against a background of increasingly critical patient demand. It is possible to work extremely long hours for a limited duration—and perhaps for a bit longer if you are well paid for it—but if there is no light at the end of the tunnel disillusion tends to set in.

We were all delighted when the Prime Minister announced great increases in spending on the National Health Service to bring us up to the average GDP expenditure of the European Union a year or so ago. The Prime Minister's intervention occurred after he was brought face to face with the reality of the situation in a famous televised interview which took place with NHS staff at St Thomas's Hospital. This happened at about the same time as the frank and, again, famous interview given by my noble friend Lord Winston in the New Statesman, in which he said that the situation in the National Health Service was becoming intolerable. That made the Prime Minister sit up and a lot of money was promised.

The Prime Minister said at the time that it would take a long time for that money to show through at the workface. People had a momentary sense of euphoria when it was announced, but a certain amount of disillusionment has now set in because it seems to be taking such a long time for the fruits to be experienced by the people working with patients.

But some good plans have been laid. The national service frameworks are universally approved and the NHS Plan is, on the whole, welcomed and has the backing of professional colleagues from right across the spectrum.

One way of improving morale in the health service would be for little things to be done locally. Most workers have innovative ideas about what could be done to improve their personal situation at their workplace. These ideas should be encouraged by trust managers. Local forums should be established and the Government should provide extra money to enable managers to implement such plans. This would make people in the front line feel that they are being listened to, and that in itself would improve morale.

As to the situation in general practice, the BMA suggests that we need 10,000, not 2,000, new doctors. This is based on the fact that each of three extra jobs that GPs will have to carry out will require the equivalent of 3,000 general practitioners. That is three times 3,000, which makes 9,000—so 10,000 doctors altogether.

At the moment, the new contract for GPs is being discussed at the Department of Health.I hope very much that during the coming year there will be a full and frank exchange while the contract is being developed. If any new jobs are given to GPs in that contract, the money to back them must be offered as well. I hope that the new contract will provide more incentives for doctors to work in deprived areas.

Finally, I hope that tomorrow my noble friend will be able to agree to an amendment to allow doctors providing personal medical services—as well as those providing general medical services—to have their terms and conditions of work discussed with the General Practitioners Committee of the BMA. This would set the tone for fruitful negotiations on the contract for the following year.

4.5 p.m.

Lord Harris of Peckham

My Lords, I wish to speak about my experience as chairman of the Guy's and Lewisham Trust from 1991 to 1993. A shadow trust was formed in February 1991, and when I arrived I was surprised to find that morale was very low—that is something of an understatement—but that the staff, especially the nurses, were very committed to the NHS.

Quite honestly, management did not know what to do. When one considers that Guy's and Lewisham had a budget of £148 million controlled by a general manager and a financial director, that is not surprising. Budgets were overspent in all departments; we closed eight wards at that time and operations were being cancelled.

When I agreed to become chairman of the trust I was told that there would be a £1.5 million surplus that year. In fact, there was a £1.5 million deficit. When I asked for the budget for the next year—1991–92—I found that one had not been prepared. So the finance director, myself and the general manager worked through a budget. If we had carried on in exactly the same way as we were, the next year would have seen a £7 million deficit.

My first job was to get a management team in place: a chief executive, a finance director, a director of nursing, who came from inside, a medical director, who came from Lewisham, two general managers—one for Lewisham and one for Guy's—and a board of non-executive directors. The team was in place within four months. I made the non-executives responsible for different parts of the hospital: one for patient care, which is very important; one for the hospital personnel; one for building maintenance; and one for buying equipment.

Perhaps I may give the House two amazing figures. When I arrived at Guy's, the drugs budget was£2.8 million per year. When I left two years later, the drugs budget was £850,000 per year—a huge saving which went towards patient care. The wastage in drugs at Guy's was colossal.

Of course, we had to make £7 million-worth of savings. It was very difficult to explain to staff that we had to make those savings—after just getting there and becoming the flagship trust in London. Of course, most of the savings had to come through staff redundancies. We did not take any doctors, nurses or sisters—we made sure that patient care was strong—and most of the posts were lost through natural wastage. Of course, it was not a popular decision at the time.

However, we worked closely with our staff; we had meetings, and staff morale started to improve. I believed that it was not a case of throwing money at the problem but about better management of the money that we received.

After six months, I produced charters to tell people what we were going to achieve and how we were going to achieve it. At the beginning, everyone thought that this was a gimmick; at the end, they were very pleased with what we were doing. If any noble Lords would like copies, I shall be pleased to provide them.

As to the charters, I first made sure that we did not run out of money every February and March. I budgeted that we spent 45 per cent of our money in the first half of the year and 55 per cent in the second half. That meant that when other hospitals were running out of money and could not treat patients, we could. In the first full year of our trust we treated 6,000 more in patients—a 10 per cent increase on the previous year. Eighty-five per cent of people waited no longer than 30 minutes in the out-patients department; 90 per cent of patients waited less than 12 months to be admitted—a 12-month wait is not very good, but in the previous year the waiting time was more than double that. We improved the sign-posting of the hospital; and we sent a card to every patient asking what he or she thought of our service. We did all that without any increase in income.

The big change took place on 6th January 1992. We gave all low-paid staff—those earning less than £4.92 an hour—a £6 bonus for turning up to work five days a week. The attendance rate was less than 70 per cent. After we started paying the bonus it rose to over 90 per cent. Our approach was self-funding, and over a full year it produced a saving of over £1 million.

When the details of the running of Guy's were looked into, it was found that 2,000 staff were paid weekly in cash. Imagine the cost. So we changed to paying those people monthly, and that paid us back over 12 months. We took a risk and we lost some money, but overall it saved us more than half a million pounds—more money for patient care. Any new staff were subject to the same conditions.

In 1992, supervisors in the NHS received £2.50 more than an ordinary worker—about £5.15 per hour. We changed that. There were 45 supervisors at Guy's hospital and about 38 at Lewisham. At Guy's alone we cut the number back to 25, but we gave those people £1,500 more in the first year and £2,500 more in the second. That represented a saving to the hospital of £290,000—again, more money for patient care.

We reduced the hours of junior doctors. By the end of 1992, no junior doctor worked more than 72 hours a week. We did so by changing the way in which blood samples taken by junior doctors were delivered to the laboratories for testing. It was done by the doctors themselves. We introduced a system whereby porters did it for them, which meant that the doctors spent more time treating patients rather than carrying samples around.

In 1992–93 we treated 6,500 more in-patients—a rise of over 10 per cent. Over the year, our waiting list was reduced from 2,200 to 680. The goal for the following year was to reduce the figure to nil. In fact, we got it down to 150.

It is important that a hospital should be clean and tidy; so we decided to paint the exterior of the whole hospital. We received an estimate of over£2.5 million for the work. We decided to employ 22 of our own painters. They took 12 months to do the job and the cost was under £1 million—again, a big saving to go towards patient care.

