National Health Service

HL Deb 08 May 2002 vol 634 cc1148-89

3.8 p.m.

Baroness Pitkeathley

rose to call attention to the Government's 10-year plan to improve service quality in the NHS; and to move for Papers.

The noble Baroness said: My Lords, it is both a pleasure and a privilege to open this important debate this afternoon. I cannot but begin by telling your Lordships what a terribly important date this is for me personally. Exactly one year ago today, almost to the hour, I was in an operating theatre at the Middlesex Hospital undergoing the last in a long series of life-threatening operations from which, as your Lordships will see, I have made a miraculous recovery.

Noble Lords

Hear, hear!

Baroness Pitkeathley

My Lords, so today, on this very important anniversary, noble Lords will not be surprised to learn that I come to praise the NHS, and I have every reason to do so.

On 8th May last year, I was surrounded by the most skilled of surgeons, the most well equipped of intensive care units, the most able nurses and the most committed ancillary staff that any gravely ill person could wish for. The care given to me was extended to my family, who were always kept fully informed, consulted and involved in the procedures. That care was exemplified perhaps by the nurses who came in to sit with them and me while they were waiting to see if I would recover consciousness, even they were supposed to be off duty.

Visitors who came in to see me as I began to recover were apt to say that this was the NHS at its best. It was certainly the NHS at its most magnificent, but at its best? I do not think so. Most people, I am glad to say, do not need to see the NHS as I did, but every one of us sees it constantly in our lives, and most of the time we see it at its best.

For example, we have experienced the GP who listened to us when we needed it; we may be one of the 85 per cent of people who receive free prescriptions; we may have an older relative who has received tender and loving care, as well as a hip replacement, which transformed their lives; we may be one of the 30,000 people who get a free eye test every week, and so on, and on. This is what the NHS means to most of us. My anecdotal evidence—in spite of what the media tell us and in spite of the odd bad experience which all of us could quote—shows that most people have good experiences of the health service. If they did not, would the institution be held so dear in the hearts of the majority of the population?

Most people now do not remember what life was like without the NHS but I shall never forget the story my grandmother told me which first made me realise its value. A young widow, just after the First World War, she had two small children ill with whooping cough, a killer disease in those days. She called the doctor, who came to the door and asked her before entering if she had his fee. She replied that she did not. The doctor turned and walked away. That was the situation which in 1948 the Labour Government vowed to remedy. We should all be proud of the huge progress which has been made which allows us, in some ways, to take for granted that the NHS is always there for us.

But at the beginning of the 21st century it is not enough to have a health service which provides life-saving procedures at moments of great crisis and a GP on hand when our children are sick. We must have an NHS which is fit for purpose for our life now and in the foreseeable future.

It must address the needs of an ageing population where illnesses are increasingly complex; where treatments which were once pioneering have become common place; where new drugs are constantly being developed; where access to technology has transformed all our lives; and, perhaps most of all, where patients are no longer content to be passive recipients of whatever the NHS is prepared to provide but are increasingly well informed and demanding.

The Government's 10-year plan, drawn up with patient and public involvement and endorsed by a very wide-ranging group of healthcare professionals and patient and care representatives, is a plan for delivering a health service for the 21st century. It sets out important principles—for example, that the NHS must be a universal service for all based on clinical need, not ability to pay; that it must be a comprehensive service which covers not only treatment for illness but self-care, health promotion and prevention; and that it must tackle inequalities in society. Most importantly, in my view, it also endorses the principle that the NHS must shape its services around the individual needs and preferences of individual patients, their families and their carers.

Following on from this 10-year plan, the recent Budget of my right honourable friend the Chancellor of the Exchequer provided unprecedented amounts of funding to deliver these important commitments. While we must acknowledge that decades of underfunding cannot be easily rectified, it is clear that measurable improvements will result from the huge amount of extra investment to which the Government are committed—investment which will provide 35,000 extra nurses, 15,000 extra doctors, 100 new hospitals by 2010, 500 new primary care health centres, and 7,000 extra beds in hospitals and IT.

The fact that this massive investment and the means of raising the money to pay for it have found such widespread public approval—with some 74 per cent of the population expressing approval for the decision to raise national insurance contributions to fund more spending on the NHS— shows that the basic health of the health service is seen to be good and widely supported.

I imagine that many of your Lordships were as amused as I was at the sight and sound of TV and radio reporters trying rather desperately on the days following the Budget to find people to interview who disapproved of the proposals, and for the most part failing miserably. Certain sections of I he media have, as we know, for some time now tried to promote the view that the NHS is beyond repair, that its disintegration is inevitable. This is clearly not a view endorsed by the majority of the population.

What was universally endorsed, however, by government, by NHS staff, by patients and everyone else, was that investment alone is not enough, no matter how large that investment. Money has to be accompanied by modernisation, and it is this vision of the new NHS which is set out in the document, The NHS Plan, and in the subsequent document, published on the day after the Budget,Delivering the NHS Plan.

Time is too short to cover here all the plans for modernisation, but by far the most important one, in my view, is the intention to move the bulk of the funding—75 per cent eventually—to the primary care level. I welcome this for two reasons. First, it will recognise that primary care, in your own community, in your own home, is where most healthcare happens. Almost 1 million people visit their general practitioner or the surgery every day. For most people it is their first contact with the NHS, for many their only contact, and yet we habitually talk of, and too often think of, the NHS in terms of hospitals and secondary care.

My second reason for welcoming this new emphasis on primary care is that it will enable the rhetoric of patient involvement to become reality. Patients forums and patient advocacy and liaison services are welcome innovations, but we must remember also that patients will be decision makers as non-executive directors of primary care trusts. They will also have the choice about accessing services through NHS Direct, e-mailing or phoning the practice nurse or the GP for advice, and they will be able to book appointments on line. Round-the-clock medical care will be available for minor ailments and accidents near your own home, while electronic patients' records will enable therapists and doctors to maintain continuity of care and knowledge of their patients. As someone whose medical records now stand more than a foot high in four manila folders, your Lordships can imagine that I am particularly pleased with that.

These changes in primary care will ease the pressure on hospitals so that they can concentrate on providing specialist care. In addition—what a relief this will be to patients—appointments at hospitals will be pre-booked to suit patients and tests and diagnosis will usually be carried out on the same day.

Plans which I welcome especially are those which encourage greater co-operation between health and social services to ensure smoother discharge from hospital and greater home support for those who need it. Rigid institutional boundaries between health and social services, between business and community organisations, have done no favours for patients over the years. They have particularly inhibited the ability to work productively on prevention and to tackle health inequalities.

The virtues of promoting such partnerships and the positive effect they can have on the health of a community has been very much brought home to me in my work as chair of the New Opportunities Fund, the largest of the lottery distributors. By this summer we will have allocated money for 400 healthy living centres, targeted at the most disadvantaged areas in the United Kingdom. Partnerships between the local authorities, the NHS, the private and voluntary sectors and with the communities themselves is enabling a sea change in the health of those communities, encouraging people to take responsibility for their own health, to take more exercise, to grow their own food and to deal with stress and local community problems in a way which will have a profound effect in the future on the way they use the health service.

People who are less than fully committed to the continuation of the NHS are fond of saying that however much money you put into the service itself it can never deliver adequately as the needs are too great ever to be satisfied. There may be a grain of truth in that if we continue to think of it only as a sickness service. But I know that the Government are committed to ensuring that public health features very highly on the NHS agenda, and especially to tackling the inequalities in health which continue to mar our record. Only when lifestyle, housing, education and, above all, poverty are seen as factors affecting health, and when cross-cutting approaches are adopted by all interested agencies, will we be able to bring the needs and the provision to meet the needs into balance. This is the approach the Government are adopting. Their courageous commitment to measurable improvements in both the treatment of illness and the fostering of good health will surely bring results.

But commitment to modernisation in these and many other areas is, in turn, not enough. The NHS is to be provided with much clearer incentives to encourage better performance. There are of course existing incentives to improve performance, but until now they have focused too much on efficiency and getting more for the same amount of money. Ask any doctor or nurse how they feel about those and they will mostly tell you that what is needed are incentives which encourage quality services and responsiveness to patients. This is the success that the NHS Plan says must be rewarded, not the throughput.

However, the public must be assured that the extra resources to be put in provide value for money. That is why new forms of inspection are to be introduced. The introduction of a commission for health care audit and improvement and the merger of the Social Services Inspectorate and the National Care Standards Commission have been widely welcomed as a means of driving up standards and strengthening accountability to the public, although some of us might have wished that the timing of these reforms had been a little more tactfully handled.

I hope that other noble Lords will be able to speak in more detail about some of the reforms to which I have been able to refer only briefly, and about those which I have not had time to mention.

In conclusion, we stand on the threshold of what may prove to be the most exciting of times in the long and proud history of the NHS. We should never forget that the major changes that we are making require even more than money and even more than modernisation. They require a huge cultural change in the attitudes of those who serve the health service and those who use it. Empowerment of patients is easy to pay lip service to, but is perhaps harder to make a way of life both for staff and for patients themselves since it requires a reassessment of fundamental relationships which were in existence even before the National Health Service began.

Few people are as aware as Members of this House that changes in culture are more difficult to bring about than changes in organisation or structure. I am, however, convinced that the will and determination exist to make these changes. At the beginning of my remarks I referred to the NHS at its best. Aneurin Bevan said that the aim of the NHS should be to universalise the best. I believe that that is what the NHS Plan will do. My Lords, I beg to move for Papers.

3.21 p.m.

Baroness Gardner of Parkes

My Lords, I am pleased to be only the second speaker in the debate, because I intend to speak about dentistry—and rarely does it ever receive high-level rating in debates. I have looked through the 144-page NHS Plan: a Plan for Investment, a Plan for Reform and can find nothing in it about the future of dentistry. It certainly contains nothing to give general dental practitioners any hope of an ongoing future in the National Health Service.

In opening the debate, the noble Baroness, Lady Pitkeathley, applauded the fact that 75 per cent of funding has moved to primary care. General dental services are a basic part of primary healthcare, but the funding is definitely not going towards such services—and the funding that is going to them is badly used. In an attempt to support the Prime Minister's pledge that by autumn 2001 everyone in this country would have access to national health dentistry, the Government developed catch-all access centres. The centres cost over £1 million each to set up and they cost a great deal more money to run. They are prohibitively expensive, they are not working as intended, and some centres are advertising to attract patients—I refer in particular to the centre in Penge. So it is not the case that NHS patients are looking to the access centres as the answer in terms of dental treatment. At present, most people will tell you that they simply cannot get NHS dental treatment. At lunch today, I sat next to a Member of Parliament from the North East of England, where I spent time last year. I remarked how much better dental services were in that part of England. He said: yes, they were, but even in the North East the situation was giving great cause for concern because NHS dentistry there was gradually vanishing.

One of the problems relates to quality, which is the subject of this debate. Dentists have no problem 'with wishing to deliver the best quality of service and one standard of treatment for all patients, but they cannot afford to do so. NHS fees are so bad that practitioners cannot cover all the new restrictions and demands placed on them.

