HL Deb 23 June 2004 vol 662 cc1249-329

3.27 p.m.

Lord Hunt of Kings Heath

rose to call attention to Her Majesty's Government's policies on healthcare and on public health; and to move for Papers.

The noble Lord said: My Lords, I declare an interest as an adviser to KPMG and Beechcroft Wansbroughs, and as chair of the National Patient Safety Agency. I have a number of other health service interests, which are declared in the Register of Lords' Interests.

It is a great honour to move the Motion today and take part in this debate about the National Health Service and wider aspects of public health in this country. I am delighted that such a long and distinguished list of speakers will take part in the debate. I particularly welcome my noble friend Lord Drayson, who will be making his maiden speech. He is a great innovator and entrepreneur, and has done wonders for the biotech industry in this country. We look forward with great anticipation to what he has to say today.

One of my noble friends who, sadly, is not able to take part is the noble Lord, Lord Bruce of Donington. However, through the kind auspices of my noble friend Lord Graham, he has written me a letter, and I would like to start by quoting a couple of paragraphs from it. He says: The National Health Service is the culmination of over one and a half centuries of effort starting in the little mining village of Tredeger in South Wales by working miners who banded together in the local miners' lodge to pay the local medical practitioners some 6d per week per member to obtain medical attention … From such a small beginning and after a political struggle against extremely powerful interests and that of the organised medical professions"— some things do not change— Aneurin Bevan, was appointed by the Prime Minister Clement Attlee, the first Labour Prime Minister following World War II, to be Minister of Health charged specifically with the mammoth task of establishing a National Health Service for all the people, to be free of charge to those wishing to use it and to be financed out of general taxation".

My noble friend Lord Bruce is well qualified to remind us of those heady days for, on 30 April 1946, he sat behind Nye Bevan—who I guess sat where the noble Earl, Lord Howe, now sits when this Chamber was used by the House of Commons as a temporary home—when he moved that the then NHS Bill be read a second time.

Noble Lords

No, he sat on this side.

Lord Hunt of Kings Heath

My Lords, I think I am right because, without entering a debate about the arrangements in 1946, the furniture was moved around to replicate that of the House of Commons. I have authentication of that from the noble Lord, Lord Bruce.

What a heady day that was, when Nye Bevan moved the Second Reading. He presented his vision of the National Health Service that he wanted. He talked about an NHS that would lift the fear of the financial consequences of illness from millions of people. He talked about a service that would relieve suffering and that would keep many people alive who otherwise would have died. He talked about a higher standard of practice from the medical profession. He said that the NHS would make a great contribution to the well-being of the people of this country. Whatever the problems and struggles that the NHS has had over the years since it was formed in 1948, who could doubt the legacy of the Bevan vision? Millions of our fellow citizens have had good reason to be grateful for the NHS over those years.

Nye Bevan was a visionary, but also a realist. In that debate he pointed to some of the problems that would face the NHS when it was established. He talked about the shortage of nurses, of facilities and the uneasiness of the health services that existed just after the Second World War. For all of the achievements of the NHS, if he had been alive in 1997, when this Government came to office, he would have recognised still many of the problems facing the National Health Service.

All governments when they first come to office open up the books and declare that things are much worse than they had thought. But in the case of the NHS, that was exactly the case in 1997. I say that as someone who has worked in the NHS for many years. I do not think that anyone realised the critical position that the NHS faced. It had suffered from years of under-investment. It had real problems in attracting doctors and nurses. The decision of the previous government in the early 1990s to reduce nurse training places was having an enormously harmful kickback in terms of recruitment and retention of nurses. The issue of capacity was serious: hospitals were operating at such an intense capacity—at 90 to 95 per cent use of beds in many acute hospitals—that the system was creaking at the edges.

The issue of patchy services and postcode prescribing was one that was remarkable after 55 or so years of a national health service. Ian Kennedy, who wrote the Bristol children's inquiry report, summed it up when he said: What marks out the NHS, is that successive governments have made claims of excellence which simply have not been realisable, given the funds allocated". That is the real background to the NHS Plan and the programme that the Government have pursued. The NHS Plan was recently described by the Nuffield Institute for Health as, the most ambitious, comprehensive and intentionally-funded national initiative to improve health care quality in the world". It was just that and we are now beginning to see the emergence of a much enhanced health service, one that is much more confident about what it is doing and a health service in which the public can have much more confidence.

For the first time we are seeing national standards developed so that there will be much greater consistency of provision throughout the country—national service frameworks, the development of the National Institute for Clinical Excellence and the establishment of an independent regulator, the health commission. All of those are aimed at driving up and giving consistency of standards throughout the NHS.

Regarding capacity, for the first time in at least 20 years we have seen an increase in the number of general and acute beds. But the improvement has not just been in acute care. In mental health the development of assertive outreach as a policy to enable people to be cared for in the community has been an outstanding success. NHS Direct is used by millions of people every year. It is innovative and a world beater. It is also a characteristic of what we are seeing in the NHS, of a service that other health care systems are looking to follow and learn from.

Staff improvements have meant over 50,000 more nurses and 15,000 more doctors since the NHS Plan was conceived and developed. Those are notable achievements. Waiting times, perhaps the most visible indicator of any healthcare system, this March hit the nine-month maximum waiting time target for in-patient waits. It is not long ago that waits of up to two, three or even four years were the norm for many patients. Over the next three years acute waiting lists in this country will be virtually eradicated.

We have seen great investment. It is almost unbelievable that after years of under-investment, by 2008 the GDP spend on health will be 9.4 per cent, which is equal to that of the French. We are in the middle of a five-year programme of 7.4 per cent real growth per year. That is a remarkable achievement. It is not just a question of input, but what one gets for it. For me, the most pleasing indicators of progress have been in relation to cancer and coronary heart disease, where we are now beginning to see the corner turned—better outcomes and fewer people affected critically by those terrifying diseases.

Only a month ago the NHS Modernisation Board said that: throughout the NHS, there are dramatically different and better services compared with four years ago, many as a result of a rethink, a change in attitude and culture". In my home patch—Birmingham and the Black Country—I see a service that is second to none and where there has been a 25 per cent increase in the number of nurses since 1997 and a 27 per cent increase in the number of doctors. There have been real improvements in reducing deaths from cancer and coronary heart disease and there are only 364 patients waiting for more than six months for in-patient treatment. If my noble friend the Minister would give Birmingham and the Black Country a little more money, the waiting lists could be reduced even more quickly there. No doubt the residents of Hodge Hill in Birmingham would take note of that.

The health service is making progress, but there is no room for complacency. Nye Bevan said: The service must always be changing, growing and improving". The health service has to move on. It is not just a matter of waiting lists, although they are important; it is about the quality and safety of service. It is about choice. Indeed, it is about how we can develop a service that is more agile and focused on the individual needs of patients. So we need to move on and see some changes in approach. I welcome the intention to refocus the role of government essentially around funding, the setting of key priorities, ensuring independent regulation and then leaving much more space for the NHS at local level to do what it does best—to innovate and really make the services first rate for the people of this country.

That is why I welcome so much the creation of foundation trusts. That is a strong move to make local NHS organisations accountable to local people. Again, I refer to my local trust, the University of Birmingham trust, which has thousands of local people in its membership. There is a real linkage between the hospital and the people whom it is there to serve.

I say to my noble friend Lord Warner that, hand in hand with local ownership of our hospitals, we need to strengthen the commissioning function of primary care trusts. They have a mammoth task to perform and I hope he can say a little more about how we can strengthen the commissioning function and ensure that the commissioning primary care trusts will be engaged with the local community and develop more local legitimacy.

The title of the debate before us relates both to the NHS and to public health and today many noble Lords will talk about public health issues. I welcome that. As the NHS gets better and better, it gives us the space to concentrate on public health, in particular to reduce the still frightening gap between the health expectancy of poor people and that of more well-off people in our society.

A White Paper on public health is due in the next few months and it is hard not to detect a certain tension between those who believe we should focus on people's individual lifestyle and emphasise messages on health education—for example, on smoking, drinking and food—and those who believe that a collectivist approach is required. I suspect that ultimately there is a balance. There will always be room for individual messages around personal lifestyles to help people to take decisions to improve their health. But if we really are to tackle the gap in health between the well-off and the poorer in society, the real way to do it is to tackle the gap in society itself. I have no doubt whatever that that goes to the heart of the issue of health.

That is why we should greatly welcome the initiatives taken on, say, tax credits and Sure Start. They are trying to get to grips with some of the chronic and structural issues in our society. I urge my noble friend to do everything he can to ensure that in the White Paper on public health, the recognition of what government and society as a whole can do to improve the conditions under which people's own healthy lifestyles can be improved will be an important part of taking that policy forward.

Today's debate will rightfully focus on this Government's stewardship of our National Health Service. But I hope that it will also be an opportunity to examine what the opposition parties have to offer us on health. I have no doubt that the noble Lord, Lord Clement-Jones, will take the Government to task for the number of restructurings that have been undertaken. Indeed, I was responsible for quite a few in my time as health Minister. But it would be interesting to know why the Liberal Democrats' number one policy, according to an interview Paul Burstow gave in the Health Service Journal only two weeks ago, is a restructuring of the health service, the abolition of strategic health authorities and foundation trusts and the removal of the commissioning function from primary care trusts. The last thing the NHS needs at the moment, when it is going so well, is the kind of restructuring on offer from the noble Lord, Lord Clement-Jones.

As for the noble Earl, Lord Howe, I pose only one simple question to him about Conservative policies on health. Why is the Conservative Party proposing to take millions of pounds from the NHS to subsidise well-off people to use the private sector? It is a simple question and I hope we shall receive the answer at the end of our debate.

The National Health Service has been a key part of the fabric of our nation for 55 years. It has had its ups and downs and at times its whole future has been in doubt. But what has shone through the difficulties and tribulations during that time has been the essential idealism that lay behind its formation and the dedication and commitment of its staff, who have battled sometimes against the odds—sometimes against considerable odds—to keep the service going. We all owe a great debt of gratitude to those people.

But now we can see how important that battle was. Now we can see a renewed NHS arise and it is surely impossible not to be optimistic about its future. At last we have the levels of investment that Nye Bevan could only dream about. At last we are getting more staff and better training and support for them. At last we are getting an increased capacity and seeing new services come on stream. And, as I said, we are starting to get to grips with the public health agenda.

I believe that the NHS is in good hands. I believe that this Government have every reason to be proud of what they have done. Long may they continue. I beg to move for Papers.

3.46 p.m.

Lord Colwyn

My Lords, I am sure that the whole House will be grateful to the noble Lord, Lord Hunt, for his historical information and comprehensive explanation of the Government's health policies. In view of the impending announcements from the department, I congratulate him on his exquisite timing of the debate. I am much more used to speaking lower down the list and spending some time striking out sections of my speech that have already been covered, thus keeping to the time limit. I am looking forward to a stimulating afternoon.

The Government have made great strides since they came to power to change the way we think about healthcare in this country. It would be churlish to say that there have not been some discernable results, with a record number of doctors and nurses working in the NHS and huge investment in our hospitals. This they should be proud of. They have started a considerable number of worthwhile initiatives and schemes, but that is also part of the problem.

While I fully accept that change and reform in our healthcare systems take time, the Government, by not properly thinking through their policies or having joined-up spending in the NHS, have left indecision and uncertainty within many health professions. This is no more true than in dentistry and it is the provision of dental services that I shall address today. I am sorry that the noble Lord, Lord Hunt, did not have a word for the UK dentists. He was recognised as a sympathetic and understanding Minister in the Department of Health. I declare an interest as a practising dental surgeon who worked in the health service for 20 years.

There has previously been much good faith and enthusiasm for the Government's policies towards NHS dentistry, yet this has now turned to frustration and consternation because of the lack of detail in the policies coming from the Department of Health. In the debate in this House in response to the Queen's Speech in November last year, I was happy to congratulate the Government on their genuine interest in improving the way dentistry is funded and administered. This was summed up by the passing of the Health and Social Care (Community Health and Standards) Act 2003, which represented some of the biggest changes to dental commissioning in the history of the NHS. I was happy to be a critical friend of the Government during the legislative stages of the Bill in this House and was pleased by the details in the Options for Change White Paper in 2002, which clearly set out the way dentists would be able to get off the NHS treadmill of work.

I know that the Government have made huge strides in changing a system that basically remains much as it was at the inception of the NHS in 1948. This is something the profession broadly supports, along with the underlying principles of Options for Change. But the Government cannot leave the profession in its current state of limbo; of announcing wide-ranging changes without the proper detail to back it up. The announcement of a framework for general dental practitioners due to commence in April 2005 is a case in point.

The Government have publicly declared that they will guarantee dentists' current income for three years, but what happens after this? How will practice owners be able properly to plan their businesses financially and strategically with such important questions still outstanding? Unfortunately, it is not just the practice owners who need to know this information; it is the banks and financiers who loan hundreds of millions of pounds to dentists each year for their dental businesses. This is not just confined to private dentists, but affects all those general dental practitioners who work in the NHS who want to expand their practices, buy new equipment and improve the service to their patients.

Dentists still do not know for which patients they will be expected to be responsible and for how long that responsibility will continue. They still do not know what role primary care trusts will take, and there is scepticism that PCTs will even have the capacity to deal with these new responsibilities. There is huge uncertainty in the profession, confirmed by the results of the BDA's recent consultation with its members. Nearly 60 per cent of high street dentists will either reduce their NHS commitment or quit the NHS altogether. Just 2 per cent of high street dentists said that they would increase their NHS workload on the back of the Government's proposals, while a shocking 16 per cent said that they would stop providing NHS dentistry altogether.

Those figures have been well rehearsed in the media—not to mention in previous Questions and debates in this House—but the Government are still unmoved. They have failed to give any indication to the profession of the exact details of the framework proposals or to tell members of the profession when they will find out what those proposals are. Telling them that they are to be "published soon"—a phrase used far too often by this Government in relation to dentistry—is not good enough and it simply underscores the mistrust felt by many dentists.

The Department of Health cannot realistically expect the profession to sign up to new contracts and ways of working without solid assurances about the details of the new contract, yet the Government seem determined to introduce these seismic and untried changes in just 10 months' time.

I urge the Minister to speak urgently to the dentistry Minister, Rosie Winterton, asking her to discuss with the dental profession the possibility of adopting a phased introduction of the new system. It is not too late. It will mean that ideas can be properly tested and evaluated, while not holding back those dentists who wish to proceed with change at a faster rate. This is, after all, exactly what the Government detailed in Options for Change as the basis for introducing the new framework. That report advocated the testing of ideas through field sites and developing different commissioning options and new forms of contracting with a gradual rollout on a voluntary basis. That is surely the most sensible way forward and would show that the Government are listening to what the dental profession is saying about the direction that it considers to be the best way forward for the service.

The other current on-hold, or soon-to-be-announced, subject is the NHS dental workforce review. In 2001, the noble Lord, Lord Hunt, announced the review, yet three years on we still do not have any clear indication about when it will be published. There was much speculation that it would be before last Christmas, with parliamentary Answers to me as well as to those in the other place saying as much, yet it seems to be slipping further and further down the department's list of priorities. Perhaps it is to do with negotiations with the Treasury and the competition for health budgets.

Whatever the reason, the bottom line is clear: this country needs, as the BDA has consistently made clear, a 25 per cent increase in dental student numbers in order to ensure that there are enough dentists to meet the current huge demand for dental services. With any increase in student numbers, there also needs to be an increase in funding for teaching, research facilities and staff costs. Due to widespread shortages, academic staff are already working to, and beyond, capacity. Many clinical academics have reported that, for some teaching vacancies at dental schools, they have not received a single application for the posts available.

It is encouraging that the Government are putting an extra £90 million into NHS dentistry. However, the Minister will know that, while spending in the NHS as a whole has increased substantially, the gross spend on NHS dentistry has gone down from 4.4 per cent of the whole NHS budget in 1992–93 to just 3.1 per cent in 2002–03. Following research, the British Dental Association has calculated that, even if funding had remained at the 1992 level, NHS dentistry would have seen £1 billion more coming into the service. If the Government are serious about improving NHS dentistry, they need to fund the service properly and increase and maintain its share of NHS spending.

Oral health is an important aspect of general public health. Too often oral health has been forgotten when politicians have debated improving the nation's public health, yet its importance is indisputable.

I congratulate wholeheartedly this Government on taking forward the thorny issue of targeted water fluoridation. I shall not rehearse the debate about that subject, except to say that this House showed its usual wisdom and expertise when the amendment on the issue was first introduced to the Water Bill back in July 2003. I very much hope that the Government will offer local communities the leadership that is needed on this subject to ensure that the local consultation exercises will be balanced and well informed.

Information is one of the strongest tools that health professionals have, and dentists are among the best-placed professionals to promote good health, information and education. Despite the current debate about NHS registrations, more than 25 million people in the UK visit the dentist on a regular basis—that is more than the number who go to their family doctor. Dentists are uniquely placed to play a major role in smoking cessation interventions, which evidence suggests are both effective and cost-effective.

The current campaign on obesity and diet is also an area in which dentists are well placed to provide advice. Advice on safe foods and drinks could not only improve oral health but have a knock-on effect on the number of calories consumed per day. I hope that the Minister will be able to offer some encouraging words for expanding that provision.

In conclusion, the loyalty and dedication of NHS dentists are great assets to this country but they should not be taken for granted. It is clear from the BDA's research that trust among dentists is at rock bottom—something that the Government should ignore at their peril. I urge the noble Lord to impress upon his colleagues in the other place the urgent need to engage properly with members of the dental profession, to make them partners in this new journey for NHS dentistry and to bring an end to this constant hiatus. Only then will the Government fulfil the same ambitions for dentistry as they have for the rest of the NHS.

3.55 p.m.

Baroness Miller of Chilthorne Domer

My Lords, I congratulate the noble Lord, Lord Hunt of Kings Heath, on securing this debate and on introducing it in such a lively way. Not being a health professional and not being involved in the health service, I, too, was slightly taken aback to be so high up the list of speakers.

Nevertheless, it gives me a chance at an early stage to respond to the noble Lord, who accused the Liberal Democrats of not having very strong policies in this area. I draw to the noble Lord's attention the fact that on its website the Labour Party is kind enough to give the Liberal Democrat policies some very good publicity, listing no fewer than 100 of them. Indeed, the top two are concerned with health. The first is the fact that we would make NHS dental check-ups and eye checks free. The second—the subject of my speech this afternoon—is that we should tackle the root causes of ill health and not only the consequences. It points out that it is more effective to prevent people becoming ill in the first place. The noble Lord may be aware that many of our policies are outlined on the Labour Party website. I thank the Labour Party very much for giving us that publicity and for enabling me to point that out this afternoon.

I shall concentrate on two preventive measures that can be taken: food and outdoor exercise. The first leads me to declare my interests as vice-president of BTCV—the British Trust for Conservation Volunteers—and the Council for National Parks. It is the British Trust for Conservation Volunteers scheme, in particular, that I want to bring to the attention of noble Lords this afternoon.

From 5 to 13 June, BTCV promoted healthy hearts. It ran, with Home Office support—on which I congratulate the Home Office—a series of taster sessions for its Green Gym scheme. If noble Lords have not come across a Green Gym, perhaps this quotation from a user will help them to understand what it is: I went to the health centre … and saw the Green Gym advertised, and thought, 'Wow! Two things with one stone—getting a bit healthier and conserving the environment as well'. It seemed like a good idea to me, so I joined up".

The Green Gym offers regular sessions of conservation activities in accordance with health and safety guidelines. People can take part for an hour or so a week or more often if they have the time. The leaders have practical skills to encourage people to work according to their capabilities. The gyms are open to people of all ages and from all walks of life. Health professionals—GPs, nurses and health visitors—play an important role in recommending the Green Gym to their patients. Where appropriate, BTCV facilitates Green Gym community groups.