In order to increase morale in the hospital, which was already rising sharply, we gave the nurses in each ward a small budget, a small equipment grant, of £2,500 every six months. We let them choose what they wanted for their wards instead of making the choices ourselves, not knowing what they wanted. We put a system in place whereby out-patients would be seen within 30 minutes and GP referrals would receive a response within 10 days, against a previous period of three weeks.

Those are just a few of our achievements over the two and a half years of my chairmanship. In real terms, we saved £20 million each year. Over the two years we treated over 13,000 patients, and we provided a much better service for patients. I am still proud of the fact that the unions wrote to the hospital management stating: It is the best the hospital has been run in the last 20 years". I am very pleased to say that when I left Guy's morale was very high. Throwing money at problems is not the answer. It is a matter of getting the right management in place.

4.14 p.m.

Baroness Gardner of Parkes

My Lords, I am delighted to listen to the noble Lord, Lord Harris. He did so many practical things of which I thoroughly approve, and with marvellous results.

Listening to the complaints from those in the health service, morale certainly appears to be low. Complaints relate to paperwork, bureaucracy, long hours, staff shortages and the lack of relief staff when someone is off sick. Even today we have heard of the discredited position in which NICE finds itself. We were waiting to hear about the abolition of postcode prescribing, but that has not happened. It is still considering whether or not certain drugs for multiple sclerosis should be available on the NHS. It is my belief that a decision has been put off because of the election.

There was a Question earlier today from the right reverend Prelate the Bishop of Durham about fluoride. The water authorities have made it clear that unless fluoridation of the water supply is made mandatory they will not go ahead with it because they are not prepared to face possible litigation; also, there is an added cost and their shareholders would complain about that. I hope that fluoridation will be made mandatory.

Two other speakers referred to the loss of status in the professions. That is true whether one is a GP, a consultant or a dentist. All those in the caring professions have been left so far behind financially in comparison to those working in the financial industries or in big business that people feel it strongly. There is the question of stress. There is also the threat of litigation. Now, everyone has to be so careful in every thing that is done because we have become a litigation-conscious country. The National Health Service has to keep putting more money away to deal with that. It used to be good enough if you did your best for patients; now, it is not good enough.

There are also the constant announcements of what is supposedly new money going into the health service. People then find that it is not new money at all; it is money that has been mentioned before. All their hopes are raised and then dashed. Expectations are possibly the worst aspect. I know from personal experience as a hospital trust chairman that people believed that when the country had a Labour government all their problems would be solved. Yesterday, a right reverend Prelate said that people had even prayed for a Labour government in order to solve the matter of compensation for the miners. That is a typical example.

Over the past four years, in answer to almost every Question I have asked about the health service, I have been told that the Government inherited the problems from the Conservative government. Fortunately, the noble Lord, Lord Hunt, has stopped saying that. Four years on, I cannot honestly accept that story. The question now is: "Well, what have you done in the four years?".

I practised as a dentist in the National Health Service for 35 years. That was the bottom end of the line. Dentistry is almost a thing of the past in NHS terms, although outside London it is still working well in some areas. I was fascinated to meet a dentist recently who is building new surgeries in the north-east of England and who has been told that for his five surgeries he must have 20 car-parking spaces. It fascinated me—in London, one would be lucky to have a surgery, let alone a car-parking space.

There are good things, and there are things that are mixed. The mixture was referred to my noble friend Lady Eccles. There are too many changes. For as long as I can remember people have been reorganising the health service. Every time it is just beginning to run smoothly, someone comes along and reorganises it again. We have had area health authorities; and when I first started there were executive councils. There is constant change. People are so busy adjusting to all the changes, and they involve so much extra work, that they are never able to catch up. Now it is the intention to involve the local authorities again. I was a member of an area health authority at a time when we had local authority representation. It certainly did not do us any good—in fact, it did a great deal of harm. The local councillors never turned up to meetings because they had so much else to do. They could not spare the time for the health service as well. All these things are about the swing of the pendulum. We had all the problems about junior hospital doctors being overworked. By the time that problem was solved, it was a case of the consultants being overworked.

We all wanted a higher status for nurses. Sure enough, they can now gain degrees, which is marvellous. But the entry qualifications required have prevented those who do not attain sufficient A-levels from entering nursing. I believe that those people have a great role to play in the health service. There should be an opportunity for them to work for the NHS under some kind of nursing assistant scheme.

I am delighted about the major role that pharmacists will play. They will take a load off the doctors in terms of prescribing, and so on, and provide an immediate first base for people to approach. Everyone has a local pharinacist—certainly in built-up areas—and this is a good move. However, I accept that there will never be enough money for the health service. I believe that it is time for the Government to review prescription charges; indeed, only a Labour government could do so. As I am the right age, I receive all my prescriptions free; but why should I? I could well afford to pay for them. I read in newspaper reports—and I know it is true—that many people go to their GP simply to get a prescription for something that might cost them less than £1 over the counter. But because they can get it free, they go to a GP and take up his or her time in order to get the prescription.

As I said, there will never be enough money for the NHS. But morale and pride in one's work are the really marvellous concepts that exist in the health service. All of those working in it are to be congratulated on the wonderful job that they carry out under difficult circumstances. Above all, they need to know that the work they are doing is appreciated both by those receiving the care and the public in general. The patient is the most important consideration. The true, genuine and dedicated National Health Service worker does put the patient first. That will always help people to retain pride in their work, and lead to good morale.

4.21 p.m.

Lord Vivian

My Lords, I too am grateful to my noble friend Lady Noakes for introducing this debate today. However, at this stage I have to declare an interest as I am a special trustee at the Chelsea and Westminster Hospital and, up until last month, I was Honorary Colonel to 306 Field Hospital of the Territorial Army.

Although the NHS is in a critical state with trusts, consultants, GPs, nurses, administrators, ancillary staff and porters whose morale can go no lower, it should not be forgotten that all these people do a magnificent job under the most frustrating conditions. I praise them for the way that they continue to do their work; I praise them for their dedicated commitment to their profession; I praise them for their concern for and care of their patients; and I praise them for their loyalty to the hospitals where they work.

The NHS will not improve unless radical steps are taken immediately, not over a period until 2004, but now, this year. According to various surveys, more than 75 per cent of personnel in the North West could not cope with their workload and in the South East some 70 per cent said that there was a shortage of staff. Forty eight per cent of hospital staff felt communications in their trust were poor; 37 per cent thought they were not well enough protected from attack and abuse; and 30 per cent thought they had not been trained well enough.

The Government must stop pretending to the general public that everything is all right within the NHS and that their proposals due to be implemented over the next few years will solve the state of low morale and resolve all the problems that are causing this crisis in the NHS. They will not. Unless urgent action is taken now the NHS may implode.