My experience in NHS dentistry goes back 35 years. I can even remember the days when we did not have sealed injections for patients; we dropped a pellet into a bottle of sterile water and that was considered safe to inject into patients. Nowadays, people would have a fit if that kind of thing happened. Now, there are water regulations, amalgam separation, sterilisation to prevent cross-infection, all to standards that were never in place in the past. Indeed, there was even a suggestion that each instrument would have to be identified with the name of every patient on which it was used so that it could be identified subsequently. I gather that the whole dental profession has risen up in protest against the idea and it is not going ahead.

Dentists do not in any way oppose regulations to improve standards, but such regulations must be taken into account in terms of funding. Unless the funding is available, how can people suddenly be asked to carry out all these additional practices—which are presumably to be paid for out of their own pocket? That is where the ethical dilemma arises for practitioners. They want to do their best for everyone, they want to provide first-class National Health Service treatment for patients, and yet it is totally unviable and they are unable to do so.

The point that emerged from the NHS review group, NHS Dentistry: Options for Change, was that there must be extra funding. None of the proposals salaried system, capitation, sessional fees—are viable unless it is known how and when they are to be funded. The Government must state whether they intend to retain an NHS dental service. They must decide whether it is to be a universal service, free to all at the time the service is delivered—at present there is no free dental service, except for a few priority classes—or whether it will be a service provided only for exempt patients.

I have spoken to representatives of the General Dental Practitioners Association, the body most representative of grass-roots dental practitioners. Its information is that there will be not a penny more for dentistry and that the Government are looking at a core service only. If that is true, the Government should come clean and say so. Why are we trying to fool people that everyone will receive top-line National Health Service treatment in every part of the NHS if that is not the case? That is just trying to deceive people.

Every year dentists are asked to comply with more and more new regulations. A great deal of new registration will be required. Later this year, the registration of technicians and dental nurses will be a requirement, and dental nurses will have to undergo further training. All of this may be very good, and very helpful for patients; but it will be very helpful for patients only if they can actually get to see a dentist who has those facilities and receive the treatment that they deserve.

Whatever field of the National Health Service we are in, we must protect people against every conceivable risk, and the Government have gone to a great deal of trouble to try to do that. But we can protect only against risks that are reasonably foreseeable. New problems can arise all the time. If we think back a few years, none of us envisaged the hazards of HIV/AIDS or hepatitis. I am thinking of the days when needles could be re-used, and when one of the biggest dangers was broken needles. No one ever has a broken needle now; needles cannot be re-used, because they cannot be sterilised against hepatitis. One risk has been removed, but it has been replaced by a new risk.

The General Dental Practitioners Association believes that all dentists should be able to provide one standard of care to all patients—the highest standard. But it believes that certain criteria are important: first, the standards must be set; then they must be delivered; they must be monitored; and they must be paid for.

Will the Minister tell the House whether the Government are prepared to make a commitment to make adequate National Health Service dental treatment available to all patients in this country? Or do they intend to make NHS dentistry simply a core service? If the intention is to provide a service to all patients, will the Minister assure the House that the funding that is required to provide that service to the proper standard and quality will be made available? I emphasise that this debate is about quality. It is very wrong—and it is a terrible ethical choice for a dentist to have to make—that he can offer the service, but not up to the proper standard. It is unfair to ask that of any practitioner. I ask the Minister to think seriously about this matter. I hope that he will be able to give us an assurance that National Health Service dentistry will continue to be universally available to people in this country, at a fee or not, but at least adequately funded to enable the service to continue.

3.29 p.m.

Lord Clement-Jones

My Lords, I add my thanks to the noble Baroness, Lady Pitkeathley, for initiating the debate. I recognise her personal experiences that have led her to raise this subject. However, I am rather baffled by the title of the debate, especially as the NHS Plan was published in 2000. This debate is about the future. It has a slight flavour of a petition to the First Secretary of the Supreme Soviet congratulating him on his far-sighted plans for tractor production in the next 10 years or the superb expected growth in the grain harvest.

One of the reasons for bafflement is that the plans set out by the Secretary of State never seem to stick. He is perpetually chopping and changing targets and methods of implementation. We have moved from traffic light systems to stars and from earned autonomy to foundation hospitals in quick succession. Now we are expecting a new NHS Bill before the ink is dry on the current one.

Despite that, on these Benches we shall treat the debate as an opportunity to mark the Government's scorecard on their progress so far on the NHS Plan and to make a few humble suggestions about where it should go in the future. We have the great benefit of having not only the recently published chief executive's report commenting on NHS performance under the NHS Plan and targets, but also the King's Fund's Five-year Health Check, the January report of the Modernisation Agency and the Department of Health's report, published at the end of last year. They all deal with different issues relating to the NHS Plan in different ways.

From the outset it must be acknowledged that the Government are making a massive commitment to the NHS, unlike the Conservatives, who are not prepared to publish their alternative proposals but seem content to sit about like a vulture, waiting for the NHS to weaken. I regret that it does not appear that we shall hear any concrete proposals in the short term from the Conservative Party.

I hope that this debate will not be purely about targets and whether they have been met, although they deserve a mention. There are far too many targets in the original NHS Plan. There are also targets in the Department of Health public service agreement following the Comprehensive Spending Review for 1999-2002.

However, one set of targets, on recruitment and retention, is paramount. As Derek Wanless acknowledged in his report, capacity in the NHS is the key issue. There is a need for an extra 15,000 consultants, with 7,500 needed by 2004. We also need 35,000 nurses, midwives and health visitors, with 20,000 of them needed by 2004. Facilities are also key. We need 7,000 new acute and intermediate beds by 2004. The noble Baroness, Lady Pitkeathley, also mentioned the important target of 100 new hospitals by 2010. Those are all noble targets.

I suspect that the chief executive's report on progress, published last month, is intended by and large as a good news document. It touches lightly on recruitment and retention issues and does not highlight the failure to meet the target for the number of outpatients waiting more than 26 weeks or the delays in meeting ambulance response time targets by 2001. It also fails mention the fact that only 47 per cent of people in England were registered with an NHS dentist in 2001. I share the concerns of the noble Baroness, Lady Gardner of Parkes, in that respect. It does not even highlight the fact that outpatient numbers have risen sharply.

Where are we on the 35 public service agreement targets following the 1999 Comprehensive Spending Review? By my calculations, only eight have been achieved. Another five appear to be on course, but many of the remainder have been fudged or failed and many have been changed in mid stream.

Some might think that that casts doubt on the value of targets. The Government risk being hoist by their own petard on targets. In a recent study, Professor Nicholas Bosanquet says that he believes that the six months waiting time target will not be met by 2005.

Despite the myriad targets, we need to remind ourselves of the really important targets—not only the capacity targets, but the outcome targets, on which we need to reach European standards. Ambitious targets have been set for cancer, circulatory diseases and mental illness, but it is far too early to tell whether they will be met, as they should be.

However, it is clear that the Government badly need to learn from their stewardship of the NHS so far in the broader sense of whether they are managing the process of reform correctly. The best study so far is the King's Fund's Five-year Health Check published last month. It gives the Government positive marks for the increase in funding, for not having flirted with alternative funding mechanisms and for having started a pattern of closer integration of health and social care. It cites the good start made by CHI and describes the national service frameworks and NHS Direct as positive developments.

In other areas, the report is not so positive. It agrees with critics that policies on waiting lists for NHS treatment threaten to distort clinical priorities. It points out that, despite NICE, there are many unresolved rationing dilemmas in acute care. In primary care, too much is being attempted too quickly. In workforce planning, the report is positive about some of the new processes adopted by the Government, but it is not clear that the NHS can hold on to its current staff.

I could go through a catalogue of individual comments from the report. It also makes some important overall observations. It cites tension between central and local management and the unwillingness of the centre to let go, despite the stated aim of decentralisation. It cites the secondary billing given to tackling health inequalities and social care. The latter has been left with junior Ministers to date and has been woefully underfunded, as the Help the Aged report published today makes clear. A holistic approach between health and social care and in tackling health inequalities, combined with the NHS, is clearly needed.

The report also cites the tension between radical and conservative philosophies, particularly in pursuing a preventative health agenda as opposed to one that concentrates purely on the NHS. In that context it criticises the Government for locking themselves into PFI, which commits them to traditional patterns of acute care for 30 years or more. The report reaches the damning conclusion that there has been no substantial risk transfer from public to private sector.

As we have done on these Benches, the King's Fund also criticises the Government's hyperactive approach to quality assurance and improvement in the NHS, risking confusion and delaying real changes to service provision. It says that the NHS is being overwhelmed by a torrent of well meaning initiatives and managers, and clinicians are buckling under the weight. Above all, it says that Labour has not yet developed a coherent and principled set of criteria to guide its decisions. Its rhetoric is often radical, but its actions are essentially conservative.

That is quite a charge sheet. We recognise that the NHS is a massive organisation with 1.2 million employees, but along their five-year pilgrimage this Government have made a major contribution to its problems. Waiting list targets have badly skewed clinical priorities, as have central initiatives.

I could go on with a number of particular aspects, but in conclusion I hope that the Government will listen and learn from reports such as hat of the King's Fund. I hope that the recent Gallup poll—which shows that only 13 per cent of the public think the NHS is getting better and 40 per cent believe it is getting worse—represents only a passing trend and not a continuing public attitude.

We must all acknowledge that this will he a long haul. The Government have a mountain to climb. The paradox is that patients' expectations are very high. We cannot expect results overnight, but we can expect the Government to act on evidence, to empower those who work in the health service, to make fewer promises and to set fewer targets. As a senior member of the NHS Confederation said this morning, the NHS needs a period of getting to grips with some of the changes that have been thrust upon it. I thought that he put it rather well when he said that the motto should now be, "Don't just do something; stand there".

3.39 p.m.

The Lord Bishop of Guildford

My Lords, I am grateful to the noble Baroness, Lady Pitkeathley, for giving us the opportunity to have this important debate. I want to share with your Lordships some concerns I have about the nature of our public discourse on health.

I want to take your Lordships first of all to the north of Mozambique, which I visited in 1998, to a small town which had been badly affected by the war. The hospital there was in a fairly derelict state, with no fresh water or electricity, but it had a rather good antenatal clinic. The health priorities in the town were concerned with re-establishing the peace, clean water throughout the town, education for the children and, above all else, improving the capacity of families in the community to grow good and wholesome food.

In the public mind and in our public debate on health issues in this country I believe that we have so united the notion of health with the National Health Service that we have come to believe that the only solution to the health challenges of the 21st century lies in better funding and better management of the National Health Service. I served on the late John Smith's Social Justice Commission. Some fairly Left-wing researchers suggested to us, deliberately provocatively, that we would not improve the nation's health while we continued to pour endless funds clown the open throat of the National Health Service. That was a provocative remark, not that I thought that they believed that we should not properly fund and manage the service. However, they wanted to make us think about what we were trying to achieve in healthcare.

I am concerned about public understanding. My fear is that as our community continues to prosper demand for health services will increase and in five to 10 years' time we shall face a similar challenge of not enough resources to meet increasing demand; or, worse, we shall enter difficult economic times and will not be able to afford to sustain the level of service upon which people have come to depend. I say with my international development hat on that there is not a ghost of a chance of those kind of healthcare facilities being available to vast numbers of people in our world.