Radio 4 devotees may have heard a programme last week entitled "Ramblings", which followed a group of BTCV volunteers from, I believe, Glasgow on a walk. The noble Lord, Lord Hunt, clearly heard the programme. Noble Lords may not think that that is a particularly remarkable thing to do, but for those who do not very often leave the city, who do not have a car, and who view the wide open countryside with trepidation, simply going for a walk with a walk leader is very important. BTCV has followed up this initiative by ensuring that such people know how to access that same open countryside, on their own or with their families, by public transport. It also provides a great deal of other information. The scheme is a good example of the kind of preventive measures that can be taken.

As regards the importance of food and diet to the health of our nation, at the moment obesity is on everyone's mind and is increasing at a worrying rate. In a similar debate a few years ago the main issue would have been anorexia. Both are symptoms of an unhealthy attitude to food that has been encouraged for one reason or another. I am not saying that it has been encouraged by the Government, but their role now is to turn it around and address the issue of the nation's diet. I do not believe that to be a nanny state attitude; the Government must show leadership.

It is the job of the Food Standards Agency to advise the Government on nutrition but it is ill placed to do so. It was created to carry out an important role in food safety and food regulation; nutrition is not its prime role and it does not have board members with backgrounds in that subject. The Government might consider creating a nutrition council, the membership of which would reflect its remit. Such a body would then be well placed to offer the Government the independent advice they clearly need.

I am sure that the Government are fully seized of the fact that the only way to change the nation's diet in the long term is through education. The national curriculum must offer basic cooking skills and a far more comprehensive approach towards what constitutes a healthy diet. This would equip young people leaving school at 16 with both the knowledge and the skills to be responsible for their own diet. Addressing the issue of labelling alone will never do.

Basic issues such as drinking water being freely available in schools are critical. It has been proved by research that drinking water can improve young people's concentration, performance and behaviour in school. Vending machines full of soft and fizzy drinks do quite the reverse.

The Government have introduced the fruit scheme, which is extremely good. However, I believe that it is only for children up to the age of seven—the Minister will correct me if I am wrong—and I hope that the Government will consider extending it to all school-age children to enable them to acquire the habit of eating fresh fruit. I hope that schools will soon be able to return to a situation where they are able to offer freshly cooked meals in order to underpin the habit of sitting down and eating a healthy meal. Education has a critical role to play in that regard.

Before I conclude my speech, I should like to pay a personal tribute to the NHS. Two years ago, I had a major operation for a brain tumour. Considering the extent of the surgery, it is remarkable to me that I am able to stand here and deliver an eight-minute speech at all. I claim no credit for that. The credit has to go to Southampton Hospital, the remarkable surgeons there and the care that I received during the 10 hours of the operation. I pay tribute to the NHS and I am deeply grateful. I am living proof of the value of the NHS.

4.5 p.m.

Baroness Billingham

My Lords, I, too, congratulate my noble friend Lord Hunt on initiating today's debate on what is evidently the most topical issue of the moment. This will be fully illustrated by the major statements today and tomorrow by both Tony Blair and Michael Howard. Battle lines are being drawn and we must welcome the opportunity today to have a full debate in your Lordships' House, with so many distinguished speakers who are experts in the field. My noble friend's timing for the debate is quite perfect—considerably better than Tim's at Wimbledon yesterday, but with full confidence that better is to follow.

It is my intention to use purely factual evidence to substantiate the claim made by the Prime Minister that the extra investment and reform to which the Government have been committed in recent years have brought real improvements in capacity and performance across the public services, and that the recent reports of the NHS chief executive and the NHS Modernisation Board show that clear progress has been made in the health service.

Drawing on first-hand experience always strengthens the argument, and so I intend to focus my attention on the geographical area that I know best—Northamptonshire and Leicester—having represented it as an MEP in the past, but also using my current major preoccupation, Catalyst Corby, an urban regeneration company which I chair and which relies entirely for its health provision on the Leicestershire, Northamptonshire and Rutland Strategic Health Authority. As a town set to double in size, the quality and quantity of health provision is crucial to its residents, who demand and deserve the best possible service. Leicester South is a key provider for us, and my research on its current performance gives me great reassurance about its ability to serve the local needs.

The facts simply speak for themselves and I make no apology whatever for sharing them with your Lordships. The key achievements in Leicester South include the following. The number of nurses has been increased by 963; the number of doctors by 459; and the number of GPs has risen by 66 since 1997. These are the bedrock of better performance and are already delivering vastly improved services.

Let me use waiting times as a key indicator. Waits of 12 months are down by 100 per cent. In March 1997, 365 patients waited for more than 12 months; in March 2003, no patients waited that long. Waits of nine months are down by 50 per cent, from 2,245 in March 1997. Ninety-one per cent of all A&E patients were admitted, transferred or discharged within four hours in the last quarter of 2003; 100 per cent of people suspected of having cancer are now seen by a specialist within two weeks of being referred; 96.2 per cent of people can now see a GP within 48 hours in the quarter to 2003; 97.3 per cent of people are offered appointments to see a primary care professional within one working day.

What does all that add up to in the lives of people living in Leicester South? Confidence, peace of mind and tangible evidence that the Government's injection of huge extra sums of money into the National Health Service is indeed working and that even more can be expected in the future. In the same health region, there has been a fall in mortality rates; a 17 per cent drop in premature cancer deaths since 1997; and a 24 per cent fall in deaths due to circulatory diseases in the same period.

So what is the real record of the Government's new capital for Leicester South? It is deeply impressive: £23 million will be invested as pure capital this year and that includes investment in cardiac services in Leicester itself. There is also a PFI scheme at the University Hospitals of Leicester, worth in excess of £400 million. That will include the establishment of a planned care and rehabilitation site. The scheme is working towards the selection of a preferred bidder later this year, with financial close late in 2005.

Other firsts in this area include the fact that University Hospitals of Leicester NHS Trust has employed a paediatric consultant in accident and emergency and a professor in emergency medicine. With an ear to Corby, where our health record within the population is particularly poor, I welcome the simple statistic that 1,146 people quit smoking in the four weeks up to the end of December 2003, which is a 7.4 reduction on the 2000–01 figure.

While facts and figures are important in this debate, they deliver only part of the programme. The people in the service make the service work for its communities. An example is Dr Angela Lennox who works on a very deprived estate in Leicester South, the St Matthews estate. She led a campaign to tackle the health problems in that area and has been remarkably successful. Prince Philip House is now up and running thanks to capital funding for the surgery from the Government. Her vision linked to the Government's willingness to fund and support local initiatives is a blueprint for the future.

Health and happiness is not a cliché, but a fact of life—tell someone who is unable to sleep or walk in comfort because of chronic hip pain that he or she must wait years for a replacement hip. Those agonising years have gone. Clearly, it is this Government's intention to underpin and to provide a service of the highest quality for all who need it. Leicester South itself provides undeniable evidence that the Government's policies are working; I welcome that on behalf of everyone who benefits from a transformation of the local healthcare in that area.

4.12 p.m.

Lord Jones

My Lords, I thank my noble friend for initiating the debate, for the excellence of his stint as a Minister and for the authoritative manner in which he delivered his speech. I have learnt from all the preceding speeches. My noble friend mentioned the name of Mr Bevan whose political testament is entitled In Place of Fear. It resides in the Library and I submit that the chapter on the health service is apposite for this debate.

A long time ago, as a health Minister, I served in the administrations of Harold Wilson and my noble friend Lord Callaghan. Under Mr Wilson I had the experience of working alongside a fiery Cabinet Minister named Barbara Castle. She had very strong views about the role and future objectives of the NHS. It was instructive—indeed awesome—to observe her harangue the assembled host of the presidents of the Royal Colleges. Their self-esteem, double-barrelled names and pin-striped suits were insufficient to protect them from Mrs Castle's fury. It was the age of confrontation, perhaps even of dinosaurs.

So the supple and subtle Prime Minister, Harold Wilson, decided upon a Royal Commission, perhaps as much to circumnavigate Mrs Castle as to assess the problems of the NHS. Brisk and businesslike, my noble friend Lord Callaghan, on assuming the premiership, did not include Mrs Castle in his administration. The Royal Commission continued.

I look back only to make a point. The principal problems facing Britain's health service appear, in some respects, to remain somewhat similar today, some 30 years later. My noble friend Lord Callaghan set up a working party called RAWP (the Resource Allocation Working Party). It created consternation within the ranks of NHS administrators and focused minds on hard choices and on priorities. It was designed to consider not only the needs of prosperous communities, but also the needs of underprivileged communities in Britain. It sought decisions within the context of rapid social changes, scarce financial resources, rising expectations and miraculous technical advances. It might be said that that is where we are now.

Mrs Castle told me that the NHS was a battlefield. Of course, she was a warrior. She said that the battles were fought between, first, the administrators, secondly, the professionals and, thirdly, the various competitive trade unions serving within the health service.

How far have we advanced since the working party RAWP was set up in the mid-1970s? Do the battles continue? Are there fair shares throughout our country? How shall the health service cope with the requirements of the rapidly expanding senior citizen segment of the British population? What would happen to the current very generous rates of investment in the health service were those rates to slow down? Indeed, is Britain ever likely to be prepared to pay higher taxes to sustain high investment in our health service?

Those are tough questions for any administration, so I remain haunted by the implications of the resource allocation debate. How can we obtain continuing social justice in the context of health service provision? One can only be proud of the current administration's massive investment in the improvement and modernisation of our health service. I would like to think that under this administration we are in sight of the broad sunlit uplands. Nevertheless, it is a truism that the health service is always under pressure from relentlessly increasing demands.

I now draw attention briefly to the work of the National Association of Hospital and Community Friends. The organisation is on a totally different scale from the National Health Service. I believe that it displays huge commitment to the health service. Hospital and community friends are volunteers who work to improve the quality of life for people affected by ill health and disability. Now, there are over 43,000 volunteers in some 760 friends charities affiliated to the national association. Every year they raise over £45 million by running retail services and fundraising for equipment and extras for patients. They also run and fund hundreds of patient-focused projects, meeting needs as diverse as transport, befriending and remedial activities for people of all ages.

I should declare an interest as president of the Deeside Community Hospital League of Friends in Flintshire. Led by the chairman, Mrs Kathleen Fox, the vice-chairman, Mrs Megan Jolly, and the treasurer, Mr Beamish, the committee of friends carries out marvellous work for the National Health Service locally. They raised, for example, tens of thousands of pounds for a state-of-the-art scanner which enabled local people to meet their consultant without expensive and extensive travel penalties on journeys to far-flung district hospitals.

We have endowed the busy day hospital with a splendid conservatory where friends and families can meet patients. The friends have also raised nearly £40,000 for an endoscopy appeal, again aiming to bring the consultant to the patient. Great companies such as Airbus, Redrow, Iceland and Corus have been very generous in their financial support for our appeals, as have the Rotary Club, Freemasonry, neighbouring factories and other good-hearted voluntary organisations.

The fact is that the League of Friends unites a whole community in aid of a wonderful hospital. I instance self-help, innovation, flexibility and community involvement. Patients and families and towns and villages are linked together by vigorous fund raising.

The League of Friends across Britain is a very helpful, inclusive ally of the National Health Service. It enables individuals to make a personal contribution and unites the professions and the consumer in our health service.

Of course a budget of £45 million is minuscule alongside the mighty health budget of Her Majesty's Government, but I hope that the Minister tonight will acknowledge the good work that is carried out throughout Britain by warm-hearted and dedicated voluntary workers in the League of Friends.

4.20 p.m.

Baroness Finlay of Llandaff

My Lords, I, too, thank the noble Lord, Lord Hunt, for having introduced the debate and pay tribute to his enormous contribution to the health service, both during his time as Minister and now. He has never lost sight of the fact that the health service is there for the patients—that is what it is about. He deserves our praise and congratulations for all that he has done.

The debate gives everyone an opportunity to speak. I must declare an interest. I work in the NHS, in cancer care for the Velindre NHS Trust in Wales and Marie Curie. I shall talk a little about cancer. I live in Wales. Every time I go shopping I pass Nye Bevan's statue. As he gazes formidably down on me he reminds me that even though I am not on call, which is why I am browsing around the dress shops and the sales, my patients are still in the hospital being cared for by someone else, and that they will still be there when I have done my shopping, gone home and back to work.

The Government have focused on the patients and deserve congratulations. They have invested a huge amount of money. By 2008 the total UK health spending will be 9.4 per cent of national income, well above the current EU average of 8 per cent.

A great many people have cancer, but the speed with which they are being diagnosed has improved. The Government took the imaginative and innovative step of appointing a cancer czar. Mike Richards deserves praise for all that he has done. He has focused people's minds on cancer as an issue, and he has not fought shy of being upfront and open when problems have arisen and has done something about them. He deserves praise for that.

However, I am afraid that the Government have fought shy of doing the one thing that could really improve the health of the nation. If there were only one public health measure, it should be to tackle tobacco more aggressively than they have done. We need to look at tobacco on the global scale. I should like to quote from the report of the Committee of Experts on Tobacco Industry Documents published in 2000 because this comes from the World Health Organisation. It states: Evidence from tobacco industry documents reveals that tobacco companies have operated for many years with the deliberate purpose of subverting the efforts of the World Health Organisation (WHO) to control tobacco use. The attempted subversion has been elaborate, well financed, sophisticated and usually invisible. The tobacco companies' own documents show they viewed the WHO, as an international public health agency, as one of their foremost enemies". I am sure that I must also be on their list of enemies. As I speak, a voodoo doll is probably having pins stuck in it.

Doing something about tobacco would make a difference. We go to restaurants and take it for granted that we shall have clean water to drink. In this country we generally have very high standards of hygiene, but we cannot take it for granted that we shall be able to breathe clean, uncontaminated air. Apart from prevention measures, there are other things that we need to address and not ignore.

In the UK there have been big increases in malignant melanoma, in uterine cancer and in prostate cancer, but that is probably because of early diagnosis. However, there has been a fall in stomach cancer because of the diagnosis of helicobacter and improved treatment. The cervical screening programme has shown real improvement. With cervical screening, 2,991 cases of the disease were diagnosed in 2000, which is a fall of 13 per cent in five years. So the programme is doing well. Unfortunately, there seems to be a link between cervical cancer and sexual activity. There is ever continuing pressure on the NHS to cope with changes in lifestyle as our young people have increased numbers of sexual partners and often do not use protective barriers or contraception.

An appalling figure relates to lung cancer. Lung cancer figures among men are falling. Only one in eight of the population realise what a devastating disease it is. Seven out of eight people think that it can be treated with surgery or with chemotherapy and radiotherapy and that those patients will do well. However, the disease carries an appalling mortality rate. The population is almost complacent because we are doing so well.

There is the risk of melanoma. In the past ten years instances of malignant melanoma have doubled. You are more at risk if you have a close relative who has had malignant melanoma; you have lots of moles; are fair skinned, particularly if you are fair skinned with blue eyes; if your family has a history of melanoma; and if you were born and lived as a child in a hot, sunny climate, probably because you got burnt then. Preventive programmes that relate to sun protection are very important. No one should think that it is only fair skinned people who get malignant melanoma. It occurs in all parts of the population, but it is more prevalent in the fair skinned group. Sun beds are probably implicated in this, yet we have been remarkably complacent in giving out clear health messages about their use.

How are we going to collect the data regarding all the treatments that we are offering and how effective they are? How can the Government demonstrate that they are really doing what they claim? It depends on registries. We have a fantastic cancer registry in this country. It is the largest in the world. It gets 70 per cent of its reports from pathology departments, others from hospital administration systems, and about 8,000 to 10,000 registrations come through death certificates, which is very poor-quality data as it is incomplete.

I ask the Minister: how advanced are the plans for patient-held records and for their link into the cancer registry? How advanced are they in detecting not only the bald facts of diagnosis but the incidents along the way, such as spinal cord compression or infection post-chemotherapy, which may even be fatal, so that we really understand the complexities and complications of the treatment we are giving?

The new research projects, such as the BioBank UK project and the Gene Park project, need to be integrally linked in to the registries so that we can understand what is happening and allow the registries to continue their research programme of flagging workers, such as those who work in the asbestos industry, to look for mesothelioma and lung cancer.

At the moment we have the Patient Information Advisory Group (PIAG), but that is short term. We need to look at the whole issue of registration data. I also want the Minister to tell us what moves there are towards opting-out consents and regarding where all cancers are registered, so that people can opt out rather than looking towards an opting in consent. Is the Minister aware of the difficulty with anonymisation procedures and linking with the clinical record, and the importance of that clinical record to understanding what has been happening?

If we move on to the end of life, to the area in which I have worked for a long time, 56 per cent of people want to die at home. Currently, only about 20 per cent do so. It has been estimated that by spending £75 million we could allow 30,000 more people to die at home annually in England, with an additional amount for the other parts of the UK. To achieve that we are not really going to save money; we will free up about £2 from the hospitals for every £1 spent on someone dying at home.

These are future investments that we have to make if we are really going to allow people, when they are suffering and need our help, to have imaginative care that is rapidly responsive.

4.29 p.m.

Baroness Jay of Paddington

My Lords, I, too, congratulate my noble friend Lord Hunt of Kings Heath on securing this timely debate—and, indeed, on his customarily authoritative introduction. I also look forward to hearing the maiden speech of my noble friend Lord Drayson. I have admired his work in healthcare, both in developing biotechnology industries and in the charitable sector, for a long time.

Listening to my noble friend Lord Hunt, I recalled the similar wider-ranging debate that we had in your Lordships' House in 1998, on the 50th anniversary of the National Health Service, to which I replied because I was then a Minister of State at the Department of Health. Re-reading that debate, I was struck by the enormous amount of hope and expectation expressed by noble Lords who spoke then, especially because they agreed—with profound relief, I think—that there was going to be a commitment to increased public investment in the NHS in real terms every year.

I say "relief? because I agree with my noble friend Lord Hunt. When we came to office in 1997, many of us were depressed by the state of the health service. We were concerned that the fundamental principles of the service, to which my noble friend alluded, were declining and that inappropriate market models were distorting basic standards of care. At the same time, I remember being especially concerned that lack of accountability and the inability to measure performance and make comparative assessments between providers of care made it extremely difficult to grasp the levers of change.

However, in concluding that 1998 debate, I said: The orderly management of decline is not part of our agenda for the NHS or for Britain".—[Official Report, 4/2/98; c. 710.]. So that has proved. As my noble friend spelt out so graphically, in 2004, investment and reform have produced not just green shoots but a maturing crop of real NHS change. Last month, the chief executive of the health service, Sir Nigel Crisp, published an optimistic annual report, emphasising that record investment and reform had speeded up treatment and improved patient care. He wrote that it is clear that something really significant is happening in the health service. Just last weekend, the Times, which does not always support government actions, describe the NHS as "resurgent".

As several noble Lords have said, the NHS is now the fastest-growing health service in any major European country and the huge growth in capacity has been key to all its success. It can never be said too often that by 2008, UK health spending will have more than doubled since 1997. With that expansion has come the real planning and strategic development that means with the 10-year plan and the new guidance, which we expect to be unveiled tomorrow, on the next five years, uncertainty will cease to be a problem for the development of the health service. Personally, I believe that targeting and the development and use of national service frameworks have been essential to ensure that the new money has been usefully distributed.

Proper implementation across the board is of course the key planning aim. That is the policy that we all intend to pursue now. We cannot allow our opponents to claim, as they have done so often in the past, that vast public expenditure has disappeared into an ever deeper black hole. For example, I was interested to read in a recent bulletin issued by the National Institute for Clinical Excellence that it, is launching a programme of work to support implementation of its guidance in the NHS. By the end of 2004, over 250 sets of recommendations will have been issued", so the institute is this month advertising for an executive director with responsibilities for implementation. Equally interesting, it cites the institute's website as having, a new section to support those responsible for implementing NICE guidance in the NHS". The use of integrated information technology in the system is one of the profound changes that has occurred during the past five years. I declare two interests in that respect: one historically as a Minister who tried rather unsuccessfully to make changes in that field during my time at the Department of Health; and now as a non-executive director of British Telecom, which has taken on corporate responsibility for a great deal of IT changes being made today.