So what are these problems? One is increasing workloads, bureaucratic form filling and staff shortages. And one of the reasons for deteriorating morale is the low rates of pay that the Government are prepared to pay consultants, GPs and nurses. Clearly the solution here lies in even higher levels of pay, although they were increased from 1st April this year. The pay for Inner London nurses has risen between 3.7 per cent and 9 per cent. This brings the starting pay for a new nurse to about £19,000, including all allowances. The basic pay for a grade D nurse is only some £15,000.

One survey stated that there are 20,000 vacancies for nurses and that vacancies for physiotherapists had nearly doubled. If it is not possible to increase the rates of pay further, the Government should make even greater efforts to recruit doctors and nurses from overseas English-speaking countries. Some years ago, the Chelsea and Westminster Hospital recruited successfully Dutch and Finnish nurses on a three-year contract, and they much enjoyed being in London. I spoke to them on several occasions and they fitted in well, were highly efficient and were well liked by patients and staff. Perhaps the Minister will address that point when he responds.

Another factor is the high cost of living in London. The Inner London allowance of £2,635, plus 5 per cent of salary, goes virtually nowhere towards covering these high costs. There is a lack of affordable accommodation and staff at all levels have difficulty finding somewhere to live, particularly in the centre of London. It is clearly necessary to pay a meaningful London allowance to those working in London. Perhaps the Minister, again, will comment.

There is a lack of childcare facilities. This is becoming more and more important to staff in their choice of their workplace and employer. There has been an increase in aggression and abuse against staff, which is demoralising and upsetting. It is certainly no help to those suffering from low morale and stress. It would appear that NHS staff have no recourse to any form of redress. There is a general feeling of not being involved in management issues and decision-making processes, brought about by a clear lack of leadership.

Lastly, I should like to touch on funding, which currently does not allow the system to have the flexibility that managers need. The dissemination of funding from central government can have a stop/start effect as it is distributed in tranches which does not allow for seamless planning of schemes.

Ministry of Defence health units located in National Health Service hospitals come under the Defence Medical Services secondary care system linked to the NHS. There is a strong requirement for close liaison between the MoD and the NHS. There are three important aspects about the military use of the NHS since military hospitals were closed. These are the need for fast tracking of servicemen and women for hospital treatment and operations; the removal of families from hospital waiting lists every time that they are posted to new stations causing, in some cases, years of frustrating delay; and the immediate need for physiotherapy when Armed Forces personnel damage limbs in training and sport.

Key targets were set earlier this year for the Defence Secondary Care Agency by the MoD. Key Target 2 concerning outpatient waiting times was intended to ensure that 45 per cent of service patients were offered a first outpatient appointment within four weeks of a referral and 90 per cent within 13 weeks. Key Target 3 concerning inpatient waiting times was to ensure that 80 per cent of service patients were offered a treatment date within 13 weeks of the decision to give inpatient treatment. Perhaps the Minister will say what instructions were given by the NHS to ensure that these targets are met and what action is being taken about waiting lists when service families are moved from one station to another. Can the Minister also confirm that the successful Treasury-funded waiting list initiative will be extended?

I do not wish my comments to be seen as criticizing the hard working and dedicated people—the GPs, consultants, and nursing staff—who are carrying out an excellent job under stress and under bad management from the NHS. They are to be praised. My criticism is directed at the Government who have allowed the NHS to reach a critical stage where it has clearly lost its ability to manage personnel and is in need of greater leadership in running the service.

4.29 p.m.

Lord Graham of Edmonton

My Lords, like the noble Baroness, Lady Eccles, I must confess that I have an interest to declare: I am not well. I have a cold, but I have brought myself here today, as the noble Baroness did, because of the subject under debate. I should like to thank the noble Baroness, Lady Noakes, most sincerely not merely for tabling the debate but also for the manner in which she introduced it. I believe that that has helped the tenor of the debate; indeed, there has been no acrimony at all.

Of course, there has been some hard hitting in the debate based on experience. I am delighted to observe the level of experience that rests in this House, which is of the highest level. I thoroughly enjoyed listening to the contribution made by the noble Lord. Lord Harris, who pointed out just what a dismal record the NHS had in 1991 in the hospital of which he subsequently became chairman and which he then improved. I enjoyed particularly the contribution of the noble Baroness, Lady Gardner of Parkes, who speaks with great authority as the chairman of a successful hospital.

One of the topics that I studied for my Open University degree in the early 1970s was that of decision-making. In that connection I considered the National Health Service. Of course there is scope for improvement in the way in which a big organisation with hundreds of thousands of employees takes its decisions. However, it is a colossal task to manage the National Health Service.

People have spoken from their experience and I shall speak from mine. Perhaps noble Lords can see a scar just below my eye. That scar resulted from a fight in which I was involved at the age of 11, some 65 years ago. The noble Lord, Lord Burlison, will know Rye Hill which runs down to Scotswood Road where I then lived. In that fight a boy stabbed me. Fortunately for me I was stabbed in the cheekbone. If I had been stabbed half an inch higher, the knife could have entered my eye and I could have been killed. My dad was not even on the dole; he was on a means test. Seven of us lived on 37 shillings a week. The doctor gave my mother a bill for his services which she paid at the rate of threepence a week for two years. When I think of the situation at that time I reflect on the ease with which people, quite rightly, are now able to receive treatment. I ask noble Lords to mention morale and to point out shortages and what is wrong, but also to remember the situation before the National Health Service came into being.

In 1948 there was a great political battle with regard to establishing the National Health Service. My noble friend Lord Bruce of Donington is present. He was the PPS to Aneurin Bevan at that time. We should try to remember what has been achieved. Reference has been made to our dear friend Lord Morris of Castle Morris. When I was Chief Whip he was my deputy. Sadly, he passed away. He rose from his sick bed in June 1998 to ask an Unstarred Question in your Lordships' House. He said: My Lords, I am not what I seem. I am No. 445590 Morris, Brian, d.o.b. 4.12.30, male, C of E. I know this because it was written on the little plastic bracelet placed on my wrist on 21st January last when I became a patient in The Royal Hospital, Chesterfield, whence I came this morning to ask the Question standing in my name".—[Official Report,16/6/98:col.1539.] My noble friend died of leukaemia. I quote further from his speech of June 1998. That was made some three years ago within 12 months of a Labour Government taking office. He further said at col. 1539: The facts are not in dispute. We are facing the worst nurse shortage crisis in 25 years: the first ever shortfall in applications for nurse education places in England. In 1993/4 there were 18,100 applications for 12,000 places. In 1996/7 there were 15,400 applications for 16,100 places. Turnover among registered nurses was 21 per cent. in 1997, up from 12 per cent. in 1992. Vacancies remain unfilled. One report in 1997 suggested that there was a shortage of more than 8,000 full-time posts across Britain. The Royal College of Nursing reports that the number of nurses aged over 55 will double over the next five years, with 25 per cent. of registered nurses in the NHS eligible for retirement by the year 2000". Some may ask: what is new? I listened with deep respect to the comments of the noble Lord, Lord Harris of Peckham. Lord Morris of Castle Morris had great experience of the National Health Service.