I have a question on which I should value some ministerial comment; that is, what are we doing about public expectations? There are two ways of tackling the challenge of health. One is to increase resources—I support, if I may say so, the proper resourcing of the health service and welcome what the Government have done—but the other is to get some control over demand. The unacceptable way of tackling the latter difficult problem is to provide high quality services for those who can afford them and not for the rest of the community.

Our aim should surely be to strengthen the capacity of people to assume greater responsibility for their own bodies, minds and spiritual growth. The provision made in the public forum is there to support individuals, families, households and communities to be successful in carrying out their own responsibilities. Whose life is it? Whose bodies, minds and spirits are we talking about? I refer to those of the people, not those of the service.

Nye Bevan created the National Health Service in the context and vision of values designed to increase, and spread the possibility of, a responsible society for all. The institution of the National Health Service was rooted in a long development of ideas and values about the common good and the way that would strengthen the capacity of ordinary people to accept greater responsibility for their own lives. Archbishop William Temple, R H Tawney and many others contributed to that debate in the 1930s and 1940s.

Two things follow from that: first, the blocks have to be removed that make it difficult for people to assume that role. Many years ago the Black report examined issues of poverty, inequality and aspects of social class and exclusion. As I stood in a queue in a store to buy groceries I noticed that the woman in front of me who had two small children filled her basket with the cheapest sliced bread and the cheapest tinned food. There was no fresh food in the basket. However, the basket of the person behind me was filled with enough alcohol to have lasted a number of years in my childhood home and with top quality foods. In that context I ask myself: what are the health issues in our community and the public attitudes towards it? Secondly, we have to try to create a different culture and to encourage the assumption of values which promote personal responsibility in society. The policies, language and discourse we pursue must promote that debate.

The House will be aware that at least 30 million people in the continent of Africa are HIV positive. In Uganda the infection rate has been reduced from 30 per cent to under 9 per cent. That has been achieved by a concerted programme of action undertaken by government, voluntary agencies, community leaders, Churches, families and schools working together in a common cause. As people are learning in South Africa, which has been a little slow off the mark in these matters, part of that strategy involves ensuring that the right healthcare facilities exist to back up that process. Part of the strategy requires dedicated professional health services but much of it, however, requires education and the changing of attitudes and lifestyles aimed at helping people take control of their own bodies, their own lifestyles and their own choices.

I submit that until we in this more prosperous and materialistic society face those questions ourselves, we may find ourselves pouring ever increasing resources into bodies such as the NHS in a self-defeating strategy and asking of the National Health Service a role it was never designed to undertake and cannot possibly fulfil.

3.47 p.m.

Lord Turnberg

My Lords, I, too, congratulate my noble friend Lady Pitkeathley on introducing this important debate and on doing so in such fine form. We ought to be grateful for the NHS.

When the NHS Plan was first published two years ago it was seen as a very ambitious programme. The vision it set out was widely supported by the public and the professions. However, it was not until the Chancellor committed the Government to repairing the enormous funding deficit in the NHS that we were given this marvellous opportunity to change the health service in the UK in what I believe is a fundamental way. So we have the vision and we have the potential funding to make it happen; all that is left is for us to decide on the tactics.

I have never believed the "bottomless pit" argument, which seems to have been one of the excuses given by previous governments for not putting money into the health service. There are at least two reasons why I believe that. First, one has only to look at countries around the world where patients are satisfied because they are seen by a doctor or other health professional at a time and a place which suit them and receive the treatment they need, in hospital or outside, in a timely way to realise that it is entirely possible to fund all reasonable needs. In Australia, New Zealand, France, Sweden, Canada and Germany patients do not seem to have a major problem with services. The doctors and governments of those countries may complain from time to time, but by and large the patients do not. Secondly, although I am no economist, it seems to me that the more affluent we become and the bigger our GDP, the bigger the proportion of our GDP we can afford to spend on healthcare. I believe that not only can we afford to pay for better services, we just have to do so.

Having got that off my chest, I should like to focus on some of the mechanisms through which the Government might be able to achieve their vision. There is some hope that the new administrative framework with PCTs, strategic health authorities, the proposed health protection agency, coupled with the quality and inspectorate agenda of CHI, NICE and so on will be helpful but, of course, only time will tell. In any case, if history is anything to go by, further reforms will occur in due course. But there are more fundamental things that can be done that patients themselves will recognise more immediately.

While we wait for the increases in the numbers of doctors and nurses and hospital beds that are promised but which cannot, with the best will in the world, appear overnight, there are many steps that can be taken that could have a more immediate effect.

First, as we increase the numbers of medical students entering medicine, which we are doing, we should also do more to retain doctors who are leaving. The average age of doctors leaving the NHS in the hospital service is between 55 and 60, depending on the specialty, at a time when they could still contribute much to the NHS. They leave for a number of reasons, among which is an increasing difficulty in coping with the considerable pressures that are placed on them, and which increase rather than decrease as they get older. There are also more services for patients, more teaching and more administrative tasks. The part of their work that they seemed to enjoy most and for which most would give their eye teeth to do is simply looking after their patients.

The Department of Health has gone some way to try to encourage trusts to offer more flexible contracts to doctors at the end of their careers so that they can continue to contribute their clinical skills and knowledge in the last five or 10 years of their careers. They could perhaps do so part time and in different ways. On the ground, it is difficult to see that much progress has been made on that front. What a waste of talent and expertise at a time when we are desperately short of doctors. I hope that the Minister will consider whether more could be done in that regard.

There is yet another need for flexibility in the employment of doctors; that is, not only because 50 or 60 per cent of our newly graduating doctors are women but also because the male graduates, too, are looking for more flexible lifestyles. We have some way to go despite much effort by the Government to persuade trusts to do more to produce flexible contracts for staff. That applies particularly to women but also to men, and not only to doctors but also to nurses and other healthcare professionals. Will the Minister consider whether that initiative could be made to work a little more effectively?

There is another hurdle that again needs to be looked at critically; that is, the so-called "workforce planning" system, by which the numbers of training posts for medical specialties are strictly controlled centrally. We are desperately short of consultants but we have strict limitations on the number of doctors who are allowed into training posts. We now have the odd situation in which there are increasing numbers of young doctors coming out of medical schools at one end, a clear need for more trained consultants at the other and a tight, restricting hand on the number of training posts in the middle, preventing many who want to train from doing so. Of course this whole process of manpower planning has to be managed—I can see that—but it is time to re-examine the whole process, which is becoming somewhat ridiculous.

There are many other actions that could be taken with the extra resources that are coming on stream and which would have an immediate effect. Investment now in medical secretaries, ward clerks and porters—the basic infrastructure of hospitals—would allow for much greater efficiency in the use or nurses, physios, doctors and others.

In the last minute of my speech, I want to put in a plea for help for poorly performing hospitals. We have heard much about the need to reward hospitals that perform well by giving them greater freedoms and funding—we do so quite rightly in my opinion. However, I am concerned about the "name, blame and shame" culture in which poorly performing hospitals become embroiled. That is somewhat inappropriate. It is like blaming the patient for being sick. Those hospitals need understanding and support—understanding through an analysis of the reasons why they are underperforming and support to help them to improve. Only the patients suffer if we do not do that.

I suggest that we need an analogue of CHI that concentrates on helping hospitals to remedy their difficulties. I propose that the Government should set up an organisation that could perhaps be called CRI— the commission for rescue and improvement—for ailing hospitals.

We have an excellent plan for the NHS and we are now being given the resources to achieve it. We must ensure that we look critically at how we can best use those resources to achieve the plan in the immediate term as well as in the more distant future.

3.54 p.m.

Lord Selsdon

My Lords, I regard this issue as probably the most significant political, economic and social issue that I have encountered in almost 40 years in your Lordships' House. I am very grateful to the noble Baroness for giving us a chance to discuss it.

These days, the honourable gentlemen in the other place are somewhat neutered—an operation that is freely available on the National Health Service. In general, we are not given the time to discuss in Parliament issues of great import. We have thrust on us ideas from government and sometimes, when a major Bill comes up, we are told, "Please do not speak on this; we do not have enough time". We have enough time today to discuss an issue that means much to me. However, I am not qualified to speak at first hand. Unlike the noble Baroness, I have suffered in that I have no experience of the NHS. I had my tonsils out many years ago and I have spent probably a few hours in bed in my life but I have never been in a hospital bed.

I was brought up in a strange world. My brother-in-law was the militant Irish leader of the young doctors, a cancer specialist who regularly appeared on television 30 years ago saying that they were underpaid, overworked, overstretched and—he was Irish—over here. My uncle was a consultant for many years at St Mary's. Having had polio, he could not fight in the war and always felt slightly ashamed of that. Another relation was a GP in the country where he doubled as a vet where necessary. He set up the pain clinic in King Edward VII Hospital.

I spend most of my time abroad. Like the right reverend Prelate the Bishop of Guildford, I believe that man has a duty to be healthy if he possibly can be. To provide the noble Baroness with great encouragement, I echo what she said and advise her that your Lordships' House, as I have said previously, has the longest life expectancy of any body of its kind in the world.

I pay tribute to the NHS as a result of an incident that happened only two weeks ago. A member of my wife's family who had been ill for many years fell downstairs in the middle of the night. He had been treated previously in Bart's and Westminster and Chelsea. A panic phone call to me got the ambulance out. It was there in four and a half minutes, and I made it in eight, not being very far away. The ambulance crew could not have been more helpful and competent. The accident and emergency department was not particularly crowded that night, but the stress and strain on the young doctors who had been working for 12 hours or more was evident. Sadly, the person died but everybody in that hospital was so competent and kind. A blind eye was turned when we came in with his favourite tipple and managed to dribble it with a sponge into the corner of his mouth. After death, the help that was provided to the bereaved was outstanding.

I compare that experience with the previous hospital where I had visited the same patient—Bares, the "St James Robertson Justice and Hattie Jacques" of the ancient world. The building is now virtually condemned and very depressing, although great skills exist there.

I raise the problem of bringing together the inherent skills and ambitions with the resources that are needed. I have spent much of my time working abroad developing hospitals and financing medical equipment. I know about the situation from the overseas side. When I look back, I see that we have one of the worst health services in the world for a nation with our history—back to Scutari and Florence Nightingale. The reasons are strange. I found a report from 1948 that said that we must make a change. I believe that that was the time when my great uncle, Stafford Cripps, was Chancellor.

We have needed change all along. The question is: do we look for revolution, which is regular change, or a revolt? A revolt is always dangerous because it causes problems. We can consider the matter with what we used to call a resource triangle. Three things are required: human resources, physical resources and buildings, and the money and the ability to complete them.

I cannot discuss human resources and I shall not explain how difficult it is when a soon-to-be member of my family—a very bright young man who has just qualified as a surgeon—says that he cannot see a career for himself in the NHS, which is sad. It is sad, too, that we have to recruit so many from overseas to fill posts. Let us assume that this great revolution of people and changes—worth the multi-billion-pound mergers of large corporations—will produce a structure that is reasonable and understandable. I worry about the size of the change that is proposed and the human stresses and strains that that may cause.