I know that it has been a struggle to achieve that change. The history of the NHS and IT systems has always been chequered. Until very recently, past procurement scandals have often inhibited change. But since December 2003, the national programme of information technology is investing £5.5 billion to transform systems for the benefit of health professionals and patients. That is a clear example of investment plus reform. By the end of next year, electronic booking systems will make it possible for patients to book hospital appointments and electronic prescribing will speed up the cumbersome procedure of obtaining and renewing prescriptions.

Perhaps the most welcome advance will be the electronic care record. After all, it has always been one of the caricatures of NHS inefficiency that patient records go missing, that brown envelopes full of data are not in the right place at the right time and that people are asked to repeat the same personal information over and over again. With the national electronic patient record—a secure one, of course, that can be appropriately transmitted to clinicians and other medical practitioners—the right information will be on-line at the right time. That will go a long way towards making the NHS feel like a 21st-century organisation.

So overall, we see an optimistic picture. All the professional indicators are rising and, significantly, the annual patient surveys are showing increasingly positive results. I raise just two questions with my noble friend on that. The first is an old concern of mine—and, I think, of most patients—about mixed-sex wards. I know that government policy has always been to eliminate those unpopular arrangements and I know how difficult it has been for some trusts to achieve that change. However, I was slightly uncomfortable to read the latest figures that state that 98 per cent of trusts now provide what is called "separate sleeping accommodation". Can my noble friend give us a slightly fuller picture? Does single-sex sleeping accommodation also include separate toilet and washing facilities? Frankly, by now, after all the efforts that I know that Ministers have made, it would be good if they could report that 100 per cent of trusts are complying with our long-established policy on single-sex accommodation.

My second query is much less specific and we will almost certainly be debating it for some time. However, it would be helpful if I could hear more from my noble friend today about the Government's new emphasis on the importance of choice. Personally, I have no difficulty with the concept, I just wonder about its relevance to all patient experiences at every stage of the health service. Choice indeed has a central role in issues of public health. In the past few months, there has been a renewed and vigorous debate about lifestyle choices and the part that the Government can or should play in promoting healthy living.

I very much welcome the new focus on topics such as obesity, smoking and the crisis in sexual health, as well as more basic socio-economic factors, because they all contribute to the health inequalities that we are all still fighting. I look forward to the autumn White Paper on public health and hope, like the noble Baroness, Lady Finlay, that the Government will seize some of the nettles, such as smoking in public places, and not be deterred by the tabloid shrieks of "Nanny state!".

My noble friends Lady Massey and Lady Gould, both of whom will take part in the debate, have done much to keep public health on the front burner in this House. In her debate on adolescent health last week, my noble friend Lady Massey said,

a great many influences feature in how people make decisions about health—their economic situation, their communities, their friends and family, their culture [and] the media".—[Official Report, 15/6/04; col. 722.]

I absolutely agree, and, in conclusion, I should like to make a proposal about government responsibility for public health which I hope will not offend all my friends and ex-colleagues. Put simply, public health policy and implementation may be too wide and complex for the Department of Health to tackle on its own. My immediate solution is to appoint a public health Minister in the Cabinet Office who chairs a Cabinet committee with cross-governmental responsibilities. In that, I draw on my experience as Minister for Women in the Cabinet Office, where I found that I could act as a pressure group across government.

Perhaps I may finish by moving away from the machinery of government and practical plans and returning to the values and principles that my noble friend Lord Hunt rightly emphasised. I mentioned earlier the very powerful 1998 debate on the anniversary of the health service. We were lucky that day to hear from some colleagues who had worked with Aneurin Bevan—my noble friend has already referred to our noble friend Lord Bruce of Donington. In 2004, the Government must be warmly congratulated on achieving many changes in the health service that are necessary for a 21st century society and, most importantly, continuing to preserve the fundamental principles of universal healthcare free at the point of need. I look forward to seeing more reform and investment based on those unchanging values.

4.40 p.m.

Lord Drayson

My Lords, I am grateful to my noble friends Lady Jay and Lord Hunt for their support for my maiden speech today.

My first experience of this House was several years ago, when I came to listen to noble Lords' debates on stem-cell research, in my capacity at that time as chairman of the Bioindustry Association, the trade body for the UK's biotech industry. I was very impressed then by the high quality of debate, the expertise in this House and the care taken by noble Lords in crafting balanced and effective legislation in this very complex and emotionally charged area. So it was with deep admiration for this House that I took my seat here just two weeks ago.

I am very grateful to the many people, both among noble Lords and among the staff and officers of this House, for the warmth and friendship that they have shown to me since I arrived here. I hope that I can demonstrate, through my dedication to the workings of this House, that their encouragement and friendship have been justified. However, my performance last night in the tug-of-war between this House and the other place could have done with some improvement.

I am a science entrepreneur. I have spent the past 20 years of my life building companies based on innovative science and technology. In that time I have learnt many things. Above all, I have learnt that a successful company is built on fairness and providing the opportunity for all staff to realise their full potential, in an environment that drives towards success. It is those two values of fairness and ambition that drew me to the Labour Party and which make me feel honoured to speak to noble Lords from these Benches today.

Over the past 10 years I have worked in the biotech sector, so I am pleased to be able to make my maiden speech on healthcare. I am a strong supporter of the NHS. In expressing my support, I must declare an interest: having been born blind in one eye, I have benefited from the NHS's wonderful care for my whole life. I am glad to have the opportunity to pay tribute to the NHS staff for the tremendous work that they do every day, and to say thank you.

Our NHS is an important national asset, but it also requires investment and reform, if it is to deliver the care that people expect in the 21st century. I declare another interest in that, for the past two years, I have chaired a fundraising campaign to help build a new children's hospital in Oxford as part of the John Radcliffe NHS Trust. I have seen first-hand the improvements taking place there. A brand new accident and emergency department opened just last month, and the concrete structure of a new 106-bed children's hospital is rising from the ground. This has been due to the hard work of many in the community who supported the campaign, which is part of a massive £200 million investment programme in the John Radcliffe Hospital Trust. I have seen how those improved facilities have not only increased the hospital's capacity but also accelerated the pace of reform, allowing new working methods and innovative new treatments. Importantly, such improvements also improve morale and enable people to embrace change. The JR in Oxford is a good example of the improvements being made in the NHS and of the wide support that the NHS has in the community.

One aspect of the current reforms that particularly excites me is the emphasis on patient-centred care. For example, when I first saw the designs for the new hospital, I was struck by the provision of a floor for parents of children undergoing long-term care. It will allow parents to cook food for their children at the hospital. Research has shown that, if parents are so involved in their children's care, the kids get better faster. Of course it is wonderful for the parents, too.

Increasingly, patient-centred medicine is at the heart of advances in medical science. As breakthroughs in the biosciences allow us to understand the genetic basis of disease and to identify patient groups with a genetic predisposition, this enables the biotech industry to develop new diagnostic tests and medicines to tackle the diseases. That alignment between good clinical practice and good science, focusing on patients as individuals, lies at the heart of healthcare in the 21st century.

However, the full realisation of these benefits will require a close partnership between the NHS and the UK's bio-pharmaceutical industry. We want to achieve what matters most: winning the fight against the mass killers in our society—cancer, heart disease and asthma. We are making good progress. Death rates for both cancer and heart disease are now falling faster in England than anywhere else in the EU. We need to build on that success. I congratulate my noble friends Lord Hunt and Lord Sainsbury on their foresight in creating the Biosciences Innovation and Growth Team in partnership with the BIA. That group has been very effective in identifying the factors that will ensure that the UK biotech industry remains the leader in Europe. A strong UK biotech industry operating within a balanced regulatory framework will be the key to building the world-class health service that we need, improving the health of the nation but also the wealth of the nation, through world-class science, innovation and enterprise.

4.47 p.m.

Lord Patel

My Lords, it is my pleasure and privilege to congratulate the noble Lord, Lord Drayson, on an outstanding maiden speech. Your Lordships' House will benefit enormously from his vast experience of the healthcare industry, particularly in vaccines and drug delivery. I am sure that the House will join me, not only in welcoming his speech today, but in looking forward to his many contributions to future debates in the House.

I, too, thank the noble Lord, Lord Hunt of Kings Heath, for securing today's debate on healthcare and public health. I congratulate him on becoming the honorary fellow of the Faculty of Public Health Medicine. I declare one key interest: I am chairman of NHS Quality Improvement—Scotland.

I want to speak mainly about public health today, but in the context of public health and mental health, and mental illness. The second Wanless report, Securing Good Health for the Whole Population, addresses many public health issues, but it does not address in any detail public health aspects of mental health. I hope that the Government White Paper on public health, soon to be published, will do so. The Mental Capacity Bill and reform of the Mental Health Act are also opportunities to put mental health at centre stage. Hitherto, despite mental health being a priority, it has still been a Cinderella service. The Government now need to turn their attention to mental health.

This in no way minimises the significant improvements that have been brought about in other areas. By way of background, let me document the size of the mental health problem. Most surveys show that about 25 per cent of the population will suffer an episode of mental disorder at some time in their lives. Just like physical illness, mental illness ranges from mild and brief self-limiting conditions to those that cause severe and lifelong disability. At any one time, one in seven adults will consider that they have a problem with their mental health, ranging from the most common mixed anxiety and depressive disorders to major psychosis such as manic depression and schizophrenia, which affect approximately 1 per cent of the population.

To those must be added the increasing problems of alcohol dependency and illicit drug use and, as people live longer, Alzheimer's and other dementias. There are also those with lifelong difficulties caused by learning disabilities.

The impact of these illnesses is a markedly increased death rate in the mentally ill, due to higher rates of illnesses, including heart disease. There is also an increased risk of suicide, which is the tenth most common cause of death in England and Wales, particularly in people with depression and schizophrenia. Among young people, it is the third highest cause of lost life years and the largest killer of young men.

There is also the significant social morbidity associated with mental illness. An Office of National Statistics survey found significant levels of unemployment and sickness associated with even mild forms of mental illness. Only 18 per cent of the long-term disabled with mental illness were employed in 2000. According to the Sainsbury Centre for Mental Health, the estimated cost of mental illness in England alone for 2002–03 was £77 billion. Yes, my Lords, £77 billion.

While all illnesses cause suffering, those people with mental illnesses are further disadvantaged by stigma and discrimination. The stigma attached to mental illness also affects the recruitment of health workers and the lack of charitable funding for research. It makes people reluctant to seek help and drives them away from services.

I will now look at some areas of public policy in the context of mental health. The Government clearly recognise the problem, because since October 1999 the various reports, White Papers and Bills still to come altogether make up 11 initiatives for improving mental health. Nonetheless, some of these activities sometimes contribute to the problem. The Community Care (Delayed Discharges etc.) Act 2003 excludes the mentally ill. This may encourage social services to increase investment in services for the physically ill at the expense of the mentally ill. The draft Disability Discrimination Bill is another example of proposed legislation that is unfairly biased towards physical disability. The draft Mental Incapacity Bill discriminates against competent persons in making decisions for medical treatment. The focus of media and government attention is often on the supposed dangers that the mentally ill pose to society. This is false and is further evidence of stigma.

Let us look at the current state of mental health services. Despite much investment in time, money and energy, the feeling among users and professionals is that the reforms are to keep society safe and not to improve the wellbeing of users. The National Service Framework for Mental Health, well intentioned and welcomed as it was, has not delivered. Both the Sainsbury Centre for Mental Health and the King's Fund report demonstrated significant under funding or worse—money designated for mental health not getting there. There is a widening gap between promise and performance in the delivery of better mental health care. There are serious shortages of all staff; doctors, nurses, psychologists, psychotherapists, occupational therapists and others. According to the Royal College of Psychiatry, there are currently nearly 490 vacant consultant posts in the United Kingdom. In general psychiatry, there is an overall 10 per cent vacancy rate in England, rising to 20 per cent in Wales.

I will now address public health issues as they apply to mental health. Public health services have paid little attention to mental health. The lifestyle and dietary choices of the individual may influence rates of heart disease and obesity, but the same arguments do not apply to most mental health problems, save for perhaps some that are due to substance misuse. While in other areas the prime responsibility for the health of the public may well lie with the public and not with the government, factors for mental illness are rarely under conscious control. However, some public health interventions can help, as shown in the recent study published in the British Journal of Psychiatry, advocating the use of techniques such as cognitive behavioural and psychological techniques, coping skills training, stress management classes and so on. Improving access to services for disadvantaged groups, such as that carried out by the Antenna project in north London, may also decrease the risk of mental illness or morbidity by earlier treatment.

What are the solutions? Stigma needs to be positively addressed as recommended in the recent Social Exclusion Unit report. Stigma and discrimination are the greatest barriers to achieving better integration into the community for people with mental health problems. The National Service Framework for Mental Health needs to be reviewed. In the light of evidence produced by the Sainsbury Centre, the King's Fund, the Royal College of Psychiatry, the Faculty of Public Health Medicine, the Royal College of Nurses, organisations such as Mind, Mentality and others, does the Minister agree that mental health services are not delivering? Does he agree that we need a new National Service Framework for Mental Health with better performance monitoring?

The mark of a civilised society is one that looks after its vulnerable groups. People with mental illness are such a group.

4.56 p.m.

Lord Winston

My Lords, I congratulate my noble friend Lord Hunt on his introduction of this debate, and thank him. I declare an interest as an active member of the NHS, working as a consultant. My noble friend was an outstanding Minister, and his reputation throughout the NHS is second to none, except possibly that of the noble Baroness, Lady Jay, who was also an extraordinarily good Minister. It is wonderful to have both of them in the House this afternoon to contribute to this debate.

I enter a slight note of dissent. Of course, I have no doubt that what this Government have done for the National Health Service is a phenomenal achievement. It has largely been due to the commitment finally to try to fund it in a proper way, and to try to fund it in the same way as some of our partners in Europe. We still face many problems. Looking through the list of speakers, there is a notable absence of speakers from the Official Opposition, so I thought that I might make a small contribution of some complaint.

I cannot help observing—I wonder whether anyone in this House has noticed—the impact of these debates on employees in the health service, which is the biggest single employer in this country, with over a million rather intelligent people. For example, today we see an extraordinary debate between my right honourable friend the Prime Minister and the Leader of Her Majesty's Opposition, the right honourable Michael Howard. It is, of course, about the issue of choice. We in the health service do not like being made a political football. It really troubles me that over the next two years we might increasingly see this kind of debate, which distracts us from the real issues. The truth is that we do not have choice in the health service. It is unlikely that we will ever have choice. It seems foolish to debate it in those terms.

We cannot have choice any more because, for whatever reason, when the party opposite was in power it brought in the internal market and radically changed the structure of the health service, in my view for the worse. That means that we cannot now have the person who is most experienced in a particular procedure, or who has experience of a disease, necessarily having that patient referred to them, because of the break-up of the health service. Admittedly, this probably would have happened anyway, because the health service is so large that it probably cannot be managed on the global scale that was the case hithertofore.

I have a suggestion for my noble friend on the Front Bench about how we might correct that. I know that he will ignore it completely when he sums up at the end of the debate.

It seems extraordinary that our party should accept the idea of creating choice by, for example, referring patients to the private sector. I do not want the House to get me wrong: I do not believe for a moment that what Michael Howard suggests is any better—it would be even more inequitable. Surely, we should bring private practice back into the health service. There are trusts than can increase the income of the health service and get consultants working in their own hospital without, therefore, being distracted by having to travel, being unable to teach or practice in the hospital of their origin. It would be better for the health service to integrate such private practice, rather than contracting it out and losing income. My trust, for example, with its hotel facilities, makes considerable sums through private practice. That is an utterly honourable thing for us to do; it is not a political issue.

The problem is that there is still a lack of long-term planning in the health service. There is short-term financing, so that, for example, we are left wondering what our budget will be, even for next year, because we do not know whether the primary care trusts will deal with it. There is a major problem of failure to recognise the importance of research and development in the health service. Nominally, we spend almost £0.5 billion on research and development, but most of that money goes to prop up clinical services because we cannot spend it in the best way.

We also have a terribly populist approach to the issues that crop up, such as Alder Hey. I shall not go into the details of the Human Tissue Bill, which we will debate later, but it worries me that we could respond in such a way to the issue of work with human tissue. Given the response to the Toft inquiry and the one mistake made by Leeds trust, I cannot help wondering whether we are going over the top to some extent.

From the Opposition, there comes an extraordinary denial of what we are saying. For example, Michael Howard said today on television that we were getting three new managers for every new doctor. Last month, I heard John Reid say on television that we had the lowest-ever number of managers in the National Health Service. Which is correct? Where are the figures? I do not know, but I suspect that the truth is somewhere between the two. Michael Howard says that doctors make miracles every hour of the day. I do not feel valued by such a statement, because I do not believe it.

The notion of a new approach—the right to choose—is missing the issue. We do not need real choice: we need respect for patients. I cannot help saying to the House that I still would not want my mother, who created a political furore four or so years ago, to be admitted as a geriatric patient to the hospital where she lives. It is filthy; the ward is disturbed and overcrowded; and the nursing is of a very low standard. My family and I have decided that, when she next has a serious attack of her basic disease, we will not try to have her admitted to hospital. We would rather have her at home, and, if she dies, she will at least die with some dignity in her own house. People do not need choice; they need to feel that they are being dealt with personally and in a way that allows them some kind of dignity.

One of the problems is that we have the notion that the Labour Party is the only party that supports the National Health Service. My noble friend Lord Hunt of Kings Heath talked about Nye Bevan: we are always banging on about Nye Bevan in this party. He was a very great man, and the National Health Service was the most extraordinary achievement, but we should move on and think about the future of healthcare. We should start to think about how healthcare must change, as it becomes increasingly expensive. Will we be able to cope with such a budget? Is it questioning a shibboleth to say that, perhaps, in the long term, a tax-only financing system for healthcare may not be entirely desirable? We have considered that question with regard to the Higher Education Bill, which has just passed through the House. We have accepted that there are parts of the public sector to which we may need to make a contribution. We should have an intelligent debate.

My suggestion to my noble friend on the Front Bench is that we should stop using the National Health Service as a political football. We have consensus among all the parties that we value the National Health Service, and we agree on about 80 per cent of the related issues. Why do we not have a health committee to run the service from day to day? If we did, there would not be the regular changes of focus and emphasis or the reforms that the system often groans under. It would be simpler. There would still be the question of its relationship with the Treasury, but achieving a consensus that healthcare was needed in a particular way would be better for the health of the country in the long term.

5.5 p.m.

Baroness Massey of Darwen

My Lords, first, I congratulate my noble friend Lord Hunt of Kings Heath on introducing the debate with such vigour. I wonder whether he has managed to orchestrate the many different contributions to the debate. I also congratulate my noble friend Lord Drayson on his stimulating maiden speech. I shall focus on the importance of treatment for drug misuse. I declare an interest as chair of the National Treatment Agency for Substance Misuse, which was set up as a special health authority in 2001 to ensure that there was more treatment, better treatment and fairer treatment.

Drug treatment falls into the categories of public health and health services. I shall use drug treatment to illustrate how successful initiatives can work. In order to make progress in delivering healthcare and public health, we must first know what the problem is; have a strategy for delivery, with targets such as the updated drugs strategy; collaborate between agencies at national and local level; monitor progress; and evaluate what works and what does not. That must include economic factors, such as how much it costs and what is saved by the health service through having a particular intervention. Such a programme also requires funding and staff development, but all solutions are not dependent on vast amounts of money. The key issue is to get things moving at a local level by involving communities in specific solutions that match specific needs.