In addition to the incident that I mentioned earlier, during the war my guts were shot out accidentally. I lay on a hillside in Wales at death's door. That incident resulted from what is now known as "friendly fire". I had my intestines in my hand, but I survived. The House has heard of the thrombosis that I suffered some three years ago when I flew back from Australia. On landing I was rushed into Whipps Cross Hospital where I received wonderful treatment.

My local GP is Dr Anwar Khan at the Loughton Health Centre. My wife suffers from the hereditary condition of Dystrophia myotonia which she has passed on to our two sons and I suffer from thrombosis, my prostate situation and diabetes. We visit the surgery regularly. We are one of Dr Khan's best customers. Round the corner there is a Co-op chemist. Therefore, I have good facilities at my disposal.

I doubt whether anything has been said this afternoon that was not already known to the Minister and his advisers. I hope that he will recognise the concern that has been expressed and that he and his colleagues will do a great deal to improve the situation. However, at the end of the day, I say, "Thank God for the National Health Service".

4.37 p.m.

Baroness Fookes

My Lords, I speak with some diffidence bearing in mind how many noble Lords have direct, extensive experience of the NHS which I do not have except as a very occasional patient. However, I am deeply grateful for the service that it has given my family. I was particularly pleased to hear the comments of my noble friend Lord Harris, as my mother was a patient at Guy's at the time of his beneficent reign there. She greatly profited from the great care and skill that was accorded to her in that hospital.

However, I am concerned about the extent to which we organise and reorganise the NHS. That point was touched on earlier, but I make no apology for mentioning it again as we must learn from experience that we need to allow time for reorganisations to be put into effect and for people to settle down in a stable environment.

I give an example which is personal in the sense that it affects a friend of mine who in early middle age left the commercial world, of which she had a great deal of experience, as she wanted to enter management in the NHS because she felt that it was a caring, serving organisation to which she wished to contribute. It was an idealistic decision. She worked in a difficult area of London at a time when fundholding was the "in" thing. It had been introduced by the previous government. She worked extraordinarily hard among about 64 GPs in a multiple fundholding system. She developed the system successfully and she felt that the doctors were happy and that the patients received far more services as a result of the change. She felt that she had done a good job.

However, scarcely had she reached that point when a change of government occurred and fundholding was "out" and primary care groups were "in". She started all over again with renewed enthusiasm to develop what was asked of her by the incoming government. However, she subsequently discovered that primary care trusts were proposed. Her previous work is now being subsumed in a new system. When I talked to her earlier in the week, I detected a certain weariness. Her sparkle and enthusiasm had disappeared to some extent. She still wanted to be of service to the NHS but there was the feeling that whatever one did, and however well one did it, before the benefits could be reaped there would be a further change and one would start all over again. I ask this Government or any other government to think carefully. However good is the theory for changing organisation, there is a limit to what individuals in the health service or any other organisation can take and still retain their enthusiasm.

I turn to the issue of GPs. I am not sure that I have ever heard so many complaints from doctors as we have done recently. It indicates an underlying malaise which is extraordinarily worrying bearing in mind that the majority of work is carried out in the front line by GPs. If we are not retaining them—they seek early retirement or other posts—that is worrying.

I note that the BMA has sought to increase the average amount of time that a GP spends with a patient to 15 minutes. That implies that at present, on average, the period must be well under that. I can recall the days when MPs had "surgeries". Unless the matter was very easy indeed, I should have found it extraordinarily difficult to deal with someone in under 15 minutes. Perhaps I was not a good manager of time, but it seemed to me that people often needed to relax before one came to the main problems from which they were suffering. For patients and doctors, too short a time is very dispiriting and demoralising. If we are going to see further shortages of GPs the situation can only get worse; and that worries me greatly.

I am also worried about the excessive targeting and monitoring to which the medical profession and the professions ancillary to it are now subject. Of course in theory it is wise to know what is happening: that we have certain important targets to reach. But if those targets are impossible to reach, that, too, can have a demoralising effect. Let us take one issue about which the doctors are worried. We understand that the "great paper" proposes that by 2004 every patient must be seen by a GP within 48 hours of asking to see a GP. Many doctors believe that the proposal is impossible: that it is another worry. One wonders whether such a general target is valuable. Presumably, the period covers both emergency and routine appointments. If it is routine, 48 hours is not remarkable. If the situation is an emergency, or very urgent, 48 hours may be too long. For a mother whose child turns out to be suffering from meningitis, it would undoubtedly be too long. Therefore I ask the Minister to query this obsession with targets and monitoring. We need to attract GPs and other health service workers by offering good conditions. Then I believe that many of those other matters will fall into place.

4.44 p.m.

Lord Turnberg

My Lords, I apologise to noble Lords for missing some of the earlier speeches, and for missing my slot. I had assumed that I would be speaking rather later. I am grateful for being allowed to speak in the gap, perhaps mercifully in a somewhat abbreviated form.

The pressures of work on doctors and nurses are undoubtedly heavy. It is not just clinical work with patients; many are working at or beyond the limits of their capacity and feel that they are failing their patients. I know that the Government have started the process of reversing this downward trend and we are grateful for that. But it will take time—perhaps 10 years or more—for the effects to be felt. Unfortunately, meanwhile we are beginning to lose the good will and energy of our most precious resources—our disillusioned nurses and doctors.

With noble Lords' permission, I should like to suggest three or four actions which, taken now, might make a more immediate difference. First, I know of many consultants in hospitals who are retiring in their late 50s. They want to be relieved of the burden of full-time responsibility for all that a consultant job now entails but would like to work perhaps part time, concentrating simply on caring for patients and teaching young doctors, free of all other administrative burdens.

The Government have accepted that it is a shameful waste of a precious, trained resource not to take advantage of those people. But in practice I know of many such doctors who are being refused by trusts which say that they cannot afford to re-employ people in this way. What a ridiculous waste of an opportunity when we are trying to reduce waiting lists and to bring in more young doctors from the medical schools to help to plug the gap. We must find a way through the problem.

Secondly, I am told that doctors on the wards are constantly distracted by having to do clerical work: seeking case notes; tracking down X-ray and laboratory results; or phoning for patients to come in. Those are jobs which ward clerks and secretaries could and should do, but in many hospitals there are nowhere near enough of these essential support staff. We need more secretaries, clerks and porters. If we double the current numbers, we shall have a more effective and efficient use of our doctors and nurses as those unnecessary pressures are taken off them.

Thirdly, we should be taking a grip on the computerised IT systems supporting the clinical work at the ward level. Current systems are often either out of date or inadequate. Yet we know that good supportive IT, providing, for example, rapid bedside access to tests results—one might think that that would be fairly simple—would bring welcome relief to staff who spend too much of their precious time phoning around for information.