I now turn to the physical side. I declare an interest as a director of one of the contracting groups— Gleeson. At present we are building six hospitals under the PFI with a total of 600 beds at a cost of £150 million. One is just over the river. I do not speak on behalf of the group but I want to mention a few problems and difficulties based on past experience.

It seems to me that in the plan the Government have simply produced a wish list. In the financial world we would say, "Take it back and come back again when you have a prospectus or a business plan". It is not a business plan, but it is full of everything that one could possibly wish to see. Therefore, naturally I and others have a duty to support the proposals.

My concern lies with the realisation of the proposals. Often in the international world one starts with conceptualisation—a wonderful word—and ends up with realisation. But between the two is the lovely word "animation", which is Walt Disney orientated. How do we bring this concept alive? How do we build 100 hospitals by the year 2010? How do we re-equip 3,000 GPs' premises and find the GPs to use the equipment, the technology and the services? How do we build 500 one-stop care units?

Today the situation is not bad. Nine new hospitals were built or commissioned last year and another nine will be built or commissioned this year. But to date none of the hospitals commissioned under the PFI has been able to cope with the problem of transfer of resources or people. I believe that it is called "transfer of employment". We have a problem with Unison. It is difficult for people who have worked for the state and the National Health Service to transfer to a new body—a new organisation with a new name. It is difficult to achieve that.

We have a further problem. At the beginning, PFI in whichever sector, whether it was water, transport or health, caused problems because it was new. We were surrounded—not surrounded, outnumbered—at meetings by the lawyers who represented the banks and others, all charging large amounts of money to advise people how not to do something. I believe that, to some extent, the problem has been solved thanks to the competence of the Government's PFU, the Private Finance Unit, whose chief executive has done an extremely good job. Standard contracts are now being advanced. But it has taken time, and it will take time, to achieve objectives. I would not say that it is not possible to achieve them, but I believe that it is highly doubtful.

That is where my concern arises. It is wrong to raise expectations too greatly and not to be able to deliver. There is nothing wrong with the plan. It may be the timescales that are difficult. Often there have to be six bidders for a hospital project, but not too many of those outside in the construction world are competent to handle large-scale activities. We are short of labour and we are very short of resources. The risk placed upon a contractor when his margin may be only 1 per cent is very high. There are risk-takers out there, but it is a difficult time. The objectives are good, but I doubt very much whether more than 50 per cent of them can at present be achieved. That is a personal, not a corporate, view.

I turn to another matter of concern. When one moves from the public to the private sector, a change of culture is necessary. Very seldom has a civil servant managed to move on to a successful career in the commercial world, and vice versa. Therefore, as we set up these new structures, who will be the people in charge? Who is the client, and who is the boss or gaffer? And what risks are they taking?

I want to raise a warning with the Minister in relation to the new proposals. These days, every accountant, lawyer and professional person has professional indemnity insurance. Are the Government guaranteeing and providing cover for those who may have jobs as the non-executive directors? I know not. However, I wish the whole project well. I believe that the wish list is extremely exciting, but there is a long, long way to go.

4.4 p.m.

Baroness Masham of Ilton

My Lords, I thank the noble Baroness, Lady Pitkeathley, for initiating this debate. The noble Baroness knows from personal experience the importance of expert medical care and the need for clean hospitals in order to prevent infections such as MRSA. Yesterday my voice disappeared, so I hope that I shall be able to say a few words in the debate today.

The 10-year plan has some important points. But one never knows what may happen during that period, and priorities may have to change. Paragraph 1.16 on page 19 of the plan states: Where patients have the most complex illnesses and conditions, such as the need for a heart operation, they will be referred to centres with the best equipment and the staff with the most appropriate expertise—even if that means travelling to a specialist centre". Yesterday I received a postcard from Harefield Hospital. It said: Please help us to save this world-famous hospital from destruction. Neither its staff nor patients will relocate to the expensive and polluted area of Paddington in London". The reputations of hospitals which are renowned world-wide cannot be built up overnight. Perhaps I may ask the Minister what the plans are for Harefield Hospital. The NHS Plan that we are discussing today stresses that the wishes of patients and staff are important. Shutting hospitals is not something that the public or NHS staff want to see. Perhaps today the Minister will say something in general about shutting hospitals.

The plan says that all patients will have a TV and telephone by their beds. That is the icing on the cake. However, where a complicated condition is involved, the vital priority should be that the patient receives the correct treatment and goes to the appropriate hospital. I declare an interest as I have been treated in a spinal injuries unit. I give as an example spinal injury resulting in paralysis. Many severe problems can arise for newly spinal-cord injured patients treated in general hospitals. They are at risk from life-threatening medical complications which general hospitals lack the facilities, expertise or specialist teams to recognise and treat—for example, autonomic dysreflexia, which is unique to the spinal-cord injured.

Admission to general hospitals can spell disaster, while appropriate spinal injury treatment and ongoing care can offer a good quality of life to a paralysed person. It is very worrying that several of the spinal units have beds closed due to staff shortages.

I applaud the appointing of modern matrons, as stated in the plan. The spinal unit at Stoke Mandeville is looking for such a person—thus far without success. I hope that the hospital will find someone who is dynamic, has strong leadership and can attract staff, and who will ensure that the unit is clean, that infections are under control and that patients enjoy their food instead of having to send out for take-aways.

The Spinal Injuries Association, of which I am president, feels that there should be a bed bureau covering all the spinal units in England and Wales so that it is known throughout the country when beds are vacant. In that way, patients will receive the correct treatment without delay. In this day and age of modern technology, that surely should be possible.

At Oswestry, the spinal unit has set up some halfway houses, with care provided, so that paralysed patients waiting for their homes to be adapted or for new ones to be made available do not block the acute beds in the hospital. That is an excellent example or the NHS, social services and the voluntary sector working together.

The title on page 50 of the plan is "Investing in NHS Staff". One sub-title refers to improving the working lives of staff. Last Saturday I heard of a nurse who had come from abroad and was working and resident in a hospital in Wakefield. Her car was vandalised within the hospital grounds and, in addition, hospital windows were smashed. Many people no Ionizer seem to respect hospitals and the people inside them as they did in the past. If staff and patients are to feel safe, security will have to be stepped up.

Investing in NHS staff must be one of the biggest challenges. Yesterday I chaired a meeting of the Associate Parliamentary Group on Skin on the manpower crisis in dermatology. There are some serious black spots where posts are vacant. Registrars becoming consultants replace those retiring. More women doctors are working part time. There is not a flood of doctors coming from abroad and it takes four extra years to train a dermatologist. Children in agony with serious eczema are waiting months for treatment. The same story is heard about rheumatologists and the lack of rehabilitation facilities for long-term disabilities.

Specialist nurses in diabetes, Parkinson's disease, dermatological and other conditions are a great help, but one needs the whole team for a successful outcome. The Government should be given credit for trying but I hope that they will listen to the patients and the staff nearest to them who really understand the problems, which I hope will be overcome.

4.11 p.m.

Baroness Gibson of Market Rasen

My Lords, I thank my noble friend Lady Pitkeathley for initiating this debate today. I thank her also for the first part of her speech in which she mentioned her illness, which I found moving. Many of us were praying for you, Jill, this time last year.

I always find it easier to criticise than to praise but today I want to praise the National Health Service. Like my noble friend Lady Pitkeathley, I believe that the NHS is one of Britain's greatest achievements. The Government are on record as believing that the NHS should be free at the point of need, that it is the best insurance policy in the world and that a taxpayer-funded NHS is best for all concerned.

When the King's Fund reported earlier this year, it opened its discussion paper by saying: The NHS has a history of underfunding and the consequences are that the UK suffers a lack of capacity—in terms of both staff and facilities—in comparison with its European neighbours". It identified the need for greater freedom for providers to respond to patients and purchasers of care and for incentives to retain and attract staff, including financial incentives and rewards.

A further report, the Wanless report, stressed two particular needs: greater public engagement and local flexibility in delivery. It stated that that would provide a health service fit for the 21st century. I was very pleased indeed with the Government's proposals in their 10-year plan. They have shown that they mean what they said in that plan; that is, to continue the improvement in the health service. In the latest budget there was the largest ever sustained increase in NHS resources: an increase in real terms of 48 per cent by 2008.

The Government have pledged that resources will be matched by reforms. Key elements of those reforms are that there should be a national standard; that there should be modernised, flexible professional people working within hospitals; that the staff should be rewarded adequately; that the needs of patients should be at the forefront; that there should be improved health services, especially for the poorest; that there should be intermediate care to build bridges between hospitals and homes; and that there should be a radically different relationship between health and social services to develop one care system.

On a personal note, the latter two elements are particularly welcome to me, having faced difficulties over recent years. When my mother, who is now 89, became ill, I had to sell her home and ensure that she was settled in a care home in Market Rasen. I came across the hospital, the social services, and the health services, all of which were helpful. Everyone wanted to help but there was overlap in some areas and gaps in others. I believe that one care system for the future is essential.

The Government are also committed to fundamental changes in job design and work organisation; to change in working practices, to decreasing arbitrary demarcations, and to front-line staff being given more authority. One example is that of ward sisters in charge of ward budgets. Who knows what is needed in terms of budgets better than the ward sister?

It is right and proper that staff in hospitals are praised for the work they do. So many of our lives depend upon them. Both the Prime Minister and the Secretary of State for Health are on record as paying tribute to all staff in the NHS; to those in different medical disciplines, and to those who are ancillaries, secretaries, receptionists, porters and cleaners. They all play their part and are among the best of our British public servants.

I am proud to say that during my trade union career I met many NHS staff and saw at first hand their expertise and devotion, both to their work and to those whom they administer. I often felt humbled as I listened to them speak with such enthusiasm about their work. It would be a tremendous waste of knowledge and expertise not to expand the opportunities for hospital staff. For many, their work is a cause rather than a job and we, the patients, are all the luckier for that.

NHS staff at all levels are vital to reform. The need to increase their numbers is acknowledged openly by the Government. Already, we have 2,000 modern matrons in place with the authority necessary for them to succeed. We hope that there is more to come. There is an aim to have 15,000 GPs and consultants and 30,000 more therapists and scientists under local control. I particularly welcome these developing opportunities. The professionals with whom I worked in MSF—I declare an interest; my former union, now known as Amicus, had many NHS members including clinical psychologists, radiographers, speech therapists, and so forth—emphasise the need for constant training and retraining.

The Government are committed to enhancing the role of therapists and nurses and to increasing the training of all staff, including the new health professionals. They are committed to more flexible working patterns and—vital for women in particular—to better child support. As 79 per cent of NHS staff are women, that is, indeed, an important support. Other noble Lords with far more experience than me in the health service have spoken of what is needed in relation to those commitments. I am sure that the Minister listened.

The monitoring of how the NHS is supporting and involving staff—including in personal development—to underpin progress in recruitment and retention is extremely important. It is a worthy aim, but it must be one which takes place with the involvement of those who work within the NHS. The Government also propose new contracts of employment, including for hospital consultants. Those are aimed at liberating and rewarding NHS staff.