Drug use is also at least partly influenced by health inequalities. The public health agenda must tackle broad issues such as poverty, housing and transport. The Minister may have some good examples of public health initiatives. We know that drug use can devastate individuals, families and communities and contribute to crime. It is estimated that around 4 million people use at least one illicit drug each year and that around 1 million use at least one of the most dangerous drugs, such as heroin or cocaine. There are about 250,000 problematic drug users in England and Wales. Drug misuse gives rise to social and economic costs of over £10 billion a year, 99 per cent of which is accounted for by problematic drug users. It is estimated that, for every pound spent on drug treatment, £3 is saved by the criminal justice system alone. Obviously, much more will be saved by other services, such as health.

The National Treatment Agency, which I chair, has the primary task of doubling the number of people getting access to treatment, from 100,000 in 1998 to 200,000 in 2008. Since the establishment of the NTA, the number getting access to treatment has increased by about 7 per cent a year. For example, in 2003–04, there were 141,000, as opposed to 100,000 in 2002–03. Waiting times have also fallen—dramatically, in some areas. In one London borough, the average waiting time for a prescription fell from 40 weeks in 2001 to two weeks in 2004.

Funding for drug treatment has increased. Record government funding of £390 million was spent on drug treatment in 2002–03. In addition to central funding, drug action teams receive local funding.

The Criminal Justice Intervention Programme, established last year, has turned the spotlight on the drug treatment system as a whole. The programme aims to co-ordinate the care of offenders and forces every agency involved, including police, court, probation, prison and drug treatment services, to work together and share information and integrate their practice. That is most essential in any kind of treatment. The National Treatment Agency is fairly small. We have worked with agencies at a local level, with Royal Colleges and with the voluntary sector to plan and deliver services. Collaboration and monitoring is absolutely key.

Drug action teams are required to have specific plans that are inspected by regional managers. That has proved invaluable and the performance of drug action teams has improved enormously. Only yesterday, I was looking at charts of progress of services up and down the country and they are impressive. It was gratifying that an independent survey of the National Treatment Agency's progress showed that treatment agencies, drug action teams and service users and carers all believe that the quality and quantity of drug treatment has improved in the past two years. That has not simply been a result of extra funding; it has been the result of a will to work together, more staff training development and a higher profile for drugs.

National frameworks such as the drug and alcohol national standards and models of care have also been significant in improving services as they have provided guidance and benchmarks. Some local examples of good practice include the Birmingham substance misuse service under the Birmingham and Solihull mental health trust, which has developed the blood-borne virus project. That offers drug users the option of being tested for viruses and being offered vaccination. It has offered services to around 250 clients since May last year and has tested 90 per cent of them.

Northamptonshire Drug Action Team has carried out an assessment which showed a need for additional services for homeless people, sex workers and people with mental health problems. It has mapped out services to identify provision and duplication. Excellent work is being done by many services for black and minority ethnic drug users, women and young people, although challenges remain.

A particularly outstanding initiative developed by the Department of Health's Black and Minority Ethnic Drug Misuse Needs Assessment Project has been the community engagement model which trained people in 47 communities to research local needs in drug use. Not only has that project provided useful information on which to build services, it has also encouraged more people from black and minority ethnic groups to become trained as workers in the drug field. The NTA's apprenticeship scheme, which is aimed at young black and minority ethnic groups, has attracted workers who may have otherwise been excluded.

I repeat my original thesis that certain measures that are applied to health, such as research, funding, targeted strategies, monitoring, collaboration between agencies, staff development and the sharing of good practice at a community level can and do make a difference.

Does the Minister agree that there is much good practice and many successful initiatives to share and transfer between healthcare services and that healthcare and public health need to work with local communities to raise awareness, assess needs and to act on the findings? National strategy must translate into local strategy and local implementation measures in order to improve the health of the nation. In discussing healthcare and health, a final question has to be: what about prevention strategies? How do we persuade people that protecting themselves and developing a healthy lifestyle is attractive? Does the Minister have any ideas?

5.13 p.m.

Baroness Cox

My Lords, I, too, am most grateful to the noble Lord, Lord Hunt, for initiating this debate and introducing it so comprehensively, and for the opportunity that it provides to raise concerns relating to my primary profession of nursing. In so doing, I must declare an interest as a vice-president of the Royal College of Nursing.

I must also offer a profound and reluctant apology to the Minister, to whom I have written, and to the House for having to leave early. Given that, I would not have put my name down to speak, but my noble friends Lady Emerton and Lady McFarlane are unable to be here today. It was felt important to put some issues relating to nursing on the record. I therefore hope that your Lordships will forgive my premature and reluctant departure for a very longstanding commitment.

Many nurses are fulfilling their responsibilities with deep commitment and high standards of professionalism. There are many developments in nursing that are designed to enhance the quality of healthcare and public health, which are warmly to be welcomed. But there is also widespread concern over pressures of many kinds that are making it increasingly difficult in many places to maintain high, or sometimes even adequate, standards of nursing care, such as those referred to by the noble Lord, Lord Winston. Such examples include problems relating to recruitment, retention, education and leadership.

Without adequate recruitment of well qualified students and staff, it is impossible to maintain an adequately qualified and competent workforce. However, there has been a disturbing and growing reliance on internationally recruited nurses. Many of them are dedicated, skilled and competent. But the reliance on nurses from abroad, especially from developing countries, is deeply unsatisfactory. Fifteen out of the 25 countries from which we recruit are on the "banned" list of developing countries, despite the code of practice. The policy of recruiting nurses from poorer countries deprives them of a much-needed professional input that they can ill afford to lose, and does nothing to provide a long-term solution to problems of recruitment and retention in this country.

One reason for the drive to recruit nurses from abroad has been the high rate of exodus of nurses from practice in this country. For example, the RCN employment survey of February 2004 found that 39 per cent of those working on internal rotation here are unhappy with their shift patterns, which makes them more prone to leave the NHS. In 2002–03, there was a 60 per cent increase in nurses leaving the profession: more than one in 10 says that they plan to leave nursing in the next two years and nearly one third said that they would leave the profession "if they could". More than a third more nurses are leaving this country to work abroad, while numbers moving to the United States almost doubled in a year.

It is slightly more encouraging that of those nurses still in practice 77 per cent were enthusiastic about their work and 74 per cent said that they found nursing a rewarding career. However, while those figures are encouraging, they obviously do not include those who have already left nursing or gone abroad. Also, more than a quarter of those nurses who are satisfied are now aged over 50, which indicates a possible demographic time bomb threatening the future supply of nurses.

Shortages of experienced and well qualified nurses have repercussions for nurse education. Students depend on good supervision to learn clinical competences, as well as the more intangible but essential aspects of sensitive, appropriate care for patients' psychological, cultural and spiritual needs. Good management is also essential for morale of staff and students and for ensuring high standards in all aspects of care in the clinical environment.

Mention of management and leadership leads to another minefield of problems in contemporary nursing. It is a fundamental principle that a profession should be led by its own professional practitioners. It is only they who can fully understand the essential requirements of practice. That is especially important in a clinical profession such as nursing for ensuring appropriate provision of care. Moreover, nurses represent by far the greatest proportion of professional workers in the National Health Service and provide around 80 per cent of direct patient care in the community.

Because of that close and continuing contact with patients, their families and communities, nurses are ideally placed to make informed contributions to health policies. They have a crucial contribution to make on policy formation at every level. In that context, perhaps I may refer to the role of the new chief nursing officer for England, who is soon to be appointed. The fact that he or she will have a place on the management board will be welcomed by the profession. But will the Minister give an assurance that the new chief nursing officer (CNO) will have a direct line of professional and managerial accountability to the CEO? Will the Minister also give an assurance that nurses will be represented on all key bodies, such as strategic health authorities, and be in a position thereby to influence the direction of key priorities, including clinical standards?

The introduction of the modern matron has been widely welcomed by staff and patients. He or she is someone who is visibly and, perhaps in the tradition of historical matrons, sometimes formidably responsible for the maintenance of high standards of care.

As regards community care, the Royal College of Nursing has welcomed the Government's recent plans—on 8 June—to introduce some 3,000 community matrons to manage the care of patients with long-term or chronic health problems. There are some 18 million people in the United Kingdom with chronic disease, whose care has too often been fragmented and marginalised. Senior community nurses who would take responsibility for such patients could enhance their care significantly. There are good precedents in the excellent care provided by many clinical nurse specialists for patients with conditions such as diabetes or asthma, or in providing palliative care. However, there are serious doubts about the availability of staff to fill these new managerial posts in the community. There is already a shortage of community nurses, and a large proportion of district nurses are nearing retirement age.

Finally, let me look ahead. Agenda for Change has raised great hopes. It is seen as a possible panacea for problems of recruitment and retention by bringing in significant improvements in nurses' pay, professional development and career structure. However, the recent Government announcement to delay its implementation from October to December has caused widespread dismay. At the RCN 2004 Congress, 93 per cent of members voted for the Government to honour the October date. I hope that the Minister might be able to reassure us on that this evening.

There is a fear that delay will be very detrimental to morale. Although the Government have said that pay will be backdated to 1 October, the RCN argues strongly that it will be a distinct disadvantage for nurses not to have their new pay and conditions on the promised date and that the delay will create disappointment and disillusionment—the last things the nursing profession needs at the moment.

In conclusion, commitment to the provision of the best possible standards of healthcare is the profession's priority and must be the touchstone for all of us for evaluating all proposals for change. The nursing profession will be awaiting with acute interest the Minister's replies to concerns expressed in this debate. I hope that he will offer the reassurances necessary to enable nursing to make its distinctive contribution to healthcare in a health service which respects nurses' professional commitment and maximises their professional contribution for the benefit of the patients, families and communities they serve, and for the promotion of health for all, which is the concern of all noble Lords here today.

5.13 p.m.

Lord Turnberg

My Lords, I, too, thank my noble friend Lord Hunt for securing this debate and for introducing it in such a characteristic, punchy and stimulating way, which I enjoyed very much. The debate is both timely and important.

I should like to focus my remarks on the need for research in public health, at a time when such research is at a low ebb. This is against a background of a Government who are committed to improving healthcare and are pouring in money at an unprecedented rate. That clearly has a good effect, given any measure we want to make, and noble Lords have given various statistics. However, I have a personal point of view, too. Having spent much of the past year visiting sick and ageing relatives in Hope Hospital and Wythenshawe Hospital in the north-west, I can vouch for the excellent standards of care they receive from all levels of staff, whose mood, for the first time, seems to be optimistic and cheerful. More importantly, the patients—my relatives—could not speak too highly of their care. So some things are improving.

There are also signs that medical research is advancing apace, with new and better treatments constantly coming on-stream. The Government have announced an extra £200 million for clinical research, in recognition of the fact that this type of research, which is essential if we are to transcribe the fruits of basic biomedical science into clinical practice, desperately needs more support. So this money—£100 million from the Department of Health and £100 million promised by the Chancellor to the MRC—is most welcome.

However, all this good news is, quite reasonably, in the arena of the health and sickness of individual patients. Now we must look at what we are doing in the spheres of public health and health protection and do a similar job, because our efforts in these areas are, I am afraid, creaking along. Without a strong research base, we will fail to have the evidence on which to make rational, effective public health decisions.

Yet the UK has a number of major advantages on which we can build. We have just set up the Health Protection Agency, which offers marvellous opportunities. We have a national service with a network of public health doctors, with the Chief Medical Officer at the top of the tree and directors of public health at the regional and health authority level and in the PCTs. What a seemingly great resource, theoretically capable of delivering high quality public health services in a co-ordinated way across the country as well as being a superb source of information on the health of the population. We also have a number of very high quality researchers, such as Michael Marmot and Roy Anderson, to say nothing of Sir Richard Doll, all of whom have an international reputation second to none.

On top of all that, we are about to embark on one of the most ambitious and imaginative research efforts into public health that has ever been undertaken. The UK BioBank research programme will take 500,000 people from the general population and follow them carefully over the next 10, 20 or 30 years to see what illnesses they develop. These will be correlated with their DNA make-up, their lifestyle and the environment. This will give us a powerful tool with which it should be possible to predict much more accurately who might be susceptible to what diseases and lead us more sensibly into prevention, the aim of public health.

We have a national network of public health staff, high quality researchers and BioBank coming on-stream. So what is the problem? We may well have these basic building blocks but we are unfortunately far from being capable of taking advantage of them. First, the network of NHS public health doctors is disconnected from the research base. With few exceptions, they do not have the time or the inclination to engage in research themselves and, more importantly, they do not engage with the research community in academic departments. There appears to be a disconnect, and much more effort is needed to bring the two sides together if research findigs are to be fed into practice.

On the academic side, although some very high quality researchers are doing very important work, they are few in number. Across the board, academic public health is in the doldrums, and sinking fast. Public health is not a popular subject with medical students, and few are tempted into it. According to recent figures issued by the Council of Heads of Medical Schools, public health had just 215 academic staff in our medical schools in the year 2000. Your Lordships might think that 215 is a pretty small number, but if I tell you that this fell to a mere 146 by 2003—a 32 per cent drop—you will recognise how parlous the academic base of public health really is. This drop by a third has occurred at the same time as medical student numbers have been rising. How can we teach public health and interest medical students if there is no one to do it?

This is happening at a time when there is considerable excitement at the prospect of broadening public health research to take on board the new technologies and developments in population genetics, the molecular typing of infections and, very importantly, the behavioural sciences, which must now feed in much more actively than hitherto. These opportunities will pass us by if we do not take action now. So what can we do?

First, we should strengthen the academic base by building up a number of foci of public health research-based departments around the country. These could be placed where they can build on existing areas of strength but within broad-based medical schools where they can interact closely with other disciplines—behavioural sciences, molecular genetics, and the like. Perhaps funding to set up the first three or four such foci might be sought by competition among medical schools to stimulate interest. It is then vital that they do not find themselves isolated in ivory towers but form the nodes of closely integrated networks with the NHS public health around the country as well as, most importantly, with primary care.

Much greater effort is needed to drive the interest of the public health fraternity that is providing the service in not only using the research, but becoming actively engaged as part of the research community. With a relatively modest investment—seed corn funding—we could take much fuller advantage of the resources already available. I hope that my noble friend will respond positively to those ideas. I know that he is already aware of the need for research in public health. I hope that I can give him a little encouragement.

I now turn to the need for funding for research by the Health Protection Agency, and I express an interest as an ex-chairman of the board of one of its predecessor bodies, the Public Health Laboratory Service. In order for the HPA to stay ahead as new infections emerge and as old ones re-emerge in new and more resistant forms, it is vital that the excellent scientists at the HPA are given the resources to seek new and better diagnostic tests and develop new vaccines and new treatments. It needs to be able to do the necessary research that underpins those activities, yet amazingly it is not given a research budget. It is quite successful at getting research grants in open competitions, but it is not given anything to provide seed corn funding for pilot studies which precede bids to outside bodies.

That small amount of funding, which the PHLS was able to carve out itself from its own meagre resources, is no longer available. I believe that to starve the HPA of research funds when we are threatened by SARS, bio-terrorism or any of the other new dangers—as we inevitably are—is foolhardy and dangerous. I hope that my noble friend, with his clear understanding of the need for research, will consider whether anything can be done to correct that anomalous position.

5.31 p.m.

Baroness Gale

My Lords, I would also like to thank my noble friend Lord Hunt for bringing this very topical subject to you Lordships' House tonight. There are many aspects to this topic of healthcare and public health. We have had many experts in the medical field speaking tonight. I am approaching the subject as a consumer and patient—one who has used the NHS far more in recent years than when I was younger.

I have found that using the NHS differs at different periods of one's life. When I was expecting my two children and when they were growing up, like most mothers, I was a frequent user. Then, for many years, I did not need the health service except occasionally for a dental check-up, because I am fortunate in having good health.

Although I regard myself as healthy, something happens to one's body as one gets older and there is a need to visit a GP more frequently. Eighteen months ago, I took advantage of the medical check-up that is available to all Members of your Lordships' House. Much to my astonishment, I was diagnosed as having very high blood pressure. I told the nurse that I felt perfectly healthy, but she told me, rather smartly, that it has no symptoms. She advised me to visit my GP immediately, which I did. I was given medication. Thankfully, my blood pressure is now normal. However, much more information should be given to people with high blood pressure.

I did not have much understanding of blood pressure, so I did some research on what causes high blood pressure and what can be done to avoid it in the future. Having access to the Internet was a great asset. I learned so much about how to ensure that blood pressure stays normal and how dangerous high blood pressure can be. If untreated it can cause strokes and heart attacks and, in many instances, sudden death.

Reducing the amount of salt in one's diet helps. Taking more exercise and losing weight is beneficial. I was amazed to find how much salt is in the food that we buy. It can be very difficult when one is trying to cut down on salt. I am very pleased to note that the Government are taking a great interest in this matter and are encouraging the food industry to cut down on the amount of salt that it adds to food.

I did not know that two basic foods—bread and cereals—contain high levels of salt. One of the problems in giving good information to the customer is the labelling of food. For example, unsliced bread does not come with a list of ingredients and, more often than not, unsliced bread is on sale unwrapped. I am not sure why that is allowed, because most foods now list all the ingredients, although the print is often so small that it is difficult to read. Why is bread seemingly exempt from the need for labelling, especially as it has a high salt content? It would be a great help to consumers if they were made aware of how much salt is in bread, and cutting down on salt would have a beneficial effect on the health of the nation. The Food Standards Agency is carrying out much work in this field. It has told manufacturers that it wants an average reduction target of 32 per cent in the amount of salt in manufactured foods. It also publishes useful information on salt intake.

I know from my own experience of suffering from certain food intolerances what a problem food can be, as it affects one's health. Why natural foods such as citrus fruits, tomatoes and strawberries have a bad effect on some people's health is a mystery to me, although of course I am not advocating a ban on the sales of these foods and do not hold the Government responsible. There are occasions when individuals must take responsibility for their own health. I believe that the Government have a major role in informing people of the danger of food that contains excess fat, sugar and salt. It is all about informing people who would otherwise not be aware and encouraging people to have a healthy diet, which is much easier said than done. We all have difficulty in sticking to certain diets occasionally. I hope that the current consultation paper will help in this task and I look forward to seeing what the Government's plans will be when the analysis of the responses is finalised.

On another aspect of customer use of the NHS, I have found NHS Direct very useful. Whenever I have needed to use it I have found the advice very helpful—it often does away with the need for a visit to the GP. I recently discovered NHS Online. That is a very good website—a mine of information. It is very useful all round, especially for people who do not like visiting their doctor's surgery. We should give much more publicity to the scheme. I have seen NHS Direct cards in chemists and pharmacists. Are there any plans to give greater publicity to NHS Direct and NHS Online such as making the publicity available at supermarkets, service stations, garages and at the tills of as many shops as possible, to make it handy for people to learn about the service and that information is available for them? The NHS Direct cards are similar to credit cards. They are easy to pick up and put in a purse. The more people who are made aware of these services the better, because they are such good services.

I would like to mention another topic on the health front, again from my own experience of suffering from migraine. I have found the cause, which in a sense, is a cure. I do not need to take medication to prevent migraine. I have only to avoid certain foods. I did not get that diagnosis from my GP but from a complementary medicine practitioner with a test that took only about 30 minutes. I was very pleased to discover the cause of my migraine by this method and I believe that I have saved the health service the cost of drugs to help me overcome my migraines. This type of medicine helps many people but I have not seen any coming together of the two sides—the medical and alternative practices. I am sure that there are many health problems that could be overcome. Are there any instances of a GP recommending a reliable complementary medicine practitioner to alleviate the problems such as migraines or others that I know of such as those related to dietary problems?

I know people who have changed their diet and, consequently, found relief from their symptoms on the advice of a complementary or alternative practitioner. Are their any examples of both sides of the medical field working together in that way? Would the NHS pay for that type of treatment, as I believe that it could be very beneficial to some people?