I realise that different hospitals need many other types of action which, taken now, would have an observable effect perhaps within 10 months rather than the 10 years projected for the major government initiatives in train. I propose that the Government set up yet another task force with the specific remit to develop ideas for short-term—for perhaps a period of one or two years—improvements and efficiency. I suggest that this task force be made up of the great and the good; namely, a ward sister; a non-political doctor in training; a good manager; a GP; and, of course, a patient. They know so much more about how the NHS could be run more effectively at the coalface. I could even suggest some names if the Minister cares to take forward the proposal, as I hope that he will.

4.48 p.m.

Lord Clement-Jones

My Lords, I join other noble Lords in congratulating the noble Baroness, Lady Noakes, on raising the issue of morale in the NHS. It has been a superb debate, drawing on the personal experience of so many noble Lords. That is one of the great strengths of this House.

Morale is not a new issue. The NHS has suffered for decades from under-investment, most notably during the 18 years of the last Conservative government, and we on these Benches would say from the demoralising effect of the internal market reforms of which the noble Baroness, Lady Noakes, was such an enthusiastic architect. As was pointed out by my noble friend Lady Walmsley, the very training cuts instituted by the Conservatives under their term have impacted on patients and NHS staff morale.

At the last general election, the Labour Party promised to save the NHS within a period of days. Instead, the Government spent three years unnecessarily locked into the Conservative spending plans that they inherited, which had caused the problem in the first place. We now know that this Government have spent less of the national income on the NHS than the Conservatives did in their last term of office.

Even the new NHS Plan falls far short of the Prime Minister's declared aim of bringing health spending in Britain up to the levels of our European neighbours. By 2004, it will account for about 7.5 per cent of gross domestic product but it will still fall far short of our European neighbours. As my noble friend Lady Walmsley said, outcomes in many areas are very poor compared with the United States and with other European countries.

The Liberal Democrats agree with many of the goals in last year's belated national plan, but there has been a mad dash to get things done over the past year, with no time to build capacity. At the end of the year, some of the money was underspent. The noble Lord, Lord Turnberg, rightly pointed out that there had been very little time to produce results.

That failure to spend early enough in the course of the Parliament has resulted in the problems outlined by so many noble Lords today: a shortage of beds, unacceptably long waits for treatment and a crisis in numbers for all staff—nurses, midwives, doctors and professions allied to medicine. That has led to overwork and breaches of the European Working Time Directive, which is a very important means of protecting NHS staff. I was interested to hear the noble Baroness, Lady Noakes, refer to that. NHS staff are still woefully underpaid and leaving in large numbers. The Government have failed to create enough consultant posts, as a result of poor workforce planning. There are arguments about the regulatory arrangements in many professions. There are also changes in clinical governance and problems of revalidation.

As many noble Lords have pointed out, change is at the root of some of the problems and it is all taking place at the same time. There are arguments about contracts, particularly for hospital doctors and GPs. We have a lack of training places for young doctors in a large number of specialties. We have over-centralisation of funding, which a number of noble Lords have mentioned. There is micro-management, with a proliferation of targets for issues such as waiting lists and throughputs, the introduction of performance management and a welter of centrally driven initiatives in primary and acute care. As a result, we now have a major crisis of morale and a massive number of unfilled vacancies, especially among senior consultant posts. Those problems have resulted in yesterday's industrial action by general practitioners, the ballot of GPs and the threats to resign next year. The noble Baroness, Lady Fookes, put the problem very well: that spark of enthusiasm has been or is being snuffed out among many staff.

Four out of five GPs surveyed want to leave the NHS. My noble friend Lady Northover mentioned suicide levels. There has been a massive loss of confidence in the NHS. We should tackle that rather than denying it. Some 65 per cent of people recently surveyed said that the NHS was either the same or worse under Labour compared with the situation under the Tories. The figures are even worse among doctors, with 75 per cent believing that the situation is worse. The retirement figures evidence that. I wonder how many doctors or other health professionals would advise their children to go into the NHS. I am afraid that the answers would be highly negative in many respects. That is very regrettable.

Even on current plans, the NHS will continue to lack the capacity to give patients the first-class treatment that they deserve. It is still short of staff and beds—acute, critical, intermediate or residential.

As my noble friends have explained, that view of NHS morale is not just anecdotal but is based securely on a survey of staff opinions carried out by NHS trusts in England and Wales last year, collated by my honourable friend Mr Burstow. That important collection of hard data paints a poor picture.

I do not intend to go through the worrying figures that the noble Lord, Lord Vivian, mentioned. Some 48 per cent feel that communication in their trust is not good. Communication is essential to morale, even excluding any overwork or capacity problems. Those results are stark evidence of how low morale has sunk in the NHS.

It is extraordinary that the Government have made no attempt to standardise the questions in the survey, pull the results together and publish them. The Minister ought to tell us why, because the Government intended trusts to carry out those surveys. The trusts did so, but nothing further happened. The results provide a unique snapshot of the views of NHS staff. We should start producing real information as a matter of urgency.

Belatedly, at the 11th hour, the Government are introducing a system of golden hellos, golden goodbyes and extra cash to attract GPs to deprived parts of the country. This morning, the Secretary of State made an overdue pledge to increase the number of midwives.

The key issue is not purely management or purely leadership. It is a matter of resources and capacity. At the coming election, the Liberal Democrats will pledge to provide extra training places for doctors, nurses and professions allied to medicine, as my noble friend Lady Northover outlined. We cannot deny that the shortage of staff is the main problem that faces the NHS at the start of the 21st century. Given how long it takes to train doctors or nurses, we should have started some time ago because we have an urgent problem on our hands. I take the point made by the noble Lord, Lord Turnberg, about other staff whose services are key to the efficient deployment of those highly trained professionals. The failure to invest in staff training places through the late 1980s and the 1990s, compounded by the failure of the present Government to grasp the nettle early enough, has been one of the key problems.

Pay has been at the root of many of the problems. The noble Baroness, Lady Gardner of Parkes, was particularly cogent on that. Nurses, midwives and other professional staff have not received the financial remuneration that they need. We must improve their pay as a matter of urgency. We have many proposals for doing that.

We also need to provide additional beds. To an extent, the number of beds relates to the number of staff available, but it is also a matter of facilities. The Government's track record on PFI has not been happy. We do not believe that PFI is the best instrument for delivering additional beds. There is no transparency in the comparison between financing beds through PFI and through pure public spending. PFI has not helped to increase the number of beds—indeed, if anything it has led to a decline. All that contributes to a feeling that the NHS is changing beyond recognition and to a lack of morale. It is vital to review the criteria by which PFI contracts are judged.

The Liberal Democrats are strong supporters of the NHS. We want to give members of staff cause for optimism. They do a fantastic job under the current circumstances. I agree with many noble Lords who have said that. We have the diagnosis and the prescription. I hope that the Minister and his colleagues will now administer the correct treatment.

4.59 p.m.