Whenever changes are made, even if the stated aims are good, some feelings of apprehension are felt by working people. We need to be totally open with the staff if new contracts are to work. Consultation is obviously the key. Consultation means discussions with staff and their representatives before decisions are taken, not after. It means listening to what the staff and their representatives say and using the workers' knowledge when alterations are being made. It means a flow of information up and down any chain of command so that all workers know what is happening and, above all, why it is happening. After all, the staff are in the best position to know about local needs, local differences and local responsibility. If the proposed investment and incentives are implemented with the betterment of the staff in mind, then the NHS will be better for workers. More importantly, it will also be better for patients, which must be our ultimate aim.

4.20 p.m.

Lord Lyell

My Lords, I thank the noble Baroness, Lady Pitkeathley, for giving us the opportunity to discuss this enormously important subject. The speeches so far have been outstanding. I hope that the Minister will forgive me as I am a relative novice when speaking on health matters.

It was interesting, encouraging and moving to hear the noble Baroness, Lady Pitkeathley, give the reason for her speech on the occasion of her debate. I am delighted to see that my noble friend Lord McColl is on the Front Bench. Eleven months ago I had my first non-orthopaedic visit to a hospital. Alas, something happened to me, which is often mentioned here: a dreadful thing called a hernia. I am sure that my noble friend and your Lordships will be aware that this month is the season for professional footballers getting hernias. I do not know why, but they are all rushed into hospital with them. If noble Lords put their noble noses into the "boulevard "press they will see that every week and month players from every club run in for these types of operations. Indeed, it happened to me, so it seems that I am not entirely alone.

The report that we are discussing has been admirably covered by the noble Baroness, Lady Pitkeathley, and other noble Lords. One of the first excerpts that I noted was in the introduction. It stated: More money is, however, only the starting point". The speeches that we have heard so far take that issue into account. No doubt we shall hear more about it. But there is a great deal more to the matter than that. My noble friend Lord Selsdon referred to the tripod—that is to say, money, facilities and, above all, the people who are involved. That aspect is beautifully covered in the report.

Page 10 of the report is classified as the "Executive summary". I hope that that is not aimed at the more novice-like and perhaps—I would not hesitate to say—idle Members of your Lordships who would glance through the "Executive summary". I am delighted to see that it mentions the National Institute for Clinical Excellence.

The report refers to what is a kind of dreadful postcode success regarding cancer. About 10 or 12 years ago I had a colleague and friend in Kirriemuir— my hometown—who suffers from multiple sclerosis. It was agonising explaining to him why a similar sufferer, with whom no doubt he was in contact, just across the water in the Kingdom of Fife, was able to receive treatment. The medicine was called beta-interferon, which apparently provides excellent relief for intermittent sufferers of multiple sclerosis. If he had lived or attended hospital in Fife he would have received it. He did not receive it in Angus and in Tayside. That was purely a clinical judgment, although I suspect that the cost-effectiveness of the drug had something to do with it. Happily, that matter now seems to have been resolved. That was in Scotland. However, at some stage I hope that the Minister can reassure me that similar cases are covered. He does not need to do that today. Perhaps he will write to me.

In chapter 2, paragraph 2.16 in the report, I was delighted to see the excellent comment that, the top 25% of hospitals get nearly double the output from their consultants as the bottom 25%". For someone who has only been passive—luckily—in hospital, it struck a chill through my heart that somewhere, somehow there would be a hunch of supervisors in the operating theatre chasing up—if I can put it tactfully—the consultants, saying, "Get a move on with that. There are others behind. Look sharp with that scalpel. Come along. There are people waiting". I wonder what was being aimed at in that paragraph. I hope that the quotation was comparing like with like; for example, regions and types of disease. As your Lordships will know, some diseases are found to be more endemic in some areas than in others.

I looked at page 31 of the report. It did not seem to be classified as a chapter. It is headed, "An under-invested system". I noticed there the interesting but stern quotation that between the years 1979–1997, the average annual increase in Government spending on health was … 2.9%". That dropped a penny with me. I wondered whether your Lordships might care to look at earlier periods—perhaps 1960 or 1964–1979 or since. It has been an ongoing thought today that however much one spends on the National Health Service we need to look at how those funds are spent.

Chapter 3 is headed "Options for funding healthcare". I was fascinated to find in paragraph 3.14 that the United States and Switzerland have two systems of funding their health service. The wicked word "regressive" was used. I have two points to make about Switzerland. First, one will not find a more egalitarian country; and, secondly, I have considerable personal experience of it. I am delighted to see my noble friend Lord Astor of Hever in his place. We share considerable experience of Swiss medicine and healing. Indeed, he is a perfect example of how fit one can be.

In paragraph 3.25 there are two figures which equate more with my discipline as an accountant. In France 3 per cent of health expenditure was on generic medicines whereas in the United Kingdom the figure was 60 per cent. That is interesting, particularly in view of chapter 11 where the report refers to changes in relationships between the NHS and the private sector. There is a particularly helpful comment dealing with the pharmaceutical and the bio-pharmaceutical industries. Two figures are mentioned which are useful to accountants and to businessmen, such as my noble friend Lord Selsdon. There is a helpful quotation in chapter 11.11. The Minister agrees with me on this matter. It states that the, National Health Service has a major role to play in ensuring that the UK remains an attractive base for the industry". I must conclude. In chapter 13 there are considerable and helpful references to what I would call "preventive medicine and good health". I look around the House and hope that noble Lords are examples of that. But there are references to smoking, diet and nutrition, but above all to drugs and to alcohol.

I am a little worried by the lack of emphasis in chapter 16 and the final summary on the prevention of drug and alcohol abuse. That is certainly a drain on resources. In view of what the right reverend Prelate pointed out, I hope that the effects of drugs and alcohol will not replace other ancient diseases–the noble Baroness, Lady Pitkeathley, mentioned whooping cough. No doubt we shall hear more about such matters from the Minister. I once again thank the noble Baroness, Lady Pitkeathley, for initiating the debate.

4.28 p.m.

The Earl of Listowel

My Lords, I am most grateful to the noble Baroness, Lady Pitkeathley, for allowing us to debate the NHS Plan today.

I shall concentrate my remarks on one aspect of child and adolescent mental health services. I begin by welcoming the addition of 335 mental health teams to provide an immediate response to young people undergoing mental health crises, which is announced in the plan. I welcome the announcement of a significant increase in the number of midwives and health visitors to be trained each year by 2004. They play an essential role in ensuring the good mental health of our infants and children.

In the same spirit I welcome the major expansion of Sure Start projects to cover one-third of children aged under four years living in poverty. Sure Start seems to have been one of the great successes of this Government as regards vulnerable families.

By reducing child poverty, the Government are also removing some of the stress on our most vulnerable families, particularly lone parent families, giving their children a much better prospect of growing up feeling well nurtured and ready to take on the world and enjoy it. In that context I hope that I can persuade the Minister that funding for child and adolescent mental health services should take the highest priority when decisions are taken about the use of the revenue from additional national insurance moneys.

I am advised that mental health services for children have suffered from the Government's decision not to ring-fence last year's grant of £10 million to child and adolescent mental health services. I am very disturbed to learn from the Royal College of Psychiatrists of the shortage of appropriate in-patient beds for children and young people with mental health problems. This shortage is a chronic problem and is deeply unsettling. One would have expected more to have happened by now. However, I understand that the Government are now in the process of closing child and adolescent mental health service beds in the South East.

My chief concern, however, is the dearth of mental health professionals in the multi-disciplinary teams increasingly serving our children and young people. Can the Minister say whether this need for qualified mental health professionals to participate in these multi-disciplinary groups is recognised; whether an appropriate qualification is being formulated for them and when; and in what numbers these professionals will be delivered? I apologise for not giving the Minister warning of these detailed questions. Perhaps he would be good enough to write to me if that would be most convenient.

Last night I met a young woman in a hostel for the homeless. We recognised each other from an earlier visit that she had paid two years previously when she was 16. She was a gifted gospel singer due to record with a celebrated popular singer this coming weekend. She was attractive and seemed intelligent. Why then was she doing a second stint in the hostel? It may well have been that there was an aspect of her experience which a mental health professional might have been able to identify and address. Without adequate mental health input young people like her are unlikely to receive the more emotionally aware attention they need. The Connexions service, the youth offending teams and other schemes are seriously handicapped without a mental health input.

I recently met with head teachers from Newham, Peckham and other London boroughs. One of the conclusions of our meeting was that teachers and head teachers need to receive training in the management of challenging and vulnerable children. The Prince's Trust has produced a report involving interviews with children excluded from school. Very often children reported that their schooling broke down as a result of a poor relationship with a particular teacher. We really cannot expect our secondary school teachers to befriend and parent every child in their class. There is the danger of overburdening them with pastoral responsibilities. But we can equip them to be emotionally intelligent enough to deal tactfully and effectively with challenging children. Mental health professionals would be very well placed to provide this training and support.

I was very pleased to learn that Centrepoint has employed for this year a mental health professional to review all its services from the mental health perspective. Clearly, if we wish to deliver to our children and young people the help they need to keep them in school, out of prison and on the path to employment, independence and a healthy family life of their own, we must ensure that the Government's 10-year plan and its national service frameworks for children and mental health allows sufficient investment to procure the mental health professionals, the Connexions service, the youth offending teams, the care and education systems and all their needs.

A couple of weeks ago a hostel manager described to me the helpful advice that he had received from a trainer with a psychology degree. He said that last year he had seen a young man who had stabbed his wrist repeatedly with a fork until he had made a nasty wound. The other residents were very concerned. It was very hard to know how best to react to his action, which was in the context of the frustration of his desire to go beyond the rules of the hostel. He wished that he had known then that this action could be understood as a call for attention. That may seem obvious to your Lordships, but in the heat of the moment, when there is so much chaos in the environment, it is perhaps less easy to understand and react appropriately. The appropriate response, therefore, was to deal with the wound in a calm fashion and to maintain one's sang froid.

Of course, one's immediate reaction is to show a great deal of concern and interest in the young man. However, this response amounts to encouragement to the young person to repeat the self-harming activity whenever he feels distressed. It is better to be calm and make sure that he is very well aware that there are other means of his raising his concerns. One has to steer a careful path between neglect and hysteria. That was the advice, as I remember it, that the mental health professional gave. He wished that he had been more aware of it at the time and that he had had that advice before. We cannot allow staff, working with our most vulnerable young people in all settings, to work in the dark. Their work needs to be illuminated by proper psychological input.

4.37 p.m.

Lord Desai

My Lords, it is always good to be the last speaker because most of the things I wanted to say have been said. Therefore, I had to think of something new to say.

My experience as a patient has been very typical of the NHS. I had very good service when I tore ligaments in my knee late one evening before Christmas Eve about seven years ago. I got an ambulance to St Thomas's hospital. I had to wait a few hours on a trolley. But it is a very comfortable existence lying in bed in a room. There is nothing to complain about. I got very good treatment and there was no problem. We have excellent service from the accident and emergency services.

But recently I said to my GP that I had a hearing problem and that I should have my hearing tested. He said that that would be no problem and that he would write off for an appointment. I have one in nine months' time. That is appalling. I know that everyone has to wait and I know why. I know the consequences of 20 years of under-investment. We have many shortages and so forth. We love our NHS.