I have spoken purely as a lay person who believes in the value of a free National Health Service available to everyone who needs it. It is a great institution of which we can be proud. The Government have put many resources into the NHS over the past seven years and the evidence is there for everyone to see. In my own area we have a great new hospital, the Royal Glamorgan, and there are plans for a badly needed new hospital to be built in the Rhondda.

Health is a devolved matter in Wales, and I am very pleased that the Welsh Assembly has been given additional money to spend on the health services in Wales. We are seeing the benefit. My own experience and that of my family and friends in using the health service is that it is something that we often take for granted, knowing that it is there when we need it. We may have some grumbles, but we know that we do not have financial worries when we need healthcare. It is the knowledge that if we become ill we will be taken care of by a range of dedicated National Health Service staff. That is the great story of the NHS.

5.41 p.m.

Lord Soulsby of Swaffham Prior

My Lords, this House should be grateful to the noble Lord, Lord Hunt of Kings Heath, for setting down this debate, as there are issues here for careful and detailed consideration. I shall concentrate on the issue of public health. I declare an interest in that I am the incoming president of the Royal Institute of Public Health.

The threats to both normal health and public health in this country are constant. It is not a question of whether but when the next epidemic will occur. It may be imported from abroad through increases in travel or transport of animals; or illegal transport of substances and meat and meat products, such as bushmeat coming in from Africa; or it may arise from ignorance or from ignoring strong advice given within the country.

The noble Baroness, Lady Finlay, referred to the question of tobacco. I was privileged to hear a lecture by Sir Richard Peto about two weeks ago at the Royal Society for the Promotion of Health. He produced alarming statistics on the number of people—especially teenagers—who were taking up smoking, and the health consequences of that being a massive number of deaths from smoking-related diseases in the coming decades, amounting to tens of millions of people worldwide. That is one of those major areas of which we are all aware, but we do not seem to be able to get the message across of the impact of tobacco on our health.

In December 2003, this House debated the Science and Technology Committee report on fighting infections, which related to infectious disease. The report was well received, and a major development coming out of the report, and out of the evidence provided for it, was the establishment of the Health Protection Agency. This debate may serve in part to assess the progress of the Health Protection Agency in the intervening months from when it was set up.

Of course, public health involves more than infectious disease alone. Rather, it is bringing together all the aspects of the environment—buildings, ventilation, drainage, sanitation and human behaviour. Recent examples of how all those put together both contributed to and provided a solution to the problem of SARS is now well documented, as is the example of Legionnaire's Disease.

Historically, the United Kingdom has relied very much on its own experience in developing policy for public health, but it should no longer do that since disease in all its forms is given to serendipity and outbreaks of disease and epidemics can occur at any time—and often at an inappropriate time when we are unprepared for it. We must learn much from the experience of others elsewhere in the world, in areas where the United Kingdom record is more patchy than it should be.

Hitherto, a vulnerable point has been the co-ordination of local, regional and national bodies in this country as a whole. The House of Lords committee's report strongly emphasised the need for improved collaboration between the different agencies and their relationships across the many services that they will deal with, especially during the epidemic of a disease, be it an infective or non-infective disease. The specific recommendation made by the House of Lords committee report was that the Health Protection Agency be provided with resources to take on specific and primary responsibility for integrating surveillance relating to human, animal and food-borne diseases.

During our inquiry, we were concerned to learn that there was a growing national shortage of environmental health officers—the personnel concerned at a very basic level with surveillance of diseases in all forms. They are very basic to the approach to public health, by way of food inspection, investigation of local conditions, the hygiene of food provision establishments and so on. We hoped that the Government would investigate the reason for that decline in numbers and take steps to reverse it. I hope that the Minister will give some information as to what has happened with that recommendation and how it may have affected the supply of those valuable people.

Important components in the fight against disease and the maintenance of health are the development of diagnostic aids, facilities and vaccines. That issue was referred to in the maiden speech of the noble Lord, Lord Drayson, on which I congratulate him. The early diagnostic aids, such as bedside aids, when they are reliable, are very important in the surveillance, epidemiology and hence the detection and prevention of the spread of disease. For example, if an infective agent can be identified at the bedside by one of those technologies, such as the dipstick technology, and we can establish its susceptibility or otherwise to an antibiotic, we will move forward most effectively in disease control and public health. But such diagnostic tests take time to develop.

One of our recommendations in the report was that the Government, through the Health Protection Agency, should recognise the need for further funding to be placed for such developments. That plea was echoed by the noble Lord, Lord Turnberg, in his speech.

Finally, I must once again come to the issue of vaccines and their development. We should all be concerned that the United Kingdom facilities for vaccine production have declined in recent years. The Government have agreed with that finding. There was, and is still, a significant deficit in vaccine capacity. The Select Committee saw the need for a secure supply of vaccines in the event of a major global epidemic, such as might occur should there be re-assortment between the avian flu virus that is now sweeping the Far East and the human flu virus, leading to a viral strain that could equal the Spanish flu pandemic. In particular, the HPA Porton, previously known as the Centre for Applied Microbiology and Research or CA M R, could well serve as a centre for such development of vaccines. Many organisations in this country, and elsewhere for that matter, consider it to be imprudent not to have a strong vaccine capability at HPA Porton. Will the Minister bring the House up to date on this important issue?

In my opening comments, I suggested that this debate could serve in part to identify the progress of the HPA in the months since it was established. While I believe that it has progressed well and is responding most effectively to emergency situations such as SARS, there has been a question about the adequacy of funding since its establishment, which the noble Lord, Lord Turnberg, has identified. Can the Minister assure the House that this is being adequately addressed?

5.51 p.m.

Baroness Gould of Potternewton

My Lords, like other noble Lords, I thank my noble friend Lord Hunt of Kings Heath for initiating this debate and for his inspiring introduction to it, which reminded us of some of the progress that has been made in healthcare. It is progress that we all too often take for granted. We accept the benefits without appreciating the efforts that have gone into making those changes.

I shall concentrate my remarks on sexual health as a public health issue. Before doing so, I must declare an interest as chair of the Independent Advisory Group for Sexual Health and HIV, president of the FPA and chair of the All Party Pro-Choice and Sexual Health Group.

I start by congratulating the Government on their initiative in setting up the review of sexual health, ratifying its conclusions and putting in resources to make the strategy work. The Government should also be congratulated on defining sexual health as an important part of physical and mental health, and of an individual's well-being, not just as a peripheral issue, which it is seen as all too often. We must recognise that when the Government took that initiative there had been years of under-resourcing, lack of central direction, lack of priority, and low awareness and understanding of sexual health issues.

The question now is how much progress has been made on the strategy and what remains to be done. The response to that question has to take into account two fundamental developments since the strategy was produced. They are the shifting of the balance of power—a terrible jargon expression for transferring power from the centre to the newly established primary care trusts—and the continued rise of new diagnoses of STIs and HIV.

I make no apologies for repeating the state of the nation in respect of sexual health. There are 50,000 people living with HIV, which is 20 per cent more than in 2001–02. Cases of gonorrhoea are up by 148 per cent, cases of infectious syphilis by 380 per cent and cases of chlamydia by 195 per cent. The Government's estimate is that as many as one in 10 people are affected by chlamydia. This growth means that GUM clinics have to deal with 1.5 million clients each year.

It is crucial that we understand that we are talking about preventable transmittable diseases. It is estimated that one act of unprotected sex can create a 1 per cent risk of acquiring HIV, a 30 per cent risk of genital herpes and a 50 per cent risk of contracting gonorrhoea. There is no way that we can expect people to abstain from having sex while waiting for treatment. Speed of treatment is essential. There is no doubt that sexual health is now the greatest growing risk to public health.

It was a surprise and a delight that sexual health was included as a public health issue in the White Paper Choosing Health? Like others, I await the conclusions with interest and expectation. The response from the independent group that I chair is, I believe, robust and practical and sets out the issues fairly, as well as giving many examples of initiatives that are being taken at local level. I want to pick up three areas from our response: prevention, services and staffing.

The key to improving sexual health has to be prevention through better education, better awareness of the risks of unprotected sex and support programmes for parents and carers. It is therefore encouraging that Ofsted is to be asked to report on the teaching of SRE in schools and that expenditure is being made available for teacher training because all the evidence shows that PSHE and SRE remain patchy and underresourced and are often delivered by non-specialist, reluctant and poorly prepared teachers. It is essential that sex education is not only improved but is made a statutory part of the national curriculum, with a designated teacher in each school.

As I said in the debate last week on adolescent health, I find the lack of awareness of the risks being taken by having unprotected sex really disturbing. In a survey in Sheffield, 40 per cent of pupils aged 11 had never heard of HIV and, while there is a growing awareness of chlamydia, 40 per cent of girls still believe that the pill protects them from catching STIs. We must raise awareness. It is the key factor in prevention. The £4 million allocated by the Government to the sex lottery campaign and teenage pregnancy media campaigns is welcome, as are schemes in colleges, nightclubs, sports clubs and workplaces for promoting good sexual health. But the messages have to be imaginative and relate to the age group at which they are directed because we must counter the message, pushed by sections of the media, that sex is the norm and that having sex is really a very cool thing to do. These campaigns are rightly being accompanied by programmes designed to educate parents and carers so that there can be greater openness and understanding across the generations.

The total cost of adverse sexual health each year is more than £4 billion. Therefore, prevention not only makes healthcare sense but also economic sense. I shall give two examples. The prevention of unplanned pregnancy by NHS contraception services already saves the NHS £2.5 billion a year. Chlamydia is a recognised cause of pelvic inflammatory disease, which is a major cause of infertility. Infertility treatment, which the Government have, quite rightly, agreed should be funded by the NHS, is costly. Common sense tells us that to roll out the chlamydia screening programme more speedily would save a substantial amount of money for the NHS in the long term. I believe that we should have a slogan saying, "Invest to save by reducing the demand".

Open access to GUM clinics is almost a thing of the past. While it is encouraging that the Government are working towards a 24-hour target, it is more likely to be achieved if that target were a PCT star indicator as currently only 15 per cent of clinics can achieve it. I would like to hear whether the Minister has any plans for that to happen. Average waiting times are currently between two and four weeks, with six weeks not being unknown. Whenever a client is not seen, transmission will continue.

The Government have provided additional and welcome resources to PCTs for GUM services but a recent study showed that 40 per cent of clinics received only a proportion of that money and 21 per cent received nothing at all. The PCTs had diverted the money to other uses. It is essential that, in spite of the shifting of the balance of power, money allocated for a purpose is used for that purpose. I welcome the efforts that are being made to see how this can be achieved. I look forward to hearing what has been achieved so far. However, services will be seriously improved only when PCTs are encouraged to prioritise sexual health by its inclusion in local delivery plans that are adequately performance managed.

I shall say a brief word on staffing. I have the most enormous praise for the staff who work in sexual health. Their enthusiasm fills me with delight every time I visit clinics and have conversations with them. However, there is a real shortfall throughout the NHS. In GUM, the shortfall is estimated by the department to be of 204 consultants. There is a similar picture in NHS contraceptive services. In 2001–02, about 1.2 million women and 91,000 men attended specific family planning clinics, but only 68 consultants and 89 senior doctors worked in the area. Workforce issues have to be tackled. It is encouraging that more than 1,000 nurses have applied for the government-supported sexual health distance-learning packages. However, we should look at not only levels of staffing, but more imaginative and innovative ways of using the staff.

In congratulating the Government on the start made, I make a plea for investment to save, better co-ordination, more joined-up working between services with targeted prevention, and increased investment in awareness-raising programmes. Crucially, providing good sexual health has to be identified as a priority, nationally and locally. I ask the Minister whether that will be achieved.

6.1 p.m.

Baroness Pitkeathley

My Lords, like my noble friend Lady Jay, I remember the debate in this House on the 50th anniversary of the health service. I seem to recall that it was also initiated by my noble friend Lord Hunt, whom I congratulate on initiating this debate. I also have great pleasure in congratulating my noble friend Lord Drayson on his most excellent maiden speech.

In my speech in 1998, I emphasised that there were two clear ways in which we could hasten improvements in the NHS. One was to make it infinitely more patient-centred than it had ever been; however welcome the NHS was in 1948, no one could pretend that the needs of patients were at its heart. The other was to start thinking about the health service as a service about the health of the nation, rather than one that focused on sickness. It is always a temptation to think of the NHS as being about elective surgery and hospitals, when it is more about chronic illness and care than surgical interventions. It is much more important to think about what will enable us to maintain good health rather than treat sickness. Six years on from that debate, I am delighted to say that enormous progress has been made in those areas. I want to highlight three of those areas in my short time today.

Many noble Lords will know that, like others in the House, I owe my life to the NHS, through the care that I received in the Middlesex Hospital over many months three years ago. The difference in the culture and attitudes of staff compared with during a previous hospitalisation 14 years before was striking. Not once in the seven long months that I spent as an in-patient did anyone carry out a procedure, administer any drugs or do anything at all without involving me in the process and checking it out with me. The more cynical among your Lordships may say that that is because I am articulate, would have made a fuss if they had not done so—as indeed I would—and that they do not get many Baronesses on a public ward. However, it was not just me—that attitude was present with every patient on the ward.

Since that time, we have gone even further in enshrining patient participation and involvement in the NHS, with the setting up of the Commission for Patient and Public Involvement in Health and the establishment of a specific post at the Department of Health to promote it. That post is in the very capable hands of Harry Cayton, who is having such an effect on the attitudes of policymakers. To be sure, putting patients at the heart of things is more a matter of changing culture than of procedures. It is hard to do, but huge strides have been made and everyone involved deserves our congratulations. The one criticism I might have had about my care was that my notes stood more than one foot high in manila folders, so no one could ever find anything. However, I am delighted to say that that problem has been addressed by the Government's IT programme for patient records.

The second area to which I want to refer is support for those who provide the bulk of healthcare in our society. That is not doctors, nurses or even care workers, but families. There are 6 million carers throughout the UK, around 2 million of whom start or stop caring every year. The care that they provide has been valued at £57 billion, equivalent to a second NHS. They outnumber NHS professionals six to one. Over the past few decades, carers have called and campaigned for much greater involvement, and for a greater say in the planning and delivery of healthcare. Recent years have seen a number of pieces of legislation that have vastly improved the situation for carers. As a result of that legislation, there cannot be a single NHS body that does not specifically include carers as part of its planning processes.

The Health Act 1999 and the Health and Social Care Act 2001 emphasise involving carers in planning, while the National Health Service Reform and Health Care Professions Act 2002 mentions carers specifically and gives them a place on the boards of patients forums. Discharge procedures now include ensuring services for carers. I am pleased to say that there has been further progress on identification of carers by primary care professionals.

One study of carers' experiences of the NHS, carried out in 1998, asked them to rank their priorities for the NHS. The top priorities included closer working between health and social services, more funding for the NHS, training for doctors and nurses in carers' needs, and regular health checks for carers. Great progress has been made with all those elements of recognition and support for carers, which are important not only in enabling them to care better and with less stress, but also in helping them to maintain their own health as long as possible. Make no mistake, it makes sound economic as well as moral good sense to support carers as part of our NHS and social care policies. I am delighted to say that yet another Private Member's Bill on the subject—the third in recent years and the second under this Government—comes to the House on Friday under the wise guidance of the noble Lord, Lord Ashley.

In a link with my remarks about a health service rather than a sickness service, we have also made significant progress, so far as public health is concerned, on focusing on the causes of ill health, and from there on the prevention of illness. The single most identifiable cause of ill health is simply poverty, and I am proud to be associated with a Government who accept that and have the courage to start tackling it. Where we have poverty, poor housing, lack of employment and fewer people taking up educational opportunities is where health needs are greatest, and where deaths from diseases associated with poor diet, lack of exercise and lack of knowledge about what contributes to good health are highest. That includes, of course, those diseases high on the Government's targeted priority list, especially cancers associated with smoking and diet as well as coronary heart disease and stroke. The Government are to be congratulated on making those targets for special attention, which undoubtedly has redistributed some resources.

Nor should we forget that poverty is associated with those diseases that are not actually killers but none the less have a devastating effect on families and communities, such as depression and other forms of mental illness. The establishment of health action zones, undertaken by the Government shortly after they came to power, was a major step forward in addressing inequalities in health. However, the most important change that we can bring about in this area is to educate patients and potential patients about how best to care for their own health. In that regard, I draw attention to a very important programme run by the New Opportunities Fund, now the Big Lottery Fund, of which I was chair until recently. It was one of the original programmes given to us by the Government under the National Lottery Act 1998.

Healthy living centres promote good health in the widest possible context, with 350 now established throughout the United Kingdom, targeted at the most deprived communities. They offer a range of activities, addressing the wider determinants of health. Many of the planned activities address public health priorities. For example, 80 per cent offer services for coronary heart disease and stroke, while 50 per cent work with teenage mothers, a key group for reducing infant mortality and improving the lives of women and their children. About half the centres provide dietary advice, run food co-operatives or offer cookery classes, and some do all three. Some 64 per cent offer smoking cessation services and many offer services for young people on the topics of drugs and sexual health.

One example of good practice is the Sussex Downs and Weald Primary Care Trust, which is particularly relevant to our current concerns about obesity. There a partnerships aims to promote a sustainable local food system that supports good nutrition and human health and works for the benefit of consumers, producers and the environment. Target groups include those on low incomes, adults with disabilities, children and adults in care or day centres, older people, school children, older men living alone and those living in rural areas. Two community chefs promote access to healthy diets by delivering cookery programmes and demonstrations for community groups and schools. They offer community food projects, training in schools, breakfast clubs, healthy tuck shops and farm visits. Interested shopkeepers are trained in extending their range of local produce and linking with local farmers.

That imaginative use of lottery money is just one of the many ways in which this Government are tackling public health issues and, of course, has a close link with the £750 million of lottery money allocated to encouraging physical activity in schools. Educating our nation about health and encouraging people to live healthier lives is as important as providing better services. That this Government are managing to do both is a record of which to be proud.

6.11 p.m.

Baroness Masham of Ilton

My Lords, I thank the noble Lord, Lord Hunt of Kings Heath, for introducing this most interesting and important debate, enhanced by the excellent maiden speech of the noble Lord, Lord Drayson.

The Government must be congratulated on putting extra money into the National Health Service, but the question is whether this money is reaching patients who need correct, efficient and caring treatment and the most appropriate equipment for the seriously disabled if they need it in their own homes.

For some years I have been concerned when health authority members who were non-executives were cut and replaced with professional executive members who had formerly been advisers. I do not know whether patients have benefited, but I do think that the number of managers has increased. Perhaps "jobs for the boys" was the result of those management changes, which took place in the time of the Conservative Government and has been carried on by the present Government. Both parties seem to say that the NHS should be patient-led, but that seems to be words rather than action, as patients or patient organisations have not been given independent tools to do this. If I am wrong, I hope that the Minister will correct me.

I want to raise yet again with your Lordships the important subject of MRSA. Methicillin-resistant staphylococcus aureus has become a matter of life and death. MRSA is a major problem around the world, causing hospital-acquired infections and, more recently, infections in the community. The glycopeptides, particularly vancomycin, have been the main stays of therapy for MRSA and the emergence of resistance to those agents is of great concern. It has been found that there are over 100 strains of MRSA and several are mutant and drug-resistant. It is thought that doctors will have to try different combinations of antibiotics to try to defeat the infection. That is successful in the treatment of HIV/AIDS. Encouragement should be given to researchers to beat this hazard.

I shall give three examples of cases I have heard of in the past few weeks. A one year-old boy had a heart operation which was successful in the Freeman Hospital in Newcastle-upon-Tyne, but afterwards had to fight for his life with septicaemia due to MRSA. My nephew's mother-in-law died at the Whittington Hospital in London with MRSA two weeks ago, and a woman who is in a Sheffield hospital, having had a hiatus hernia operation, developed MRSA at the site of the epidural injection that she had for anaesthetic. There is great concern about the cleanliness of the hospitals and staff and the extra time that is spent in hospital.