Lord Astor of Hever

My Lords, I, too, thank my noble friend Lady Noakes for drawing attention to morale in the NHS, which is an emotive subject at the moment. She is right that it is the people who really count—the doctors, the nurses, the consultants, the midwives, the managers and all the other NHS staff, who are working under such trying circumstances. We pay tribute to them. I am proud of my sister, a registered general nurse, married to a consultant surgeon in the NHS.

I agree with the noble Lord, Lord Clement-Jones, that we have heard some excellent and well informed speeches. I doubt whether the Minister will have enjoyed listening to many of them. He may enjoy tomorrow even less!

Like other noble Lords, I very much associate these Benches with the warm words said about Lord Morris of Castle Morris.

My noble friend Lord Harris of Peckham spoke movingly of the very great achievements of the Guys and Lewisham Trust during his chairmanship. My noble friend Lord Vivian mentioned the Defence Medical Services. I join him in stressing to the Minister the urgent need for the NHS to ensure that there is a fast-track system for the Armed Forces and that, on a new posting, service families receive priority medical treatment.

As my noble friend Lady Noakes said, four years ago, almost to the clay, many in the NHS welcomed the arrival of the Labour Government. That good will has been completely eroded by the constant flow of new government initiatives and targets, the witch hunts and the failures to tackle recruitment and retention. Now GPs and hospital consultants are on the verge of open warfare; Ministers face growing militancy from midwives; and nurses have major concerns over their workload. Managers are defensive and demoralised. It gives my party no pleasure to see that happening. We all want a strong and flourishing NHS.

A survey to be published in tomorrow's Health Service Journal will show that poor morale, an ever-increasing workload, a lack of resources and a keen desire for less government intervention are the starkest findings. Like patients, those who work in public healthcare recall the Prime Minister's, 24 hours to save the NHS". Within little more than a year, the Prime Minister was saying that huge sums of money would also be needed.

Despite the much vaunted extra money and the massive increase in advertising for Labour's health policies, people began to ask why things were getting worse. The Prime Minister identified numerous scapegoats. Whatever the problem and however serious it was, someone other than the Government was always to blame. Doctors were particular targets for scapegoating from the Secretary of State.

The UK has the lowest ratio of doctors per head of population in the OECD—1.7 doctors per 1,000 people, compared with the EU average of 3.4. Therefore, doctors are working long hours, to a high intensity, under considerable stress. That is compounded by the setting of targets which are often little more than wish lists and, in many cases, largely undeliverable.

The NHS Plan states that between now and 2004 there will be 2,000 more GPs. However, according to the GPC joint deputy chairman, morale among GPs is so low that, those who can afford to go will do so as soon as they can. In 2004, there could be 2,000 fewer doctors—not 2,000 more". Nursing is at the core of health provision, and the success of the Government's plans for the NHS depends upon adequate numbers of skilled nurses. However, the Government are failing to increase their numbers or to augment retention. The noble Baroness, Lady Northover, mentioned nurse training places. I point out to her that those were very much on the way up, not on the way down, when my party left office.

Eight out of 10 nurses feel that the NHS is a worse place in which to work than it was two years ago. For them, as for other NHS staff, too many changes have taken place too quickly: first, the primary care groups and trusts; now, the modernisation plan. For most nurses, just getting through a shift is difficult enough. My noble friends Lady Eccles, Lady Gardner of Parkes and Lady Fookes each emphasised the burdens that change puts on health professionals.

Nurses are increasingly subject to ever-higher patient expectations. That has led to more aggression and abuse. They are three times more likely to be assaulted on the job than are police officers. In many hospitals, basic working conditions are sub-standard. The Government's disastrous handling of the care homes sector is having a knock-on effect on bed utilisation in hospitals and adds to the pressure on nurses.

The RCN is asking for the creation of more consultant nurse posts across the UK and for the provision of thorough support, combined with clear monitoring of trusts to ensure that their pay adequately reflects their role. I should be grateful if the Minister would clarify the Government's thinking on that point.

Declining morale in the NHS has a knock-on effect on patients, who have suffered the consequences of being fast-tracked through the system, being squeezed as extra appointments into out-patient clinics, and discharged at lightning speed. That increases the risk of accident and error. Doctors should not be practising at a pace which jeopardises patient safety. The pressure on GPs to reduce consultation periods cannot possibly mean that patients receive the level of treatment that they have every right to expect.

However, despite the Government's distortion of clinical priorities through the waiting list initiative, patients are waiting longer than ever before. According to a King's Fund analysis, more than 2 million people are waiting to see a hospital consultant either for diagnosis or treatment, and the number shows no sign of declining. Last September, 436,000 people had waited more than three months to see a specialist. More than half of them were in pain.

Managers feel battered by the constantly enlarging management workload and by the Secretary of State's implied, but strong, criticism of health authority managers last week. My noble friend Lady Noakes pointed out that a steady trickle of the most senior managers are leaving the NHS.

We on these Benches have always realised that the challenges that continuously face the NHS are formidable: the pace of technology; the need for highly trained and experienced staff; the demographic changes taking place in Britain; and the aim that we all share to keep the NHS free at the point of delivery. Yet, the response of this Government has been very damaging.

Hard-working medical professionals are tired of the spin; they are tired of being the scapegoats for the Labour Government's failures; and they are tired of more interference, centralisation and red tape. That was well articulated by Dr Lockley from Bedfordshire in Doctor magazine, who said: The Government doesn't relate to the real NHS at all. Instead, Ministers have a virtual reality NHS into which they put all their efforts, and to which they look for their answers. This shiny new NHS is quite different from the gritty, grimy NHS in which we all work". After four years of hard Labour, Britain, the world's fourth largest economic power, really does deserve better.

5.9 p.m.

Lord Hunt of Kings Heath

My Lords, first, I congratulate the noble Baroness, Lady Noakes, on securing this debate. I congratulate her also on the quality of her speech, which set a very high standard. It has, indeed, been a very good debate, and all noble Lords have brought a wealth of experience to the House this afternoon.

Morale has been much talked about. As my noble friend Lord Haskel suggested, the issue of morale has been around for as long as the NHS has been in existence. When I joined the NHS in 1972, I remember being told by my more experienced colleagues that morale had never been lower. Those of us who have been in the NHS know that morale never having been lower is a characteristic of our working experience.

I take the advice of my noble friend Lord Graham, who suggested that we must always keep the NHS's achievements in mind. One characteristic of the NHS has been the fact that it talks up its problems and talks down its achievements. In saying that, I do not discount the pressures that people are under. The pressure is there; there is no question about that. Public expectations are rising all the time; again, there is no question about that. We are asking a lot of the people who work in the NHS.

Unlike some noble Lords who spoke today, I have been struck over the past few years by the excitement and enthusiasm of many people who work in the NHS. They are driving forward necessary change, breaking down the barriers that have often existed between the different professions in the NHS, producing real innovation and securing improved services for patients. I place on record my thanks to the dedicated staff of the NHS and stress how much we owe to them. I echo the words of the noble Lord, Lord Vivian, who praised those people.