But while it is excellent in dealing with acute emergency problems, as regards elective surgery and normal health concerns, the service is falling down. I believe that is because we started with very good intentions, which were that it should be free at the point of use and universal. Those are very good values and we should stick to them. But those values have prevented us from thinking innovatively about different ways of doing things. The 10-year plan is a very good opportunity; but all 10-year plans are a farce and a total waste of time because the detail changes. No 10-year plan should be the same 10 years on otherwise life would be very dull indeed. A 10-year plan states what is to be done for the next 18 months or so and then everything moves on. That is what 10-year plans are about.

But I believe that there are certain central principles to look for. I can claim only to have been a patient in the NHS. I have not been a member of a health trust, I am not a doctor; I have no relations who are doctors; nothing like that. As a patient, I am not at all sure that I feel that the NHS belongs to me. It belongs to nurses. I should add a word about nurses, because morale has never been lower—I have to say that, as it is part of the national debate. The NHS also belongs to consultants, who want more money and better contracts; it belongs to GPs; and it belongs to a range of administrators, who are all doing their best. However, it does not belong to the patients.

We must think of more creative ways of ensuring that the NHS belongs to patients. I do not mean patients' councils, or community health councils. They are bureaucratic structures to which people who are interested in making a career strive to be elected, and so on. I have never belonged to any such bodies; they are a ghastly waste of time. Let us just imagine what would happen if we set up a national bread service. People would not be able to buy a chapatti of choice: they would only be able to buy white bread, sliced or unsliced. That would be it. We buy our food from Tesco stores, and do not expect questions to be asked in Parliament if we get an addled egg.

I turn to the document The NHS Plan, and draw noble Lords' attention to paragraph 10 of its preface, which begins with the words: The NHS will respect the confidentiality of individual patients". Nevertheless, we had the Rose Addis case a while ago—something that is still considered one of the great disgraces of recent times. A patient's case was discussed in Parliament, with no one pointing out that it was not correct to do so.

Similarly, on page 15 of the report, in the "Introduction by the Secretary of State", we find the following words: At its heart the problem for today's NHS is that it is not sufficiently designed around the convenience and concerns of the patient". Hurrah! So let us do something about that situation. But we have to wait until we reach page 89 of the report before patients are discussed. Under the heading of "Changes for patients", we find a suggestion that is much to my liking and one that I should like to commend; namely, smart cards for patients, allowing easier access to health records". I should like everyone to have a smart card.

If, for example, I wanted to change my GP, it would not be easy to do so. I live in Hastings at the weekend, and live in London during the week. I should love to have two GPs, but I can assure noble Lords that it is complicated to find a GP who will take you on his books on that basis. Why? The system that we have established is producer led. However, a smart card system would not be difficult to introduce. You do not have to violate the principles of universality, or those relating to services being free at the point of use, in order to give every patient a smart card. Patients would feel that they had choice. They could use the card to telephone someone and gain access to their health records. We can do that in every other walk of life; but we cannot do so in the service that belongs to all of us.

I remember the debate surrounding council houses—namely, that they should not he sold. Similarly, council tenants were not free to choose the colour of their front doors, because the council would not allow them to paint doors any way that they liked. Indeed, members of my party used to think that it was a socialist principle that council tenants should not be able to choose the colour of their front doors. So I know what I am saying. That was trivial. But, thanks to the party opposite, it was subsequently decided to sell council property. In doing so, people became aware of choice.

In the next 10 years, if not before, I should like to see the development of a real sense of ownership by patients. They should genuinely feel that they can take their identity and go somewhere, plug into the system, and be able to call up someone to access a service. It should not be a top-down system. I do not believe that we need patients' advocates in hospitals. Patients need access: they need to be able to call up different people to gain access. If we can provide that kind of service and combine the free-at-the-point-of-use and the universality principles with patient ownership, that would be a brilliant 10-year plan—except that I hope it can be achieved in four years. All good 10-year plans have to be achieved in far less time.

4.45 p.m.

Baroness Howells of St Davids

My Lords, I am grateful to the House for allowing me to speak in the gap. I promise that I shall be brief. I should also like to thank my noble friend Lady Pitkeathley for sharing her health experiences with us; and, indeed, for initiating today's debate. Mary Seacole, who was a nurse at the time of Florence Nightingale, would say that my noble friend is a credit to good ministration. That is what reform of the National Health Service is about.

This morning I spent two hours with a group of senior citizens, who did not share the doubts about the reform of the NHS. They want a good, reformed National Health Service. Their past experience of it has not been very good. Their expectations are genuine and realistic.

There can be no doubt in anyone's mind that the Government inherited an NHS that existed almost only in name. Hospitals throughout the country were closed and those still standing were under-staffed. Medical and social care moving into the private sector was the expectation. A few years on, we know that there are relatively few issues in the nation that command more public attention, induce more fear and frustration and pose a greater threat than healthcare. Daily, we see highly publicised cases of horror stories throughout the country.

Therefore, it must be a matter of public interest that the Government have set out a 10-year plan of reform to bring the health service to the people—a service that is free at the point of use. No matter whether one is rich or poor, healthcare is available free of charge. The plan is one of reform and investment, with clear national standards: devolution of resources, more choice for patients, and greater flexibility for staff. The Government's investment will provide more nurses and doctors, new and improved hospitals, and primary care centres. All this will work only if we are both bold and swift with such reforms, which is what the elderly people with whom I spent time this morning wish us to be. That is why the Government's plan to establish a commission for healthcare audit and inspection is vital to ensure that higher standards of care for people in this country are easily achieved.

We know that the proposed commission will be independent of the NHS, so that it can objectively assess every part of the health service. Her Majesty's Government have acknowledged that the health service can no longer be run from Whitehall. They recognise that it serves different communities, and that to serve them well there must be a devolution of power. The services must be local at every point of need to patients, to his or her doctor, and to the local community. Those working at the local hospital must be the ones who are making the real decisions, thereby providing local accountability. That is why the establishment of local primary care trusts is such a bold and brave move in the reforms.

There is also a radical change in nurse training. The new powers given to nurses will enhance their standing and free up doctors to do the things that doctors do best. I welcome the reform of the National Health Service.

4.50 p.m.

Baroness Finlay of Llandaff

My Lords, I, too, am most grateful to the House for letting me speak in the gap. I also congratulate the noble Baroness, Lady Pitkeathley, on her anniversary and thank her for introducing this important debate. In the words of my grandmother, I wish her health and happiness—health must come first, for without health, it is difficult to have happiness.

I passionately believe in the NHS. I do not want to work in a system where I must send the bill to the bereaved or cease treatment because insurance runs out. No government can be unaware that, as we drive up standards in primary care, we increase pressures on secondary care. In my university hospital, open access to MRI scanning from primary care has now meant that neuroradiologists cannot cope. They are drowning under request forms. Capacity is a major problem. It was previously identified in intensive care units and studies have shown that pre-intensive care admissions management of patients significantly alters outcome.

We need concrete milestones to mark the ambitious changes that are planned, but it is through training and retraining that standards will be driven up. I have just come from an exciting study day on ethics at the Royal Society of Medicine, and I reassure the noble Lord, Lord Desai, that patients' views and wishes in planning their care were absolutely at the centre of the debate and taken as a given. There was no dispute that patients' views must be paramount.

But research is also needed and must be safeguarded in our new NHS. It identifies the root causes of disease and evaluates service changes that have been introduced. A recent example of great importance is the awareness of nutrition to the foetus: smaller birth weight babies are at greatly increased risk of developing diabetes. So care at one point avoids storing up problems for the future. But research needs support. Only 8 per cent of cancer patients in this country are in trials. The proportion should be much greater—I should like it to be nearer 80 per cent—if we are to make major breakthroughs. That research must be collaborative. The recent research assessment exercise has sadly done little to promote research and has ended up with departments that scored lower than a five feeling demoralised and risking losing funds.

We hear about the increased number of students to provide the workforce of the future in medicine, nursing and other healthcare professions. That education needs protected resources: teaching premises, equipment and clinical academics to teach. It must be a duty on all providers to promote education, training and research. I know that there was great jubilation at the reassurance given by the noble Lord, Lord Hunt of Kings Heath, that there will be university representation on strategic health authorities. I sincerely hope that the same will be reflected in Wales.

The noble Lord, Lord Turnberg, highlighted the damaging bottlenecks in training that will continue to demoralise keen young doctors who are unable to pursue the career to which they feel inspired. Another problem is early retirement. We are losing enormous wisdom that could do much to help the clinical teaching, ongoing training and research that are so important. I urge the Government and the Treasury to consider how to encourage flexibility in retirement, so that people could retire without their pensions being jeopardised and their wisdom used in the NHS for another five to eight years to meet those education, training and research requirements.

4.54 p.m.

Baroness Northover

My Lords, I, too, would like to thank the noble Baroness, Lady Pitkeathley, for so effectively introducing this excellent debate. Please excuse my sneezes and sniffles, but I know from the Government's excellent public health campaign that there is no point my going to see a doctor. Perhaps my expectations are suitably low and the right reverend Prelate the Bishop of Guildford will approve.

We can examine the issue on two levels. The first is from the principle of the National Health Service free at point of need and available to all. It is clear from the contributions to this debate that there is overwhelming commitment here to that. We must remember that that has not always been the case, and is not always so even now. I welcome the fact that the principle is widely shared here. The noble Baroness, Lady Pitkeathley, is right to emphasise the value and worth of the NHS. My experience of other health systems is that they are often excellent for the haves but hopeless for the have-nots. That reinforces my support for our NHS.

The noble Baroness, Lady Gardner, is right to highlight dentistry. That should stand as a cautionary tale of what can happen when services are not universal. Dentistry was never properly integrated into the NHS, and now only 47 per cent of people are on an NHS dentist's list. Given the vital importance of dental care in preventive care, dentistry should surely be far higher on the Government's agenda. That would show a real commitment to universal service.

The second level of the debate refers not to the principle of the NHS but to the National Health Service as it is today. Here, as we have heard, the picture is much more complicated. When, in his most recent Budget, the Chancellor finally agreed to give increased funding to the NHS, a large majority thought that that was the right thing to do. However, only a small minority thought that it would make any difference.

For years, the Conservatives underfunded the NHS and, timidly, when first elected, the Labour Government followed Tory spending plans. It is not surprising that things went from bad to worse in the health service, and the Government seem surprised at how long it takes to turn things around. We seem to have initiative after initiative, reorganisation after reorganisation, in the hope that that will achieve rapid improvements in the quality of service provided by the NHS.

As my noble friend, Lord Clement-Jones, argued, those initiatives may be well-meaning, but constant change becomes in itself disruptive. Organisations are set up to report on parts of the service and visit after visit has to be prepared for. Targets must be met and budget deficits filled.

So what is required for the NHS to flourish? Funding, certainly, and I trust that we are now moving into a more positive era. I welcome that. But the NHS also needs stability and consistency, which has been remarkably lacking. Right now, in the last stages of its progress, there is a Bill which is intended to achieve things that have already been overtaken by a new document with new plans for organisations that have barely come into being. Can the Minister tell us whether stability and consistency will ever be recognised as themselves having value?