Can the Minister say if Bioquell has been found to be a successful cleaning agent against MRSA? How much research is being carried out—and in which places? I know that the Minister has been out of the country recently, but will he agree that MRSA has become an important public health issue, illustrated by the recent research undertaken by checking MRSA at bus, tube, train, tram and coach stations. It was found on ticket machines, doors, escalators, lavatories, telephones and in many other places. Manchester and Westminster were worst affected.

Tony Field, who was a victim himself and went on to found the MRSA Support group, said: This illness, which started in hospitals has now spread to every sphere of society. Failure to observe hygiene discipline can turn medical staff from dedicated professionals into carriers, with potentially tragic consequences". Much is said about patients having a choice of hospital. When I had to be admitted to hospital last year when I broke my leg in one of your Lordships' fire doors, my choice was to go to a hospital where I could avoid getting MRSA.

Good communication is so important when one is dealing with seriously ill patients. Over the Easter Recess my husband was in intensive care, desperately ill, in North Yorkshire. He was looked after by a military surgeon as a result of the closure of the Catterick military hospital. The military personnel have moved to the local hospital and I found both the military doctors and nurses had better communication skills than the civilian staff. I have also found that improvements could be made between hospital therapy staff and social services departments. Unfortunately, in our case these are not coterminous.

A frustrating example that is still going on is the provision of a sling suitable for my husband to sit on, which has been recommended by the hospital-trained health and safety officer. But the social services occupational therapist has not agreed to that. Why cannot they co-operate and communicate? They have managed to confuse my husband's carers, who are struggling, and this causes discomfort to my husband. On the other hand, my noble friend Lady Darcy de Knayth, who lives in Maidenhead, was provided with her equipment in record time when she came home from hospital. Provision in NHS social services is patchy across the country. So often it depends on communication between providers and managers; and when there is slow provision there will be a multitude of excuses.

In the case of patients with motor neurone disease, which is a rapidly progressive disease, it is even more vital that equipment needs are assessed quickly and equipment provided promptly. Otherwise the person may die before he or she receives it.

Specialised services account for 10 per cent of commissioning costs and affect hundreds of thousands of people with conditions such as liver disease, multiple sclerosis, renal failure, spinal injury, cystic fibrosis, pulmonary hypertension and many more. Specialised services are an integral part of the NHS but have remained a peripheral consideration in the formulation of health policy. This needs to change. The healthcare standards being drawn up by the Department of Health need to reflect the importance of commissioning and make suitable reference to the specialised services national definition set.

It is encouraging to hear about the testing by pharmacists being developed for diabetes, chlamydia and blood pressure. Early diagnosis helps to prevent deterioration of health and the spread of infection. A quick new test for HIV being is also being developed, but this will need counselling facilities.

Government departments should join together to promote good health and warn the public against risky living.

6.20 p.m.

Baroness Warwick of Undercliffe

My Lords, I, too, congratulate my noble friend Lord Hunt of Kings Heath on enabling our House to debate this timely issue and on a most stimulating introduction. I also add my compliments to my noble friend Lord Drayson.

I need not remind the House that universities are key players in the delivery of modern healthcare services. Therefore, I declare an interest as chief executive of Universities UK.

A well educated workforce is at the heart of high-quality service delivery and underpins the delivery of the NHS Plan. More than 300,000 students are studying health courses in the UK. At a conservative estimate, UK higher education institutions are providing services to the health service worth some £1.5 billion annually. Over 21 per cent of all expenditure in universities is health-related.

It is an area of universities' work in which there have been significant developments in the past few years. The integration of nursing, midwifery and allied health professional training within higher education has been a great success. Not only have universities added value to the acquisition of traditional skills and competencies, but they have laid the foundations which are enabling nurses and midwives to take on new clinical responsibilities.

Meanwhile, the planned intake from autumn 2005 of nearly 6,000 new medical students represents an increase of 57 per cent in the numbers of doctors our universities are training. Four new medical schools have been established—at the University of East Anglia, the Peninsula Medical School and in partnerships between the universities of Brighton and Sussex and Hull and York—as well as a further four new centres of medical education. So universities play a vital role in delivering the healthcare and modernisation agenda. It is therefore crucial that the Government continue to support them in their work.

I warmly welcome the Government's decision to make available additional funding to enable universities in England fully to implement the consultant clinical academic contract. This will enable parity of employment conditions to be maintained across the NHS and university sectors. And I trust that my noble friend the Minister will recognise the vital importance of maintaining this parity into the future.

My noble friend will know, however, that there is an urgent need for a resolution of the funding issues for pre-registration courses in nursing, midwifery and the allied health professions. As the House will know, it is intended that students on such courses should not pay variable fees. On the basis of a shared commitment among universities, the price for such courses is to be determined centrally by the Department of Health. This shared commitment might be put at risk if there is further delay in reaching an agreement on a standard contract and price. I hope that my noble friend will be in a position to reassure me on this point.

However, I am delighted by the Government's decision to increase substantially the Department of Health's research and development budget from £1 billion to £1.2 billion by 2008. I also welcome the decision to establish a clinical research network. These decisions, alongside the Government's work on a 10-year science strategy, provide an ideal opportunity to establish a new forward-looking research strategy based on partnership with universities.

My noble friend Lord Turnberg spoke eloquently on the huge importance of research to public health and on the dangers it currently faces. I want only to reinforce the points he made about the need for investment. Future priorities for investment should recognise the need for, on the one hand, investment in the laboratories which underpins clinical research and, on the other hand, investment in areas where research is under-developed, including primary care, public health, nursing and the allied health professions.

It is critical that we think about the medium and longer term needs of the nation and how universities can help to address the challenges we will face. The Government are rightly placing an increased emphasis on health promotion and I think there is an opportunity here—and indeed a need—to unlock the creativity which exists in our universities so that they can contribute fully to the public health agenda.

One of the lessons of the report published by the Health Select Committee in another place is that a society-wide approach is required if we are to tackle the problem of obesity. Universities are ideally placed to take forward such an approach due to the breadth of their subject portfolios. Disciplines as diverse as psychology, environmental studies, marketing, consumer studies and the creative arts all have the potential to make a significant contribution. Indeed, by engaging a much broader range of subjects on an inter-disciplinary basis, universities have the potential to make a significant contribution to the health of the nation.

Inter-disciplinary learning is becoming increasingly characteristic of healthcare-related education in our universities. Many of the allied health professions, such as physiotherapy, occupational therapy and radiography, have benefited from close integration with higher education. More generally, closer links are being established across a range of health and social care disciplines. The goal is an holistic approach to healthcare—both from the point of view of the individual patient and more broadly at a strategic level.

The recent establishment of the cross-departmental Strategic Learning and Research Advisory Group has provided a valuable forum within which the strategic aspects of teaching and research in health and social care can be addressed. While I am pleased that universities are represented on this group, I would like to take this opportunity to highlight again the potential for them to contribute much more to the policy development process.

But I want to end with a word of warning. One of the unintended consequences of the structural changes in the NHS and the move to greater localisation is likely to be the splintering of teaching, research and patient care. I hope that Universities UK's publication, Partners in Care, demonstrated that teaching and research are integral to efficient patient care. There is a serious concern that over time this contribution may be placed in jeopardy as a result of the pressure in the NHS to focus on immediate local service priorities.

I am sure that the opposite direction is the right one. We need long-term strategic thinking if we are to face up to the challenges our health service will have to meet in this century. Our universities have already made a vital contribution to patient care. We should now recognise their potential to play a broader, more strategic role in improving the health of the nation.

6.28 p.m.

Lord Desai

My Lords, I, too, thank my noble friend Lord Hunt for introducing the debate. As he indicated, much has happened since the NHS was inaugurated, but, clearly, much still needs to be done. Like my noble friend Lady Gale, I find that I use the NHS more as I get older. As I use it, I do not like it very much. I find it somewhat troublesome. Of all the public and private services I use, it is one of the most difficult to use. I am sorry to say that. It is very good for acute and emergency problems, as at least two noble Baronesses indicated they experienced, but it is slow. I have to wait a long time and I do not get things as quickly as I should. Although it is free at the point of use, I would like to have better service.

I want briefly to devote my comments to how I would see the NHS improve. I do not think that anyone will take any of my remarks seriously but I shall make them anyway. First, I want to see greater patient ownership of the service. I have proposed a device in the past and I shall propose it again. Every patient should have a card which, like an air miles card, indicates a number of points which can be used. Let us say that we spend roughly £1,000 per person per year from the NHS budget and, as this is a simple example, let us give everyone 1,000 points. The little plastic card would carry the patient's National Health Service number and indicate that 1,000 points were available. It would enable the patient to go anywhere and use any NHS facility. He would not be confined to his local area nor, it is hoped, would he be confined to his local GP; he would be able to go to a variety of places.

Such a card would make people realise that it is a national and not a local health service. People should not be confined to going to particular hospitals. We now have sufficient experience of working on-line to be able to search around to find out where the queues are shortest. After all, it is a national health service, so why should we not do that?

I should also like the card to indicate how many points I spend each time I use the service, and especially how much I spend each time I waste the health service's time by not turning up for an appointment. Points would be deducted each time I used the service. That would be very useful because people should know that, although the service is free at the point of use, it is not without cost. A resource cost is involved in everything that we do. Different hospitals might be able to charge a different number of points for services. That would be a very good comparative device and would improve allocation within what is a free National Health Service.

When I have made that suggestion in the past, people have responded, "Ah, but what if people run out of their 1,000 points?". The answer is: that is fine; they can have an overdraft. I am not worried about the few marginal or peripheral cases where people exceed their allotted number of points. People can carry them throughout their lifetime.

The reasoning behind allocating people points has nothing to do with budgetary constraints; it is that it would make people aware of the costs involved. It would give them the idea that, with that card, they could go anywhere and use whatever facilities were available. I think that that would improve matters, especially where the NHS postcode lottery comes into play. That often happens because people are confined to their local area and do not think that they can move to another area. That is my first suggestion, and I hope that some version of it can be adopted.

My second proposal is slightly more incendiary. We have had a number of discussions about obesity and what we can do about it, including the suggestion that multi-disciplinary, all-singing, all-dancing university centres should be set up to deal with the problem. My view is that the problem is not really that difficult to understand, especially in relation to children. It comes from eating the wrong foods. It is not rocket science.

Crisps, biscuits and sweet drinks not only rot the teeth, they make you fat. We know that. We can exhort people and tell them that they should not do this or that. But I am an economist, and I know that that does not work. It is simple: we should tax them. We should put just one penny on every packet of crisps and every sweet drink. After all, we tax cigarettes and alcohol on the ground that they are bad for health, so why do we resist the idea that food can be bad for health? We do so only because we still have a primitive notion of a hunter-gatherer society, in which food is essential for existence. But why cannot food be taxed?

I am a martyr to the taxation of food. I lost my job 10 years ago by saying that VAT should be put on everything, but I shall say it again. I cannot resign from the Back Benches—I am sitting as far back as I can go! I make that suggestion very seriously, and it would be consistent with the VAT regime in other European countries. It is not unknown; we would not be doing anything new. But if we are serious about countering obesity, let us tax the foods which make children fat. If we want to be subtle about it, the tax can be proportionate to the fat or salt content of a product, which can appear on the label. If scientists tell us that something is harmful and causes obesity, it should be taxed proportionately.

People will say that such a move will not make much difference because people will just spend more money and the poor will get poorer, and so on. People used to say that about congestion charges. But where the congestion charge is introduced, people's behaviour changes. If we tax fattening foods, I guarantee that people's behaviour will change. I have absolutely no doubt in my mind that, if we want our children to be healthy, we should tax food in such a way that it directs their behaviour. We do not want to restrict people's freedom to do what they want to do; we simply want to make it more expensive for them to behave badly and they will behave better. That is as true a science as I know—it is called economics, and I know that it works.

6.36 p.m.

Lord Addington

My Lords, I have the unenviable task of following the noble Lord, Lord Desai, when he is in trouble-making mood. I must admit that I asked what the thinking was about the same subject in a debate on public health about three or four weeks ago. So I have an ally and I wonder just how much farther back I can go.

My first point is that, when we talk about public health—the subject on which I want to concentrate—we must think about a cultural change so that people look after themselves. One of the most efficient ways in which we can do that is by bringing together one thing that we do with our bodies—that is, what we put into them—and what we do with them in the way of sport and exercise patterns. We must think about encouraging those activities as well as encouraging people to eat healthily. If we establish patterns of use for people's bodies, they will become more aware of what they put into them in the first place. Of course, one can look at the issue the other way round: if a person is very fat, he will not get on with exercising.

I realise that there is one duty that I have overlooked. On the subject of weight, we must remember the tug of war. The noble Lord, Lord Drayson, was ambushed into taking part in that with about three hours' notice. As the first person to rise from these Benches since the noble Lord spoke, I believe that it is my duty to congratulate him on his speech, which was a good one. But I also assure him that he was no worse than anyone else.

A Noble Lord

In the tug of war?

Lord Addington

Absolutely, my Lords. I return to the subject of activity and sporting and exercise patterns. As and when we get our hands on any power, my party will propose seriously to move ministerial responsibility for sport to the Department of Health. We have looked long and hard at this issue and have come to the conclusion that the public health aspect, and indeed the whole health aspect, would sit far better there than it does with the entertainment industry. Once one starts to consider everything that goes on in that field, there can be no real doubt about that.

The noble Lord, Lord Warner, and the noble Baroness, Lady Andrews, should expand their empire and encourage people to go out there. Sport and exercise need a big spending department behind them, with real bite, to place them in their true perspective. Investment will have to be made in order to obtain the true rewards that are available in this field. Some heavy action must be taken.

One of the major benefits for the public will not come from the elite end of sport. Increasingly, as sport becomes professionalised, it generates its own infrastructure at the top end. The benefit will be at the participation level. People at this level will include those who take sport seriously but who, either through lack of temperament or time, cannot participate in a full-time capacity or professionally. There is a blurred line between the two levels.

People who take regular exercise and look after themselves will start to address the issue of diet if they think it will play an important part in their lives. Of course we will still have to worry about teenage, or even infant, couch potatoes, but if we can get adolescents interested in exercise they will pay much more attention to what is happening to their bodies. It is in their interests to do so because it will affect how well they do something they enjoy doing. If they are active, they will not sit around for hours watching TV and shovelling in crisps, fizzy drinks, cans of beer and so on to the same extent on a regular basis.

I recall the great debate on how much exercise is needed to burn up fat. I think that it was the noble Lord, Lord Rea, who said that you had to walk up and down Canary Wharf to burn off one Mars bar. That is perfectly true. But the energy in your body is burnt up by rebuilding and changing muscle after it has been used in exercise. You are not burning up fat; your body is undergoing a different process. We need to get that information across.

Can we start getting away from the idea that obesity is only to do with weight? According to the body mass index in one of the Government's reports—I have it here—every single forward of the England rugby team that won the World Cup is obese; every single forward they played against was obese. Was there a fleet of ambulances following them up and down the touchline during games? I do not think so. Perhaps one or two.

The body mass index is a very crude measure. I declare an interest because according to the index I died of a heart attack about 10 years ago. Even rowers who are six-foot four inches tall come in as heavily overweight. It does not mean anything. Can we please stop using it? The index does not take into account a person's basic build and the fact that muscle is heavier than fat. People who play football do not need great upper body strength; they will have greater muscle density on their legs than someone who does not play football, and their weight will be higher. People who walk regularly will have greater muscle density over large parts of their bodies.

Can we please drop it? Rugby players, weightlifters and those who take part in wrestling or the grappling martial arts will be the worst affected, but anyone who takes part in any exercise will come out badly. The index probably will be counter-productive in the long run, so can we drop it and move to some other measure?

Having got my rant out of the way—I do not know why my colleagues are laughing—let me continue. I hope the Department of Health will expand its influence over the sporting world and encourage stronger links. If the public health Minister and the sports Minister could be linked together in one body, they would stand a much better chance of reaping the full benefits of such an amalgamation. They would, for example, stand a much better chance of ensuring that the Government impose the walking strategy they have promised but not delivered.

As an aside, I thank the noble Baroness for trying to answer the question about how many sports fields we need. I know that no one had then looked up the answer; perhaps they have now.

We have to introduce a more cohesive strategy connecting physical activity with public health. If we do not, we will lose several advantages. At the moment, we are giving out contradictory messages and wasting many opportunities.

6.44 p.m.

Baroness Howells of St Davids

My Lords, I welcome this opportunity to draw to the attention of the House a worrying health matter for the black community. Before doing so, I should like to add my thanks to my noble friend Lord Hunt of Kings Heath for raising such a popular debate and for his robust introduction. I congratulate my noble friend Lord Drayson on his enlightening maiden speech. We look forward to hearing from him often.

I fully understand and support the often-stated idea that the prime responsibility for improving the health of the public lies with the public themselves, and that any significant improvement in the nation's health must be accompanied by a willingness among individuals to take responsibility for their own well-being.

The role of government in supporting communities to make healthier choices is also key, but there are some instances in which—no matter how willing the Government and the community—certain problems still persist. I should like to draw attention to the seemingly unnecessary disease that affects the black community in Britain, due in no small measure to the institutionally racist nature of the society in which we live, and that disease is stress.

I congratulate the Government on the Race Relations (Amendment) Act 2000 that introduced a duty to promote race equality in Britain. I applaud the many institutions and departments that have produced strategies to achieve that noble aim. Nevertheless, while we are engaged in that process, the health of thousands of black people, young and old, is severely damaged by the insidious forms of both personal and institutional racism which cause stress. That kind of stress places a cost on all our institutions—the NHS itself, local and central government and employers.

A booklet entitled Work-related Stress answers some common questions on stress, but I could find no real study on stress brought about through being the victim of racism in the working and living environments of this country. We are aware that stress is the adverse reaction to excessive pressure—it is not classed as a disease in itself—but the intensity of stress can lead to stress-related mental and physical ill health such as depression, nervous breakdown, diabetes and heart disease. We are told by the experts that cancer can also be caused by stress.

All too often risk assessment for stress in a case of racist behaviour is not taken seriously. Several complainants about racism in the environment say that it is never taken seriously, except as a gesture to what is now disparagingly referred to as political correctness. The blame culture, the compensation culture and the phrases used to disparage the complainant mean that the victim is ignored. In every case with which I have had to deal, relationships within the family have deteriorated due to an all-consuming involvement in the hurt and in taking a case before a tribunal. This can cause sleeplessness, nausea, alcoholism, back ache and so on. The key strategies for managing stress never list racism as a cause, but it is indeed a very big problem in the black community.

Stress also links with several other areas of concern, including workplace bullying and muscular skeletal disorder, each bringing its own cost to the NHS. In London, local authorities often have several members of staff at home, on full pay, awaiting disciplinary procedures. It can take from 12 months to three years before a case is completely heard, and often dismissed. Often such a disciplinary action occurs because the person complained of racism and took the employer to a tribunal. That kind of insidious racism is endemic, yet I could not obtain statistical evidence from any local authority. That particular drain on the resources of local authorities is not accounted for. Will the Minister say whether the department could become involved in investigating the number of cases of stress brought on by racism in the workplace?

The challenge is to adapt health policies on inequalities to take into account the ethnic dimension at all times. All health policies without exception should demonstrate that no section of the population is excluded and fails to achieve the anticipated benefits. The key value here is equity. I feel sure that the Minister will agree and will be minded to investigate.

6.51 p.m.

Lord Dubs

My Lords, perhaps noble Lords will come with me on a short journey into the past. On 5 July 1948 I was a patient in Stockport Royal Infirmary near Manchester. I was the only child in the ward. The consultant came round with his team and, as one had to in those days, I lay to attention in my bed. Hospitals were not as relaxed as they are nowadays. The consultant paused for a moment and I said, "May I ask you a question?" Patients did not normally speak first to consultants; one spoke only when spoken to. He looked at me and I said, "Is there going to be a party today?" One of the nurses said, "Whatever for?", to which I said, "The hospital is ours today; the National Health Service has started".