Noble Lords opposite were unsparing in their criticisms. I regret that in their critique of this Government's record they failed to mention the contribution that their government made for 18 years to the problems that the NHS has had to face up to. I say to the noble Baroness, Lady Gardner of Parkes, that I still consider it to be my responsibility to draw the attention of noble Lords to the many failings of the previous government in their stewardship of the NHS.

It is worthy of note that the noble Baroness, Lady Noakes, who has made an extraordinary contribution to the NHS—I suspect that she is the only person in this country who understands the full mechanism of NHS finance—did not mention the paper-chase of the internal market; the glaring inconsistencies and inequalities in the service received by patients under the previous government's stewardship; their neglect of staff, which was most notably indicated by the staging of pay awards recommended by the independent pay review bodies; or the 28 per cent cut in nurse training places.

I say to the noble Lord, Lord Astor of Hever, who promises me a rough time tomorrow, that there may have been a move away from the damaging cuts of the early 1990s but, frankly, those cuts were so great that it would have been almost impossible not to have improved on the situation. Finally, noble Lords opposite made no mention of the utter lack of ownership among NHS staff in relation to the internal market changes.

In contrast, this Government have placed the NHS at the core of their endeavours, as my noble friend Lord Rea said. We have set record levels of investment in the NHS. We have set new national standards for services for cancer, heart disease, mental health and the care of older people. We have created much greater transparency over local service performance. We have created a new legal duty of quality and a new system of clinical governance to enshrine improvements throughout the NHS. We have established the National Institute for Clinical Excellence, which evaluates new treatments. We have for the first time an independent inspectorate, the Commission for Health Improvement. We have established new systems for when things go wrong and that help us to learn from what goes right. We have met the pay award recommendations of the independent pay review bodies in full over the past three years. We are giving staff such as nurses a much greater say in deciding the shape of local services. I respond in a positive manner to the suggestion of my noble friend Lord Rea that we should build on that. The £5,000 sums that we have given to ward sisters to spend on environmental improvements to their wards has been a remarkable success. I was interested in the contribution of the noble Lord, Lord Harris, on that matter. There is a real sense of ownership because we have given responsibility back at that level.

We are moving towards a patient-centred service with immediate benefits. Who can discount the impact of the booked-admissions system, which was introduced in each trust in at least two high-volume specialties or conditions? Long patient waiting times are being reduced.

Expansion is under way. There are more staff—and more staff yet to come—and there are more beds in hospitals. I listened with great interest to the comments of the noble Lord, Lord Clement-Jones, on the PFI. However, he did not acknowledge that we have in place the biggest hospital-building programme that this country has ever seen. It involves modernising 220 accident and emergency departments and more than 1,100 GP surgeries. More operations are also being undertaken. I say to the noble Lord that there is of course a long way to go. I know that staff are under real pressure. I also acknowledge that it takes time for investment to be felt at the front line. However, investment is getting through and it will be sustained.

I take very seriously the comments that noble Lords made this afternoon on the involvement of NHS staff. Such involvement ensured that the views of NHS staff on the NHS were vital to the formulation of the NHS Plan. What NHS staff wanted became apparent to us in the consultation that we undertook. They wanted to see more staff; more training; more joined-up working with social services; less bureaucracy; more action to prevent ill health; better working conditions; faster delivery of services; more focus on patients; less variation in services across the country; and less control from Whitehall. The whole idea of developing the NHS Plan was to involve the staff. All the provisions in that plan are being delivered somewhere within the NHS—the challenge is to have them applied consistently.

We have no hope of delivering the NHS Plan unless we can increase our capacity. One of our first priorities was to get more staff into place. The noble Baroness, Lady Northover, was absolutely right to point to the crucial importance of doing that. It is important to understand, as the noble Baroness suggested, that the shortfall that we have had to face up to—it involves many thousands of doctors, nurses, therapists and scientists—came about because of decisions that were made in the early 1990s. If there is one lesson that must be learned from that, it is that we must never again engage in such drastic cutbacks in training places.

The NHS Plan, which was published last July, stated that by 2004 there will be 7,500 more consultants, 2,000 more general practitioners, 1,000 more specialist registrars, 20,000 more nurses and 6,500 more therapists and other professionals. We are beginning to see the impact of that. Between 1997 and 2000, the number of staff in the NHS expanded significantly: there are 6,700 more doctors, more than 17,100 additional nurses and more than 9,600 additional scientific, therapeutic and technical staff. Like other noble Lords, I mourn the absence of our late noble friend Lord Morris of Castle Morris. How he would have enjoyed today's debate; he would have enjoined us to recognise the contribution of nurses.

Between September 1999 and September 2000 alone we saw 6,300 more nurses. Over 7,500 qualified nurses have already returned to the NHS since February 1999 and a further 2,000 are preparing to join them. Applications for nurse training have increased by 86 per cent over the past two years. UKCC figures published yesterday show a 13.2 per cent increase in the number of new registrations for newly-qualified nurses and midwives.

That is substantial progress in which we should rejoice. But we face a shortfall. That is where international recruitment comes into play. But I reassure the noble Baroness, Lady Noakes, that it is a two-way process. Welcoming staff from abroad surely enables the transfer of experience and the sharing of ideas which can be extremely beneficial both to the patients in this country and to those in the other countries concerned. I stress, as I have stressed before in your Lordships' House, that guidance issued to the service ensures that international recruitment is carried out effectively and appropriately, and only in relation to those countries where there exists a surplus of nursing staff.

My noble friend Lord Haskel also pointed to the announcement we made today in relation to the expansion in maternity services and our intention to see an extra 500 midwives working in the NHS over the next five years. That too is extremely important.

The noble Lord, Lord Astor of Hever, referred to waiting times and waiting lists. It has been a substantial achievement to reduce the number of people on waiting lists. We made it abundantly clear that clinical priority must be the main determinant of when patients are seen as out-patients or admitted as in-patients.

The noble Baroness, Lady Noakes, cast some doubt on the role of modern matrons. I doubt whether that will be shared by many Members of your Lordships' House. The noble Baroness, Lady Masham, pointed out the problems that arose in the NHS when ward sisters particularly were disempowered by having responsibilities taken away from them. It is little surprise that in looking at the experience of patients in our hospitals, many complaints arise from issues in the wards relating to cleaning and catering—issues which once upon a time would have come under the firm control of the ward sister. We are turning that around. The whole role of modern matrons is to give responsibility back to senior nurses. I am convinced that patient experience will be enhanced as a result.

Many noble Lords—the noble Baroness, Lady Eccles, and my noble friend Lord Haskel in particular—talked about the pressures under which doctors work and the changing relationship between doctors and members of the public. There can be no doubt that patients are more informed and more demanding. In addition, the work of doctors has come under ever greater scrutiny. And patients expect to know more; they expect to consent to what is happening to them. That in itself presents new challenges to the medical profession.