Most importantly, we must address the issue of NHS staff and their morale—a theme that has run through our debate. Surveys have shown how far morale has fallen. With insufficient staff there is too much pressure on those remaining in the service. The Government have necessary and ambitious plans to expand the number of doctors, nurses and other staff. But we know that there are insufficient clinical academics to teach the new medical students. As the noble Lord, Lord Turnberg, and the noble Baronesses, Lady Gibson, and Lady Howells, have said, we must address the needs of the staff. We need more flexibility, less central control and more involvement.

The time has surely come to focus on people, not structures: the people who staff the NHS and, most importantly, as the noble Lord, Lord Desai, said, the patients who use the NHS. No one has yet cracked that problem. The paternalistic but so welcome NHS of 1948 must move into a different era—one that is more patient-centred and finds ways to involve patients. Like the noble Lord, I am sceptical whether the myriad structures to which we have agreed in the Bill and which are about to slot into place will achieve that—although of course we made major improvements on the way.

It is excellent that we all share a commitment to a universal NHS. We differ on how to deliver an improved service for the 21st century.

5 p.m.

Earl Howe

My Lords, we can agree that it has been a particularly good debate on a subject in which all of us, in one way or another, have a personal and abiding interest. There can be few better among your Lordships to introduce such a Motion than the noble Baroness, Lady Pitkeathley. I congratulate her on having done so in a manner that enabled her balanced perspective and experience to shine forth.

Listening to the speeches today, I have been conscious of something that, perhaps, we concede too seldom. Although there is much in health policy that divides one side of the House from the other, there is also a good deal—perhaps, an increasing amount—that unites us. One such issue is the critical importance of service quality in all branches of healthcare. I agree with the noble Baroness that we have world-class physicians and some state of the art facilities. Our staff are hard working and dedicated, and most patients get good treatment and good care. The trouble is that people must wait, sometimes for a long time, for elective surgery. Even more seriously, outcomes in Britain for the killer diseases, where they really matter, are poorer than in other European countries—not just slightly poorer, but a great deal poorer. For cancer alone, it is estimated that if Britain could achieve the survival rates of the best countries in Europe for each cancer, over 25,000 lives a year would be saved.

Two years ago, the NHS Plan represented, by any standards, a sweeping and ambitious blueprint for change in the National Health Service. It contained an impressive array of targets for more facilities, additional staff, new systems of standard setting, new ways of working, better access for patients, better health outcomes and so on. However, it had one common and obvious aim—namely, to enhance quality and to make the NHS more responsive to the needs and wishes of patients. The objective of creating a patient-centred health service, which delivers the highest standards of care, is not something about which government and opposition have any need to argue. The argument begins only when we consider the means to achieve the end.

I have no doubt that the Government are right to say that there are two basic ingredients to improving the health service: one is money, and the other is reform. The trouble is that on the basis of what the Government have done—or said that they would do—I am on both counts something of a sceptic. In fact, one could say that I am something of a wet blanket. I do not like being a wet blanket. The recent Budget set out the Government's commitment to raising substantially the level of health spending over the next six years, over and above the levels previously announced. The White Paper published the following day laid out more of the landscape of reform as the Government envisage it. It is a landscape of greater devolution from the centre, greater patient choice and tighter accountability. What could possibly be wrong with that?

What is wrong with it is that, in key respects, the reforms do not look to go far enough. For example, despite devolution of the NHS budget and the much-vaunted shifting of the balance of power, the system itself is still, in essence, the centralised Bevanite structure of old. Strategic health authorities will, I fear, be the instruments of Richmond House in most key areas of decision making. The multitude of centrally driven targets and directives will still be very much a feature of NHS life.

The NHS Plan says that, For the first time, patients will have a real say in the NHS". However, if we analyse what is on offer, we find that choice for patients will not be genuine choice, merely an ability to express their views and hope somehow that they are heard. We shall still be light years away from the sort of real choice open to patients in other European countries, who can freely elect where they wish to be treated and by whom. The White Paper, Delivering the NHS Plan, talks the language of patient choice, but the conditions necessary for a genuine diversity of provision are not being created, and the inefficiencies and waste in the system will not have been tackled. Even at the end of the reform process, patients will still wait to receive treatment for what, in other parts of Europe, would be regarded as an unconscionable time. The Government have not recognised that the retention of a command and control structure is not compatible with real patient empowerment, nor with the need to give professionals the freedom to get on with the job that they are qualified to do.

Of course, I am delighted that the Government have recognised some of the basic building blocks of patient choice. One is the establishment of a system in which the money follows the patient. Another is the creation of additional capacity. Ministers are fond of rubbishing the internal market created under the last Conservative government. I would not argue for the re-creation of that system in all its glory; it had obvious faults and shortcomings. However, the least that we should do, in a mature debate, is understand and acknowledge what the internal market tried to achieve. It tried to make the system more responsive to the wishes of patients and, in the process, deliver better care. It could have been done better and less bureaucratically, but the central principle was valid. It was certainly not something wicked or immoral, as Ministers have sometimes painted it.

I do not know precisely how the Government will see to it that money once again follows the patient, as they have promised, or that there really will be a plurality of healthcare providers. However, assuming that both aims are somehow met, it would take a linguistic contortionist to deny that the result was a market in all meaningful senses. It is a pity that Ministers will not admit that; it would lead to a more grown-up discussion if they did.

An integral part of a patient-centred service is patient representation. It really is extraordinary that in the White Paper, Delivering the NHS Plan, no mention is made of the Commission for Patient and Public Involvement in Health. That makes me wonder how high the issue of patient representation is on the Government's agenda. Today is not the time to repeat the arguments that we had in Committee and on Report on the NHS reform Bill, but, unless the provisions in the Bill for patients councils are retained and other improvements made, we are likely to end up with a patients' voice much weaker than it is at the moment. There will be no lay overview and no ability to lobby or speak out—or, indeed, to get anything done. To the noble Lord, Lord Desai, I say that my logic on the matter is simple. If there is a state-funded monopoly provider of healthcare, the system is very powerful, and the dice are loaded against the consumer. To counterbalance that, the least that we should do is ensure that the consumer's voice is properly heard.

I am not a complete wet blanket. I do not, for a minute, belittle the improvements to service quality that the Government may achieve. All such improvements will be welcome. But how soon will they be delivered? If we examine the targets set out in the NHS Plan, we see that the pace of progress is worryingly slow. IT is an essential part of delivering the plan. The target was for 35 per cent of trusts to have introduced electronic patient records by April 2002. Only 3 per cent of trusts had actually done so. Money is so tight that supposedly ring-fenced IT budgets have been raided for other purposes. On hospital cleanliness, we are still a long way behind every other European country, as regards the prevalence of drug-resistant bacteria. On GP recruitment, where the target is to have another 2,000 doctors in post by 2004, the increase in both 1999–2000 and 2000–01 was precisely 18.

The Government say that they have already achieved their target for nurse recruitment, but a high proportion of new recruits are not full-timers, and there is still a big problem with nurses leaving the NHS. In mental health, the picture is very worrying. Practically no progress has been made in, for example, putting crisis mental services in place or recruiting new staff to help carers. The Audit Commission recently described the task of delivering the national service frameworks for mental health as great.

Overall, the number of patients being treated by the NHS is not increasing. The waiting list figures focus on in-patients, where there has been some progress, but conveniently ignore the considerable rise in out-patient waiting times. I could continue because there are some worrying areas. We all know that easing those pressures will depend critically on an expansion of capacity in both acute and intermediate care.

The Government are placing a lot of reliance on the private sector to provide the extra capacity. However, the private sector needs confidence to invest and I am afraid that the Government are simply not giving it that confidence. For example, there is still no agreement on one of the key building blocks for capacity growth—the consultant contract.

I have concentrated on some of the problems merely to point out that, with the best will in the world, the targets in the NHS Plan are difficult ones. The Minister may find it odd that I should be wishing the Government well in their efforts. I do so genuinely because the NHS, despite what may have been said today, does belong to all of us. However, the Government will be judged not on their efforts but on their success against the objectives they have set. Time will tell whether the route they have chosen is the right one.

5.11 p.m.

The Parliamentary Under-Secretary of State (Lord Hunt of Kings Heath)

My Lords, I, too, congratulate my noble friend Lady Pitkeathley on her initiative and, indeed, the high quality of her opening remarks. She said that it was the anniversary of her miraculous recovery and all noble Lords were delighted when she returned to your Lordships' House. The benefit today has been for all to see and hear.

I agree with my noble friend Lady Gibson that the NHS is one of our greatest achievements. I also agree with my noble friend Lady Howells that the expectations of the public are very real and very genuine and that they represent an incredible challenge for all those working in the National Health Service at the moment. The Government have clearly defined the direction of travel for the NHS. The NHS Plan, published in July 2000, is a 10-year programme. I believe that it provides the context, the stability and consistency that the noble Baroness, Lady Northover, asked for.

I say to my noble friend Lord Desai that in a sense I disappoint him because it is a genuine 10-year plan. One simply cannot turn around the NHS overnight. So much depends on getting the infrastructure right that I believe we are justified in setting out a long-term plan in the way that we have done. When it was published the Government made it clear that radical improvements in the NHS would require both a sustained programme of investment and reform. That is surely the message of the Budget and the implementation of the plan programme that my right honourable friend the Secretary of State announced.

There is, of course, much more to do. The effect of decades of under investment still take their toll on services. However, investment and reform are delivering benefits to patients. I say to the noble Earl, Lord Howe, that the figures show that health outcomes are improving. In the past year alone, death rates from cancer are down by 2 per cent and from heart disease by 5 per cent. Of course, we have to do more, but at least we are moving in the right direction.

Waiting times are falling. A number of noble Lords have mentioned that patients are seeing the benefits of booked admission systems which give them greater choice and convenience. Capacity constraints—not enough staff, inadequate facilities and equipment—have bedevilled the NHS for years. We are beginning to put that right. Staff numbers are increasing. The noble Earl, Lord Howe, was a little negative about the increase in the number of nurses. The number has increased by over 20,000 in just two years, achieving the NHS Plan target two years early. The number of doctors is increasing as well.

As my noble friend Lord Turnberg says, and I accept, we need to do more to retain nurses and doctors. Our approach to more flexible working practices is surely the right way forward and we will need to invest more in flexible working and child support. As the noble Baroness, Lady Finlay, suggested, we are looking at ways in which we can prevent the unnecessary early retirement of doctors. As my noble friend Lady Gibson also suggested, in so doing we have to listen to staff. We are working with them. We are in important discussions about new contracts for GPs, consultants and the rest of the workforce. It is important that we take the staff with us.

Extra investment, coupled with the work of the National Institute for Clinical Excellence, is helping us eliminate the post-code lottery for prescribing of drugs. In primary care, prescribing of cholesterol lowering drugs is up by one third. Tens of thousands of patients are receiving the latest drugs to combat cancer, heart disease, arthritis and Alzheimer's. I say to the noble Lord, Lord Lyell, that in relation to beta interferon, the National Institute for Clinical Excellence has reported that while it found that the beta interferon drugs were not cost effective, they did recommend discussions between the department and companies. The issue has been resolved. Patients coming into the agreed guidelines can now receive the drug, consistent with the guidelines published by the recognised professional association. That will lead to consistency across the country.