The consultant and his team treated me like a silly little boy, as did most of the other patients in the ward. But I felt that I had been present at an important moment in the life of the country. I had been in a hospital at the precise moment when the hospital became ours. That had an important influence on my development and on my political thinking thereafter.

Since then, when a local council member, I had the privilege to be on an area health authority which enabled me to add a local dimension to the thinking of the area health authority which was not always obvious at the time. I have also served as a non-executive director of a mental health hospital trust, a trust that indicated to me that the importance of management in the health service was to get as close to the patients and to the services as possible. That mental health hospital trust enabled one to do that, even though there had been a history of under-management for some years. Therefore, I look positively at the idea of foundation hospitals because I believe that they will also help to bring the health service closer to local people, closer to patients and provide better management for doing so.

I believe very much in choice. I believe in choice within the health service so that patients can decide for themselves to which provider, to which hospital, they can go; they can trade off a more local hospital against having treatment earlier in a hospital a little further away. It is not just choice for rich people who can choose by buying healthcare. I believe that it is important that ordinary people should have choice within the health service.

I believe that in the past few years the Government have achieved enormous improvements in the health service, stemming, at least partly, from having a prosperous and well managed economy that has added to the resources available for healthcare. We have seen big improvements in waiting times, in the falling of cancer death rates and in dramatic falls in coronary heart disease. Most people in the country have good personal experience of the improvements in the health service. But if one asks people about the health service nationally, they will say it is not so good. They will say, "I have had a good experience, but nationally it is not good". Why is that? It is because of the misinformation from newspapers and others who should know better. The Government have to correct that impression.

I have had very good experience of the health service. On two occasions, for example, I have had very good treatment in Moorfields Eye Hospital. It is an excellent hospital, providing some of the best eye care in the world. We can all replicate that from our own experience of whichever hospital we have been to.

I welcome the fact that this debate is not only about the health service, but also about related issues of public health, such as smoking, diet, exercise and so on to which I shall refer later. It was said by a noble Lord on these Benches that we should not have too much party politics in these debates. Provided there is agreement about the basic principles of the health service, that it should be a universal service for all, yes, let us not have any party political arguments. But if there is a dispute about that basic principle, there are bound to be party political differences.

I understand that today Michael Howard, the leader of the Conservative Party, spoke of getting rid of targets and bureaucrats. It seems to me that by having targets we have a way of monitoring progress in various parts of the health service because without targets we shall not know whether matters are improving or not. If we put more money into a particular service and we do not have a target against which to judge that part of the service, we shall not know whether the money is being well spent or not.

As regards the attack on bureaucrats, it seems to me that the difference between a bureaucrat and a manager is that a bureaucrat stops things from happening and a manager makes things happen. It is a matter of terminology. I believe that the National Health Service has a problem of under-management and that we need more management to make the doctors, nurses and others work in a more efficient context. My experience of the mental health trust on which I served was that it had been under-managed and it needed an improvement in management to ensure that there was better care for the patients.

On the relationship with the private sector, there is a major difference between the National Health Service using private facilities to cut waiting lists and to improve healthcare for patients and a system that says that we should encourage or bribe people, or whatever, to opt out of the health service and go into the private sector. There is a world of difference between the two. We have to ensure that the use of private facilities within the health service does not affect the fact that the service continues to be free at the point of delivery.

GPs have a crucial part to play, particularly in the sensible move to encourage GPs to undertake more primary care, which means fewer people spending time in hospitals. I wonder whether we have the balance right between increases in the numbers of hospital doctors and increases in the numbers of GPs. Perhaps my noble friend can comment on that.

I very much agree with the comments made by my noble friend Lady Howells. She speaks with much experience of the local community and I hope my noble friend will take account of that.

On issues for the future, the health service is becoming an increasingly high-tech service and there are implications for costs and savings that can stem from adopting some of the high-tech procedures. The Wanless report in 2002 said: The most frequently cited driver of productivity improvement is the impact of technology in facilitating a shift in balance of hospital activity towards day cases and dramatic falls in length of stay". That is an important quote. A problem with the National Health Service is that the level of funding can be determined by a single political decision by the government of the day. That is a vulnerability of the health service and that was why the health service suffered in the years before this Government were elected in 1997. Equally, it has enabled this Government to increase the percentage of GDP going into healthcare—a clear political decision.

I am confident that the Government will introduce a ban on smoking in public places later this year. A consultation process is taking place, but I am confident of that. I am also certain that it is right to say that the health service needs staff from overseas. We should welcome the fact that we have such staff providing essential healthcare, rather than indulging in silly arguments about immigration policy.

I have a slight criticism about GPs. In responding to the public they issue too many prescriptions. I like the GP who once said, "What do you want—a prescription or science?" I think it would be better if we were not such a prescription-dominated society; that is, we expect a prescription if we go to the doctor. Some good advice such as take exercise and eat less fatty food might be welcome.

My two final points are: first, the MRSA difficulty referred to previously is a very serious one for the health service; and, secondly, I make a plea. It is crucial that patients, particularly when they have contact with hospitals, should be treated as individuals. Hospitals which do that get many gold medals. In particular I give a gold medal to the Royal Marsden, at which my wife had treatment, for how well it treats patients and because it treats them as individuals. It would be a major improvement if the whole of the health service could treat all patients like that.

7.1 p.m.

Lord Chan

My Lords, I add my thanks to the noble Lord, Lord Hunt of Kings Heath, for securing this very important debate. I apologise to him and to other noble Lords for not being in the Chamber during his speech. I was on a train passing Rugby station when he was on his feet. Noble Lords may ask, why? It is because I had to honour a promise to the Wirral Borough Council to hold a seminar for its frontline staff on trans-cultural communication and skills. That was something I could not possibly miss, so I felt that it was better to be late than not to be here to take the tremendous opportunity of participating in this very important debate. As I am a member of the Birkenhead and Wallasey PCT, I shall speak from the point of view of a primary care trust non-executive director.

In the past six years the efforts of Her Majesty's Government have focused on healthcare rather than on public health. That has been fairly obvious. This is a double-edged sword, because the focus has been on the performance of hospitals, particularly in their care of diseases and chronic disorders.

The most significant developments in healthcare introduced by the Government have been the national service frameworks for heart disease, cancer and diabetes. The NSF for mental health has led to better services for well informed patients, who discuss their management with their health team and have choice in treatment. Other NSFs have yet to have their impact on health.

By far the most important step in improving health taken by the Government has been their concern to tackle health inequalities, beginning with the Acheson report on health inequalities published in September 1998. We know that socio-economic factors were identified as the most important reasons for the great disparity in health, particularly between the poor and the well educated.

Health inequalities demonstrate the effectiveness, or lack of effectiveness, of government policies, not only in health but also in education, employment, housing and social care. Tackling health inequalities should be at the top of the Government's agenda for public health. Political will is as important as increasing public expenditure in health and social care. I congratulate the Government on so significantly increasing the budget for the NHS and on shifting the balance of power in favour of primary health care as well as incorporating directors of public health in PCTs.

However, progress in tackling health inequalities and improving public health has been slow because in the NHS, for example, insufficient importance has been placed on public health and health targets are too narrowly defined—such as waiting times in hospital departments. Waiting time targets have distracted and even sapped the energies of NHS staff who could have been engaged in preventive health measures, as has been mentioned by other noble Lords; for example, in giving information to young people to prevent sexually transmitted diseases, an important matter focused upon by the noble Baroness, Lady Gould.

The Government have also not supported organisations campaigning against binge drinking and asking for sensible alcohol use. Instead, in the past four years sexually transmitted infections have increased and alcohol-related injuries continue to provide 70 per cent of accident and emergency department patients at weekends, particularly after midnight.

So the impression given by the Government to NHS staff, particularly in primary care, is that they are taking two steps forward and one step backwards. So what can the Government do to improve public health in the community? Here I share the views based on local experience of local authorities and PCTs on Merseyside.

First, the Government must give a national lead and be bold; for example, in supporting and commending local authorities and primary care trusts which are trying to establish work places and public places free from tobacco smoke. Liverpool is taking this bold initiative in shopping malls, restaurants and work places. It needs to be encouraged.

Secondly, Her Majesty's Government must start to tackle alcohol abuse. It is a growing public health problem that contributes to road accidents, abusive, threatening and violent behaviour and increased attendance at A&E departments in hospitals. By being silent on alcohol abuse, the increase in NHS expenditure will fund services for ill health that is eminently preventable and could be diverted to some of the very important requests made this afternoon by noble Lords, such as research and other areas of care.

Thirdly, some star ratings for PCTs work against reducing health inequalities—for example, coronary heart disease reduction is much better in social class I than in social classes 4 and 5—but the need to target the lowest 20 per cent of our population is not in the star ratings. Again, cancer deaths have been reduced but not in disadvantaged groups, particularly in black and ethnic minority smokers and social classes 4 and 5.

Fourthly, local authorities and statutory agencies should apply health impact assessments on their initiatives. Regeneration projects on Merseyside now have health impact assessments done. That is very important. As a result some public health staff in Birkenhead and Wallasey PCT have been appointed jointly with the local authority. For example, we have a regeneration manager and a housing and health manager. They are paid for jointly by the local authority, by the regeneration local strategic partnership and the PCT but they are members of the public health team. That is particularly important because their influence is seen in non-health areas and departments.

Fifthly, the Health Equity Audit, introduced earlier this year, when applied across the PCT made non-public health departments realise how little they invest in people living in deprived areas. This audit would also focus the attention of other staff—for example, in hospitals—on public health priorities and the importance of prevention.

Sixthly, the public need to be involved in public health in the community. This is being successfully established by the Sure Start programme, but more can be achieved by giving people ownership of public health through information free of medical jargon and NHS-speak. We are doing that by producing information in what look like popular magazines with famous pop stars on the front cover—and I am sure that Wayne Rooney will be on the front cover of the next one.

Finally, black and diverse ethnic communities also need information and support to lead healthy lives. Here I support the comments of the noble Baroness, Lady Howells. More than half young Bangladeshi men in the north-west of England are heavy cigarette smokers, but little is being done to target them with information and help to give up smoking.

One reason for that neglect must be related to the irregular collection of ethnic group data in the NHS. Ten years ago I was involved in persuading the chief executive of the NHS, while I was working for him, to ask for ethnic group data to be collected from all patients admitted to hospital. Training was given to all frontline staff; hospitals were visited and encouraged to use the data—for example, to calculate the number of south Asian patients who should attend a diabetic clinic, because they are three to six times more likely to develop diabetes. We now need to return to collecting ethnic group data in primary care.

I thank the noble Lord, Lord Hunt, for this opportunity to debate these issues and to bring to your Lordships' House the views of primary care trusts and local authorities. I shall attend my PCT board meeting tomorrow morning, so I look forward to the Minister's response to public health in the primary care setting and the community.

7.10 p.m.

Lord Harris of Haringey

My Lords, I, too, am grateful to my noble friend Lord Hunt of Kings Heath for giving the House the opportunity to discuss health, particularly public health, and for starting the debate with such an excellent and wide-ranging contribution. I declare my interests as a non-executive member of the London Ambulance Service NHS Trust and an adviser to a number of bodies on NHS matters, all of which are listed in the Register of Lords' Interests. In addition, my wife is employed by the NHS as a medical secretary in a north London hospital.

The Government's record of investment in the NHS is certainly impressive: 68 major new hospitals completed, more than 1,700 GP premises refurbished, 247 one-stop centres opened and 42 walk-in centres, with another 22 in the pipeline. There have also been increases in personnel: the number of doctors in the health service rose from 90,000 in 1997 to 109,000 today, while the number of nurses has gone up by 67,000.

That investment is feeding through to better outcomes. Over 76 per cent of patients suffering a heart attack receive lifesaving thrombolysis within 30 minutes of arriving in hospital, compared with 38 per cent in March 2000. Nearly 99 per cent of people with suspected cancer are seen by a specialist within two weeks of an urgent GP referral. The figure in 1997 was 63 per cent.

The style of treatment is also improving. More procedures are now carried out in local GP practices rather than in hospital. Last year the number of such procedures reached 700,000, all of which would have required a visit to hospital only a few years ago—a major improvement to the convenience of patients. For those who go into hospital, 98 per cent of trusts now provide single-sex sleeping accommodation, and 93 per cent of patients are now admitted, transferred or discharged within four hours of arrival at an A&E department. Clearly, there is more to be done, but that is real progress and demonstrates the present Government's clear commitment to the NHS.

The Government's other policies will in due course prove to have made a major contribution to improving public health. They have set challenging targets for themselves. By 2010, the Department of Health is required to have reduced health inequalities by at least 10 per cent as measured by infant mortality and life expectancy at birth.

However, I hope that there is no-one here today in your Lordships' House who does not recognise the effects of poverty on people's health. Creating jobs and giving people the skills and confidence to enter or re-enter the workforce is critical to improving health outcomes. For example, this Government's achievement of bringing 100,000 people over 50 back into work through the New Deal scheme, or the half-million young people given opportunities in the past 18 months, has made a real contribution to public health.

Increasing literacy levels—a 12 per cent increase among 11 year-olds since 1997—also plays a part in raising young people's employability and thus their good health. Tackling poverty directly by introducing the minimum wage and improving conditions at work plays its part. The Government's record on that has been solid and sustained, with a stable economy, rising employment and big reductions in unemployment and poverty. Over the next 20 or 30 years I am confident that we will see the improvement that that brings feeding into life expectancies.

That is the context in which the debate about further reform in the NHS and choice arises. Again, I congratulate my noble friend Lord Hunt of Kings Heath on his timing. This debate coincides with major speeches by both the Prime Minister and the Leader of the Opposition on these topics. Like a number of noble Lords, I fail to see what the Conservative proposals do for equity or fairness. If you take money from the NHS to subsidise the better-off to purchase private healthcare, the resources available for those who cannot afford private healthcare will be diminished. That will adversely affect standards and widen health inequalities.

But the debate initiated by the Prime Minister and the Government on choice seems in danger of being diverted so that it addresses the wrong issue. I am not convinced that the key choice for people is which hospital they go to for treatment. They may have a preference, and there is no reason why it should not be accommodated, but I suspect that what people really want is more control and more say over what is done to them, what treatment they receive and how they receive it.

The problem with the public services in the past—the NHS was no exception—was that they followed the Henry Ford dictum on choice. You could have what you were given, and you should be grateful for it. One size had to fit all. You could have any flavour you liked so long as it was vanilla.

The NHS, like most other public services, has improved enormously on that in recent years, but the tendency remains. Much more can, and should, be done, while retaining the core public service values of fairness, equity and accessibility, to make services more responsive to the needs, wishes and preferences of those who use them. But it is not primarily about people's wishes and preferences regarding which hospital or which service provider. Of course, that would be critical if the quality of the service varied greatly, but another core public service value must be that all public provision should be of a high standard. That is certainly a value vigorously pursued by this Government.

Giving people a choice of five hospitals, or indeed of every hospital in the nation, is fine and dandy, but it must not be the centrepiece of policy. In healthcare, if people wish it, they must be involved and in the driving seat for all critical decisions about their care—which procedure is to be used, what type of aftercare and even whether or not an entirely different approach to managing their condition should be taken. That choice may well extend to which clinician they would prefer to deal with, but the key component is shared decision-taking. Of course, there will always be those who want to trust the expert or who would rather not know the implications of all the choices, but if that is their preference, it, too, should be respected.

There is plenty of evidence that the outcomes are improved where patients are fully involved in all the key decisions—compliance with drug treatment and aftercare are better and people often have a clearer understanding than their doctors of what will work for them. So I hope that the debate on choice will focus on that sort of empowerment for the patient, that it will be about giving people real choice—real control—over what happens to them, and that the NHS will be given the resources and the flexibility to respond positively to what service-users individually and collectively say about their needs and preferences.

There is a perfectly respectable argument which says that the disadvantaged in society, people on a low income, or the less well educated—precisely those who already have the worst health outcomes—are least likely to be able to express their preferences and choices. It is argued that the well-off middle class, like in so much else, will be the ones able to play the system to get what they want, and, as such, will end up getting more NHS attention and resources to the detriment of the rest.

That of course could be the case, but it does not mean that the principle of offering a responsive service that gives people control over their treatment is wrong. However, it suggests that you need to have in place systems that will support those less likely to be well informed, articulate or assertive about their rights and expectations. That may mean better advocacy services, patient representation and systems for involving the public in decisions that affect them individually and as a community.

It is unfortunate, therefore, that so far the achievements of the new system for public and patient involvement have been so muted. Certainly, if further NHS reform is to deliver the better quality, more responsive service that I believe is the intention behind the Prime Minister's speech today, then that system needs to deliver much more than has hitherto been apparent. Perhaps that is a topic for another day. I hope that your Lordships will accept that the Prime Minister's vision of a responsive NHS needs a thriving and effective system for ensuring public and patient involvement, and one that specifically addresses the needs of those who are subject to disadvantage, whatever the source of that disadvantage.

Over the past seven years, the NHS has improved immeasurably. The vision set out today by the Prime Minister of choice and diversity within the framework of public service values and fairness will lead to even greater improvement. That will require effective support to ensure that that choice and diversity is there for everyone, and that the NHS can genuinely deliver it for all.

7.20 p.m.

Lord Rea

My Lords, I agree with what my noble friend Lord Harris said about the patient's view. He speaks from a long experience of working with community health councils. My noble friend Lord Hunt has invited us to fill a broad canvas; comparable in size to the huge picture in the Royal Gallery by Daniel Maclise of the Battle of Waterloo. But, so far, there have been no serious casualties in this debate, and the cavalry has consisted only of hobbyhorses.

My own will concentrate on the primary prevention of chronic, non-communicable disease: coronary heart disease, stroke, cancer and their precursors, raised blood pressure, obesity and adult type diabetes. Despite decreasing mortality, these conditions are still by far the biggest cause of ill health and mortality, and they comprise the main burden of the National Health Service. Many have their origins in childhood, so a "life course" approach is appropriate.

The second Wanless report lists a number of useful reports commissioned by the Government on public health over the years, but it points out that there has been "little change on the ground". It calls for a "fully engaged scenario" with a NHS shifting its focus from being a national sickness service to a true National Health Service focused on preventing sickness. Running through the report is the awareness, now fully shared by the Government, that inequalities in health must be tackled as a fundamental public health aim. If the whole population had the health and life expectancy of those in the professions and senior management, the task of the NHS would be much lighter.

Recently, Professor Michael Marmot, mentioned by my noble friend Lord Turnberg, has put together the results of years of research, much of it into the health of Whitehall civil servants, in his book, Status Syndrome. There is a clear gradient of sickness and death from the top to the bottom of the Civil Service. Some of this is because known risk factors for disease and mortality increase with decreasing employment status, but they only account for about one third of the gradient. When these and other measurable influences are allowed for statistically, the gradient persists. It appears that an important factor is the degree of control that an individual has over his or her life circumstances. Being at the bottom of a hierarchy causes chronic stress, which, through its effects on metabolism, decreases well-being and increases susceptibility to disease, including mental health problems. That fits in well with the speeches made by the noble Lord, Lord Patel, and my noble friend Lady Howells, who pointed out the stressful conditions of life for people of a different colour in this country. The implications for possible changes in conditions of employment and indeed the structure of society as a whole from this work are enormous, but the words of my noble friend Lord Drayson in his excellent maiden speech about the opportunities in the organisations that he is running are encouraging.