But those of us who know people working in other professions would say that those pressures are not only relevant to the medical profession; many other professions have to face up to new ways of working. We in the NHS of course have to provide support to enable the profession to face up to those pressures and challenges. One thing is for sure, they will not go away.

A number of contributions suggested that doctors in particular are feeling "under the cosh" at the moment, and of course we must address those issues. But there are indications that the latest figures show that there has been a fall in the proportion of hospital medical staff and GPs taking voluntary early retirement. I say also to my noble friend Lord Turnberg that we wish to encourage people to continue working for the NHS on a part-time basis. I am happy to pick up any specific instances of concern and examine them. It is clearly in the interests of the health service to encourage people who wish to reduce their commitment, but nevertheless continue to work in the NHS, to be enabled to do so. That is part of the NHS becoming a better employer.

We have listened to staff; we are tackling their concerns. We are investing heavily in more training places. We are looking at how to encourage more flexible and family-friendly working practices—more childcare, more flexible retirement policies. I say to the noble Lord, Lord Vivian, that we have appointed a senior official to help us provide more accommodation for nurses, particularly in central London, because I well recognise the problems that he raised.

Being a good employer applies to primary care and GPs as much as to any other member of staff. GPs work hard and we know that they are under pressure. That is why we set out in the NHS Plan our intent to recruit at least 2,000 extra GPs by 2004. We have laid the foundations for that in increasing the number of trainee places. We set out a number of measures to encourage trained GPs to return to practice, particularly women following career breaks, and GPs who wait until they are 65 to retire are being offered £10,000 golden goodbye awards.

Of course we are also committed to cutting bureaucracy and to freeing up appointment times to the equivalent of nearly 1,000 GPs. Indeed, as Dr John Oldham pointed out, A lot of very simple things can add up to making a significant difference. It's all about working smarter, not harder". Perhaps Dr Oldham goes a little too far. But he makes the point powerfully that it is not just about making more resources available; it is about making the best use of them. So I was disappointed yesterday. I noticed that the action taken by a small number of GPs was not supported by the BMA or by any significant doctors' organisation. We want to agree a new contract for GPs. But that is surely best delivered through discussion and negotiation and not through protest action which can only impact upon the experience of patients.

Most people recognise that the growth in resources is a substantial change. But it is not just a question of resources; it is a question of improving the way we work. The NHS Plan revolves very much around breaking down some of the boundaries and barriers that exist at the moment in order to produce an integrated approach to care across so many of the organisational boundaries that have always existed in the health and social care local community.

Staff must be in the driving seat of change. Doctors, nurses and scientists must use their know-how; make their innovations felt; redesign their services. I fully accept the comments made by many noble Lords that where staff are put firmly in control of what they do is where we will see the innovation that we require.

The noble Baroness, Lady Walmsley, talked about the dental strategy. We are committed to NHS dentistry, and that is why we are developing dental access centres. It is why the Prime Minister made the pledge about access to NHS dentistry and it is why we are making it abundantly clear to health authorities that they need to re-engage with the dental profession. I share with the noble Baroness, Lady Gardner of Parkes, an enthusiasm for fluoridation. But we must wait for the results of the MRC review. The noble Baroness knows where my heart lies on that question.

Again, the noble Baroness, Lady Walmsley, made an important point in relation to the pharmacy programme. I believe that pharmacies can contribute much more, as the noble Baroness, Lady Gardner, also stated, and that is why we are encouraging people to go to community pharmacies for advice where that is appropriate.

I was interested in the comments of the noble Baroness, Lady Masham, about her experience when she unfortunately had to use the NHS some time ago. I agree with the points regarding consistency of approach. That is what we are trying to do. That is what national frameworks and specialised commissioning are about.

Information technology in NHS hospitals is important. For many years the NHS has had a poor record of introducing IT. One of the key lessons from the NHS Plan discussions with staff is the need for us to get IT right. That is why we are investing £l billion in modernising NHS information systems over the lifetime of our information strategy, 1998–2005.

I refer to the remarks of the noble Lord, Lord Vivian, concerning Defence Medical Services. I am responsible in the department for liaison with the MoD on those matters. I am happy to write to him with more details. However, perhaps he will take it from me that I am committed to ensuring that the partnership works effectively. I believe that we can make that partnership work.

I was interested in the remarks of the noble Baroness, Lady Walmsley, concerning public health. That is an important matter which perhaps did not get sufficient airing in our debate today. I shall follow up with details of the screening pilots about which she asked. It is important that screening is done in the right way. That is why we have the National Screening Committee and take advice from it. There is sometimes an assumption that all screening is good. However, some screening is not particularly effective and can sometimes cause harm. Therefore, we must get it right.

I shall pass up the challenge to debate with the noble Baroness, Lady Noakes, the question of community health councils. We have debated that in your Lordships' House in the past few weeks and may well do so again next week.

Perhaps I may conclude with the issue of centralisation and decentralisation, which ran as a thread through contributions of all noble Lords today. The point about the NHS is that it is a national service. I do not believe that the public will tolerate inconsistency in either the quality or the range of services which are available in the NHS throughout the country. That is why Ministers are accountable to Parliament for its performance. It is inevitable that we will have national standards and national targets. However, we accept that we have to limit those and leave room for staff to grow and lead at local level. In essence, that is what the Secretary of State announced in his launch of the Modernisation Agency only last week.

Looking back over my 25 years of working in the National Health Service, I have never been more confident about its future than I am today. The NHS has always had the right ethos, dedicated staff and public support. We are building on that with more resources, more capacity, more staff and a plan which, for the first time in any reorganisation in living memory, has the support of all people working in the NHS. Putting that together, I believe that the NHS is in good shape. It is ready to take on the challenge of change, to innovate, and to put patients first. Surely that walks step by step with high morale among the staff. There is no better challenge for a great public service. I am confident that it is one which will be fulfilled.

5.34 p.m.

Baroness Noakes

My Lords, I am grateful to all noble Lords who have taken part in the debate. I have been passed a note which says that I have two minutes in which to wind up. Therefore, I shall make only one or two final remarks.

We are all aware of the great love and respect there is for the I\ HS. The noble Lord, Lord Graham of Edmonton, reminded us of that. That is why we care about the state of morale in the NHS. There is widespread agreement around the House that morale is in a poor state. Several noble Lords have suggested remedies. Unfortunately, I do not have time to go through the more interesting of those.

The purpose of this debate was not to solve problems. I am grateful for the Government's response. Indeed, I am glad that the Minister is confident about the future. We on these Benches would be happier if he stopped looking in the rear-view mirror, in which he is getting a distorted view of the past, and concentrated on looking forward.

The Minister referred to a number of systems and structures and constantly brought us back to the NHS Plan. The issue is whether the NHS Plan will be anything like enough to deal with the real crisis of confidence we have debated today. However, I shall take up no more of your Lordships' time. I beg leave to withdraw my Motion for Papers.

Motion for Papers, by leave, withdrawn.