For the first time we have seen an increase in the number of hospital beds. The go-ahead has been given to 68 major hospital building projects since May 1997. Thirteen have been completed and a further 15 are under construction.

I listened with great interest to the noble Lord, Lord Selsdon, describing his experience in the building of six hospitals under the PFI scheme. I would say to him that the original problems with PFI have largely been resolved. He is right; the PFI unit is issuing very good guidance to the NHS. Certainly, from my visit to a number of hospitals where they are embarking on major capital schemes with private sector partners, I believe that the NHS has learnt a lot and has considerably more expertise to act as an effective partner with the private sector.

Certainly, we want to encourage the public sector to be entrepreneurial in the way it conducts its business. That is why, when I talk about foundation trusts later, I shall say more about how we can get the conditions right so that those kind of public private partnerships do become as effective as possible.

The noble Lord, Lord Lyell, also referred to the pharmaceutical industry. I agree with him. Making the NHS an attractive base for the industry to work in partnership with is very important. The research-based pharmaceutical industry in this country is responsible for approximately one third of all commercial research and development investment in the United Kingdom. It is essential that we provide the right competitive base for that industry to thrive.

I agree with the noble Baroness, Lady Finlay, that part of a responsible effective partnership is to ensure that the incentives are there so that clinical trials can take place in this country and, in fact, to ensure that there are more in the future. That is one reason why the Government have produced new guidance in relation to research governance to try and clear up some of the problems in terms of obstacles to getting good clinical trials under way in England.

The noble Earl, Lord Listowel, raised a number of important points concerned with infant and child mental health services. We accept the importance of those services and of recruiting the professional people required. We also accept that our workforce planning mechanisms must take that into account as much as they would take into account other professionals, whether in acute services or in primary care.

The noble Baroness, Lady Gardner, knows that dentistry is a subject dear to my heart. I, too, pay testimony to the quality of our dental profession. It is a high quality profession. I believe that the dental strategy sets the right tone, consistent with the NHS Plan, for taking forward the progression of the service to the public. I believe that dental access centres have proved popular and effective. I say to those members of the public who have problems with access that their immediate course of action should be to ring NHS Direct, which will do everything it can to refer them to a dentist performing NHS services.

Very important discussions have taken place between the profession and the department looking at some of the issues that the noble Baroness raised in relation to fees, workload and the treadmill, as dentists are wont to call it. Those discussions have been most fruitful. It was recently announced that demonstration sites will be set up to test out some of the ideas and a final report is expected to be published in due course. As regards the noble Baroness's specific question, perhaps I may assure her that we remain fully committed to ensuring that the full range of dental treatment necessary to restore good oral health will remain available on the NHS.

Dentistry is but one of the many significant developments taking place. All of that is underpinned by new arrangements to enhance service standards, accountability and devolution of power to frontline staff. That is why national service frameworks are so important. That is why the Modernisation Agency has been established to set up and encourage good practice systematically.

Those are all significant developments. The NHS Plan is working, but no one could kid himself that everything is now perfect. The importance of the extra resources for the NHS and social services announced in the Budget is that they allow us to go further in driving forward the programme of reform. As the noble Lord, Lord Clement-Jones, said, that is a massive commitment to the NHS.

What improvements will that extra resource buy? The scale and significance of the investment demands as a minimum that we address two issues. First, we must set out clearly what the extra money will buy in terms of improved service quality. Secondly, my noble friend Lady Pitkeathley spoke of the situation pre-NHS. We have also to recognise that an NHS built in the 1940s must be reformed, as my noble friend so recognised. Without radical action now, we will not gain the maximum benefit from high and sustained levels of investment.

Perhaps I may deal with the first of those two issues. People will see tangible improvements in the quality and convenience of services. We will focus special effort on reducing waiting times for treatment because that is clearly the public's principal concern about the NHS. Faster services will support our objective to improve the nation's health and tackle health inequalities. We aim to reduce deaths from cancer by implementing the cancer plan's improvements to the prevention and treatment services. We aim to save around 25,000 lives by 2008 by investment and reforms in prevention and treatment services for coronary heart disease. We aim to improve mental health by ensuring that by 2008 every patient who needs it will have access to round-the-clock crisis resolution and assertive outreach services. We also aim to support a further 100,000 older people each year by 2006, enabling them to live independently at home, through extra intermediate and home care services. We are not putting aside public health. There will be greater focus on prevention and health inequalities. The extra money will allow a step-change in capacity for which many noble Lords have called.

The scale of reform goes wider. I want to flag up the key points of the programme and answer many of the substantive points made by noble Lords. I turn first to patient choice. As capacity expands, so will patient choice. From this summer, patients who have been waiting six months for a heart operation will be able to choose from a range of alternative providers who are able to offer quicker treatment. We will roll out this new approach to other clinical conditions, beginning in London later this year. By 2005, all patients and their GPs will be able to book appointments at both a time and place that is convenient to the patient.

The noble Earl, Lord Howe, tempted me to respond to him on the internal market and I shall do so. Living through the internal market, I have no doubt whatever that its fundamental precepts were fatally flawed. It was very bureaucratic. The money did not follow the patient; the patient followed the contract. It was blatantly unfair to non-fundholding, practices and it was done in a complete absence of national standards and information on which patients could compare one hospital with another.

That is the big difference. We have provided national standards through NICE, through national service frameworks and through an independent inspectorate. We are providing information to patients. We are providing choice for all patients and not just a lucky few. Our proposals for foundation trusts will surely provide the right kind of freedoms and flexibilities within the proper ethos of the NHS.

The second point I want to make is that choice will be underpinned by new incentives. The problem with the NHS over so many years is that the hospitals which do best are often seen to be penalised by the funding regime put in place. That is why we want the hospitals which have the capacity to do more to be able to earn more resources as the money follows, not the contract, but the choice made by the patients. Over time, we intend to develop a system in which the price of individual treatment is based on a regional tariff, allowing local commissioning to focus on the volume, quality and appropriateness of care.

Of course I understand the points made by my noble friend Lord Turnberg about poorly performing hospitals. Of course they need understanding and support. That is why we have the Modernisation Agency. However, we must also root out poor performance. We cannot remain in a situation in which we tend to think that all NHS hospitals are similar and that all NHS hospitals must be treated in the same way. We must distinguish and provide the right incentives for good performance.

As regards the devolution of power and resources to local level, I shall not respond to the issues of patient empowerment. We have debated the matter frequently and I look forward to debating it again when the Bill comes back from another place—as assuredly it will! However, I want to respond to the point referred to by both the noble Lord, Lord Clement-Jones, and the noble Earl, Lord Howe—their allegation of centralisation.

At the weekend, I spent an interesting day analysing the amendments which both noble Lords tabled on Report and in Committee during debates on the NHS reform Bill. I found that the majority of their amendments, far from decentralising power, centralised power, giving more to the Secretary of State or to strategic health authorities. I must say that the experience of the NHS under the previous government was not of an administration hell-bent on decentralisation. I well recall the study by the Oxford Regional Health Authority which discovered that the previous government in their priorities for the NHS had 57 different ones—which meant that there was no priority.

I believe that the NHS Plan gives us the right condition for setting out the core priorities for the NHS. Taking that with the national standards and with an independent inspectorate, we can allow so much more freedom at local level. That is what foundation trusts are all about. We want greater local ownership of those organisations and we believe that that is the best way to incentivise performance.

Within those organisations, we too want to see devolution. My noble friend Lady Gibson and the noble Baroness, Lady Masham, referred to modern matrons. The reason for developing those roles is to give to nursing staff more authority at the level of the ward so that they can run the ward in the interests of patients.

I suppose that that response is also the answer to the question posed by my noble friend Lord Desai: whether the NHS belongs to the patients or to the staff. There is no question about it: the NHS has often displayed the characteristics of a producer-orientated health service. However, I think that the new services such as NHS Direct, booked admissions and the rapid chest pain clinics demonstrate that the NHS can provide services which focus on the individual patient. My noble friend Lady Finlay suggested that professionals are also responding to the need to do so.

We also wish to break down the barriers between health and social care, which is why we have introduced these new incentives. As my noble friends Lady Pitkeathley and Lady Gibson pointed out, we have to break down rigid organisational barriers. We must also ensure that accountability is strengthened, both nationally and locally, as well as ensuring that the ethos under which the NHS conducts itself is conducive to the everlasting fundamental principles of the NHS, while allowing much greater room for manoeuvre and leadership at the local level.

The right reverend Prelate the Bishop of Guildford put the debate into perspective when he spoke of his experiences in Africa. There people desire peace, clean water, education and to be able to grow good and wholesome food. It is necessary to reflect on just how well off we are with our National Health Service when compared with so many other countries. But that does not mean that we can be complacent. And, as was suggested by the right reverend Prelate, in turning around the National Health Service and in making it much more responsive to the public, we in turn have a right to expect the public to be responsive to and responsible for the service. We want to stress patient responsibility.

In addition, we want to utilise other areas of the NHS to provide services where they are most able. For example, I am convinced that our high street pharmacists could do a great deal more in giving advice to the public. I also believe that the establishment of NHS Direct, conferring greater responsibility on nurses and giving more responsibility to the other professions, will ensure that we provide the responsive service to meet those extra demands.

Our debate has centred on the Government's programme of reform, and rightly so. I had hoped that it would also shine a little light on the proposals of the party opposite on health. Alas, that was not to be. So we have concentrated on this Government's approach: that of matching investment with reform.

I have no doubt that this is the right approach. The signs of improvement are already showing. We have the commitment of the NHS behind our proposals. I have no doubt that, given the Budget announcement and the resources and the commitment being brought to bear on the service, we can deliver the NHS that we all want, an NHS that gives a world class service.

5.33 p.m.

Baroness Pitkeathley

My Lords, it has always been apparent to me that the NHS arouses great passions: positive, negative and, sometimes, even sceptical ones. That has been made clear once again in our debate today. I am most grateful to all noble Lords who have spoken. The quality of their speeches has been outstanding. I was struck by the wide-ranging nature of the contributions, in particular by the fact that so many noble Lords put health into a wider, societal context, reminding us that improvements in how we treat illness must in the end be dependent on how we nurture and cherish the health of our society.

On that last point, I was also struck by the links between the two debates set down for today. It has been my experience that usually our Wednesday debates address totally disparate topics. However, some of us will go on to debate the relationship between sport, health and social inclusion. Again, that marks a recognition of the links between lifestyle and quality of life.

I should like to thank noble Lords on the Opposition Front Benches for permitting the inclusion of two extra speeches in the gap. Furthermore, I should like in particular to thank my noble friend on the Front Bench for his full and thoughtful response to our debate. His skill and experience are much admired on all sides of your Lordships' House. His response today has given a clear indication of why he is so admired.

Once more, with my thanks to all noble Lords who have spoken in the debate, I beg leave to withdraw my Motion for Papers.

Motion for Papers, by leave, withdrawn.