I declare an interest that I am, for my sins, the honorary secretary of the National Heart Forum, which exists to promote policies to prevent coronary heart disease and to co-ordinate the activities of some 40 national bodies with an interest in this subject. It will shortly be submitting its response to the three Department of Health documents on public health that are out for consultation, including public health generally, physical activity and diet. I hope that this response will help to shape the White Paper on public health, due some time in the autumn. I can give my noble friend a foretaste of the underlying principles involved in the response: the first, now well known, that the factors leading to non-infective disease largely lie outside the territory of the NHS. It is frequently not possible for individuals to choose the healthy options that they should follow even when they are aware of them, because of economic and social pressures.

While getting into trouble with ASH and the Royal Colleges two weeks ago, John Reid made this clear when he described the single mother on social security benefit who may derive her only relief from a stressful life through smoking cigarettes. It is difficult particularly for women in such circumstances to give up, even when they wish that they could. However, many of them felt patronised by the remarks of the Secretary of State. A further mistake that he made was to use this truism as a reason to oppose a ban on smoking in public places. I hope that he can be persuaded, despite his misgivings, that this would be a popular measure that would be effective in helping people to quit the habit. Perhaps he should go across the sea to Ireland to see that this is true.

A further strand of our response will be to recommend moves towards what we call "a health-promoting economy". Our response says: The last 20 to 25 years of the UK marketing culture has significantly affected our lifestyles, and in many instances is having a major negative impact on the health behaviours of children and young people". We come down squarely on the need for more regulation, since self regulation is never properly monitored by civil society, whether by government or the voluntary sector". We recommend that industry self regulation should be monitored closely for two years only, not three, and regulations be introduced after that if, as will almost certainly be the case, they are necessary, since public policy goals for protecting public health must take precedence over protecting trade". We praise the work of the Food Standards Agency and suggest that it be strengthened and better resourced. The whole area of health promotion should be greatly strengthened, possibly through the creation of an independent national institute of public health, which would use sophisticated social marketing techniques to bring the population into the "fully engaged scenario" of Wanless. This body would need to be adequately resourced as it would be competing with commercial interests pulling in the other direction. Therefore, it should not receive any private sector funding, and should be regarded as an investment that will in the long run lead to a fitter population and save NHS costs.

I have a section in my notes about the need for adequate cross-communication between the different government departments that are involved in public health, but I do not think that I have time for it. So, to move from the headquarters to the front line, I have heard worrying reports that the recruitment and training of health visitors is falling, for instance in Camden and Aylesbury. The average age of health visitors, at 40, is too high. They really are the basic disseminators of public health information to mothers with young children, with potential to do even more. Since we now know that many of our health problems start in childhood, it is surely short-sighted to allow this important branch of the nursing profession to wither on the vine. Sure Start is an excellent initiative, making use of many health visitors, but there are many other mothers with babies, than are in the Sure Start areas needing their help all over the country. Perhaps my noble friend can reassure me that steps are being taken to retain and expand health visitor numbers.

As a postscript or epilogue, I will give an example of the ultimate aim of public health, which is a long life, free from disease and disability and with a quick and dignified end. I refer to a ballad by Oliver Wendall Holmes, "The Deacon's Masterpiece", or "The Wonderful One-Hors Shay". Have you heard of the wonderful one-hoss shay, That was built in such a logical way It ran a hundred years to a day, And then, of a sudden, it-ah, but stay, I'll tell you what happened without delay". Thirteen stanzas then follow, telling how the shay ran perfectly for exactly 100 years, never needing any repairs at all. Then, at the very hour that it reached a hundred years of age, What do you think the parson found, When he got up and stared around? The poor old chaise in a heap or mound, As if it had been to the mill and ground. You see, of course, if you're not a dunce, How it went to pieces all at once,— All at once, and nothing first,— Just as bubbles do when they burst. End of the wonderful one-hoss shay. Logic is logic. That's all I say".

7.30 p.m.

Lord Clement-Jones

My Lords, I add my thanks to the noble Lord, Lord Hunt of Kings Heath, for initiating this broad ranging debate. We have heard some magnificent speeches today, including some magnificent poetry, and the debate has involved more of us than just the usual suspects. Even the usual suspects, such as the noble Lord, Lord Winston, and the noble Lord, Lord Harris of Haringey, uttered heresies about patient choice, and I hope to follow those up. I also congratulate the noble Lord, Lord Drayson, on making a real mark on the House with his maiden speech. I hope that he will bring to the House the same drive and enthusiasm that he has brought to the bio-industry sector.

I stand down as health spokesman as from the Recess, so I was pleased to hear the noble Lord, Lord Hunt of Kings Heath, speak in characteristic style. The noble Lord, Lord Jones, had it right when he talked about the "sunlit uplands". I got a rather misty, rose-tinted impression of the health service from the noble Lord, Lord Hunt of Kings Heath. He ranged over those sunlit uplands in fine style. I should say in passing that, if the noble Lord cares in due course to initiate a debate on Liberal Democrat policy on public health and the NHS, I will, of course, oblige him with a much more detailed statement. The debate is actually about the Government's record, and I shall take the opportunity to mark their report card for the six years that I have been involved.

I do not want to rain on the Government's parade. We share the philosophy behind many of the reforms that they have initiated, and we appreciate the eventual additional investment made in the third year of the Government's term. However, one of the problems is that the Government, although going in the right general direction, in many ways, have failed in the implementation of the reforms. They have micromanaged much of the health service. They had an initial obsession with waiting lists. They failed to listen to what many in the health service said about the structural reforms that they proposed. There was the sheer impatience of Ministers who dug up reforms by the roots to see whether they would take effect, and the Government failed to pilot many of the changes that they proposed in the mad stampede to reform. We have been extremely concerned about the Government's absolute obsession with PFI and PPP as a solution for financing capital investment in the health service.

Now, in the run-up to the general election, we face a different problem. We have an election auction of unfulfillable promises. The Tories and the Labour Party seem to be vying with each other to see who can offer the greater degree of patient choice. Noble Lords have referred to the fact that the Prime Minister made a speech on the issue today, as did Mr Howard. I suppose that we should, at least, be grateful for one thing. The Conservative Party seems to be offering the ultimate bribe of tax relief on health insurance as a central plank of their election campaign.

Earl Howe


Lord Clement-Jones

I am delighted to hear that, but it seems to be the case. The private musings of Oliver Letwin make one fear for the future of the health service even more. So, one knows one's sheep from one's goats in that respect.

I am not a misty-eyed romantic about the health service—of course not. It would be rather difficult, after having soldiered on through five or six—I have lost count—NHS reform Bills. At this juncture, I must pay tribute to all the NHS staff, who have managed to adapt to the change that the Government have imposed on them. I take the example of Alan Milburn, a former Secretary of State. He started by centralising the NHS. After all, we got rid of a permanent secretary; we merged a permanent secretary with a chief executive of the NHS. That was centralisation. Then, we had a new enthusiasm: decentralisation. Unless one is some kind of specialist sinologist, it is difficult to understand what is in a Minister's mind at any particular juncture. The trial-and-error nature of the reforms that the Government have instituted is a real problem.

Now, we have a different set of reforms. We are no longer reforming by legislation; we now seem to have reform by redefinition. The situation is not as we may have thought. We have new wording. I received a large poster the other day. Right in the middle was something about patient choice. I suppose that it was meant to explain the Government's reforms to NHS staff. It was like a jigsaw puzzle: in one corner, it said something about payment by results and then there was something about "choose and book". There is a new vocabulary. It is difficult enough for NHS staff to keep up with the reforms, let alone humble politicians. For the general public, it must be impossible to understand what is happening to their NHS.

One could make many detailed criticisms. There are some pluses, and I shall come to them shortly. I shall not tire the Minister unduly—I know how easily he tires of criticism of the NHS—but I need only say the words "specialised commissioning" to ring bells in his brain. The position is very unsatisfactory. The Nuffield Trust released a mid-term report that raised serious doubts about aspects of the PCTs. I do not share all those doubts, but I believe that PCTs are an unsuitable place to commission the 35 specialised conditions.

I think that it was the noble Lord, Lord Chan, who spoke about taking two steps forward and one back. One need only look at many of the reforms that the Government have put in place. They rejig things a little, but they do not admit that they were ever wrong—it is all just a little positioning to do with, perhaps, the way that a regulator changes its powers or some other additional changes. I have no doubt that, in due course, the Government will be forced to face up to the fact that their reforms have not worked in the area of specialised involvement.

Some of the reforms to PCTs have been successful in placing greater focus on primary care, but I am afraid that the role of GPs is in danger of being marginalised at primary care level. In many respects, PCTs harness the enthusiasm of GPs, and I am concerned that GPs and other healthcare professionals must he at the centre of the primary care system. A recent report by the King's Fund emphasised that.

I shall weary the Minister once again by using the words "patients forums". The abolition of CHCs by the Government was a disaster. I am delighted that the Minister is hiding behind the fig leaf of the review of arm's-length bodies. In due course, it may be that the marvellous commission that was set up by the Government will be merged with another, and we will have something similar to what we had before: a one-stop shop community health council-type structure with some sensible additions to the main ways in which patients interface with hospitals, such as PA LS, which we have already. As regards patients forums, we only have to look at the turnout, the number of resignations of members for personal reasons and so forth. More than one in 10 patients forum members have resigned in that period.

I could go on. We could talk about foundation hospitals. I am sure that in due course the governance of foundation hospitals will also be changed. A perfectly sensible solution would have been to have public benefit organisations set up and not the incredibly complicated structure that we agonised over in Committee and on Report during the previous health Bill.

As regards the integration of health and social care, the Government have slowly crept towards that. At every stage, in every health Bill, we have had to push further for greater integration. Currently, it is not integrated enough. In respect of long-term care, we greatly regret that the Government did not put the Royal Commission's proposals into effect. But that also applies to mental health. I agree that despite the fact that the NSF is a very sensible national service framework, not a great deal of progress has been made on mental health. It is not clear where the money is going. The failure to tackle the issue of ethnic minority patients with mental health problems is also a major issue.

The noble Lord, Lord Colwyn, is the expert on dentistry, which he illustrated enormously. Despite warnings about over-regulation, finally, after six years, the Government are getting to grips with sensible and proportionate regulation. Of course, we want greater quality, but not at the expense of too much bureaucracy.

One of the biggest failures of the Government is their very late waking up to the importance of public health. I appreciate that in terms of health inequalities, the Acheson report, which they instituted, was extremely important. I paid tribute to the Government in their first year in office for doing so. But that was not followed up. A Treasury inspired report is required to really get this Government cracking. Even so, not nearly enough is being done.

We have heard from all around the House about sexual health and obesity, and there are many other key problems. I am deeply worried about the link between poverty, class, being a member of an ethnic minority and bad health. We have to tackle that. Rather than the Secretary of State batting on about patient choice, that whole area of prevention and health inequalities must be tackled.

I briefly mention the Government's successes. The creation of NICE was a great success. CHAI was a success when they got the balance and range of duties right. We are now at the forefront of technology in terms of therapeutic cloning. In grasping that particular nettle, the Government were right. There has also been a great advance in cancer treatment, although we have huge capacity problems.

I thought that the noble Lord, Lord Harris of Haringey, was absolutely right. We should not be chasing the whole issue of choice yet: we have not even solved access, capacity or so many basic issues in terms of patient empowerment and the quality of the patient experience in the health service. Why are we talking about patient choice? That is like trying to run before we can walk. We are leaping ahead before we have solved the current problems of the health service.

We have had enough of these ministerial enthusiasms. Let us stick to the basics and ensure that we solve those problems before we start trying to engage in some kind of an election auction.

7.44 p.m.

Earl Howe

My Lords, this has been a lively and varied debate, which was made even more so by the fine maiden speech from the noble Lord, Lord Drayson, whom we all welcome and congratulate warmly. When the noble Lord, Lord Hunt, first rose to his feet, I thought that we would be in for a balanced and thoughtful analysis of the Government's health policies with perhaps a few gentle pointers for further action. Little did I anticipate that his speech would resemble the opening eulogy of the 15th plenum of the Supreme Soviet although admittedly shorter—a tone that has been echoed ever so occasionally on the Benches directly opposite.

The job of those participating on these Benches is not to deliver eulogies but to provide some equilibrium. I was therefore proud to listen to the contributions from my noble friends Lord Colwyn and Lord Soulsby who spoke with impressive personal knowledge of their chosen subjects.

If we look back at what the Government have done in the health arena over the past seven years, there is no doubt that their stewardship of the NHS has been characterised by an enormous amount of political energy. Whether that energy has been channelled in the right direction is something that we can argue about. But it is true to say that the bulk of that effort has been directed towards the fulfilment of the goals that are articulated in the two main building blocks of health policy; namely, the NHS Plan and the White Paper, Our Healthier Nation, with its subsequent refinements.

Alongside that political effort has of course come a major expansion in the amount of money that is flowing into the health service. That commitment of public money from the Chancellor has, by any standards, been very significant. But it means that the test of success for the Government's health policies is now a good deal higher than it would otherwise have been. The test of success is not just whether the Government's targets have been achieved, but whether the nation can genuinely say that it is healthier, that it has a better standard of healthcare and that the money has been spent both wisely and efficiently. Each of those tests needs to be examined in turn.

In a number of the more serious life-threatening conditions, such as certain types of cancer, which were mentioned by the noble Baroness, Lady Finlay, there is no doubt that we have seen some real improvements in survival rates in recent years, although quite often they have continued a trend that started long before the Government came to office.

Where I think that the Government can be most criticised is over their stewardship of public health. Derek Wanless confirmed what many of us already knew; that is, England performs poorly compared to other countries on measures of key health outcomes. Among eight other countries with similar population structures and healthcare systems, we have the highest infant mortality, when we used to be among the lowest. We have the highest death rate from respiratory diseases and the second-highest death rate from cancer in women.

Tobacco advertising has been banned, but since 1997 the graph of tobacco consumption has remained just about horizontal, compared to the previous 25 years when consumption went down by more than one-third. The numbers of people who are admitted to hospital with alcoholic liver failure have doubled since Labour came to office. Yet hand-in-hand with that, the Government have made it easier to sell alcohol. One-third of the population is now drinking at potentially hazardous levels. The Government's alcohol harm reduction strategy is a very positive development. But I tend to share the fears of the noble Lord, Lord Chan, and, incidentally, the Royal College of Physicians, that that will not be translated into enough tangible action to turn the graph back in the right direction.

The noble Baroness, Lady Gould, has done a better job than I ever could in highlighting the dramatic explosion in sexually transmitted diseases. That is a situation which was described by the Select Committee in another place as a "crisis". I do not think that the Minister agrees that it is a crisis, but it beats me why the Government are not willing to commission a national service framework for sexual health. At a practical level, it is truly extraordinary that despite the explosion in cases of chlamydia and HIV over the past seven years, not a single extra GUM clinic has been opened in that time. In 1997, the idea that one might have to wait several weeks to see a doctor at a GUM clinic would have been greeted with absolute horror. Now, it is commonplace. I still do not understand why the chlamydia screening programme is being rolled out only gradually.

The lack of grip on public health is perhaps most evident on the two most prevalent threats—obesity and diabetes. In 1980, 6 per cent of men and 8 per cent of women were obese. The figures are now 17 per cent and 21 per cent, and rising rapidly. It is only recently that the Government seem to have woken up to what those threats might mean. But while there are quite a few local initiatives under way to combat obesity, we still have no national strategy, no health education campaign and no single individual or Cabinet committee responsible for tackling these and other public health challenges across the whole of government.

The recent Health Select Committee report on obesity contained some messages which I hope the Government will heed, because time is now of the essence. Some of us find it quite bewildering that during our recent debates on the Health Protection Agency Bill, the proposal from my noble friend Lord Fowler that Ministers should have a duty to respond to recommendations made by the agency was roundly dismissed by the noble Lord, Lord Warner. That did not exactly demonstrate the kind of serious approach to public health concerns for which we had hoped.

The Health Protection Agency is a solid advance and I, for one, have huge confidence in it, having had the pleasure of visiting Colindale earlier this year. I say that, so long as it is funded properly. Here I very much endorse the comments of the noble Lord, Lord Turnberg, and my noble friend Lord Soulsby. But the delivery of the public health agenda depends critically on having enough professional people on the ground. Exactly the same applies in primary and secondary care. Chapter 5 of the NHS Plan identified the shortage of human resources to be one of the biggest constraints on the NHS. In fact, the number of doctors, including consultants, has grown steadily during the time of this Government and the last Conservative government. However, we are beginning to see significantly higher numbers of doctors coming through, as well as nurses. I would be the first to say that this is excellent news.

There is further to go: there are fewer GPs per patient now than there were five years ago, which cannot be satisfactory. It is hard to accept Sir Nigel Crisp's bullish assessment of last month that the NHS has now achieved "a sustained turnaround". It is true, and of course welcome, that the longest waiting times are being eliminated, but average waiting times are going relentlessly upwards. That indicates that the system is not keeping up with patient demand. The numbers of patients removed from the waiting list since 1997—about 300,000—is more than accounted for by the number of people who, during that time, have abandoned the NHS to go private. They are often people of very modest means, who go private out of necessity. As a nation, we cannot be proud of that.

Most people still trust the NHS to treat them when they have a life-threatening illness. But the Royal College of Radiologists has reported that the number of cancer patients waiting longer than the officially safe maximum time for their treatment has doubled since 1998. Waiting times for ovarian cancer and brain cancer have risen sharply since 1999. It bears out what Breakthrough Breast Cancer has said. Although the two-week target to see a consultant is very largely—indeed, almost always—met, for many patients this is simply pushing back the actual treatment.

The Government still believe that detailed target-setting has brought results, and so it has in some areas. The trouble is that target-setting in one part of healthcare shifts the focus away from other parts, and before you know it has happened, you have distorted clinical priorities in a serious way. That is what happened at Bristol Eye Hospital. Waiting time targets for new out-patients were achieved only at the expense of delaying follow-up appointments for other people. As a result, 25 patients went blind.

These are the sorts of hoops through which the star rating system forces hospitals to jump—hoops which have very little to do with the quality of patient care. That fact is extremely ironic, because if there is one achievement for which I believe the Government can take real credit, it is their agenda to drive up the quality of care in the health service through national service frameworks, healthcare audits and several other good initiatives. But they really must not delude themselves.

Dr Ian Bogle said last year when he stepped down as chairman of the BMA: We now have a healthcare system driven not by the needs of individual patients but by spreadsheets and tickboxes … The fundamental NHS principle of care based on need and need alone has been superseded by the principle of care based on numbers". The Government have to face that situation and deal with it. When they were first announced, foundation hospitals looked like being part of the answer, but our debates last year on the Bill introducing them proved how mistaken that impression was.

I say to the noble Lord, Lord Dubs, that there is a difference between targets and performance indicators. Centrally imposed targets not only distort priorities; they also erode staff morale. When professionals feel that they cannot get on with the job they were trained to do, their morale suffers, and we are seeing the result in unprecedented vacancy rates in general practice, midwifery, clinical academic medicine and dentistry.

Another result of the target culture is, of course, bureaucracy. I shall not quote any ratios about NHS administrators that may rile the Minister, but I will say quite clearly that good management in the NHS is essential if it is to succeed as we all wish. But there is an issue here: the restructuring of the health service has meant that there are a lot more NHS bodies to manage and to performance-manage. Every government initiative brings with it more people to check on how it is working. The dead hand of the state is still very much a reality.

In the four years to 2003, the number of doctors and nurses in the NHS went up, but the number of managers rose by three times that rate. The NHS employs about four and a half times more managers, administrators and support staff in proportion to its nurses than does a large private hospital in central London. We need to reflect on the message that that sends us.

The shaky morale in the NHS has translated itself into high staff turnover rates, resentment and, often, frustration. I do not know whether the Minister is aware how much real anger there is out there, at all levels of the health service. I am not just talking about what has happened—or failed to happen—to the consultants' contract or Agenda for Change. The anger is often about the little things. One vignette seemed to me to sum up the sclerosis that can too often beset health service administration. A doctor told me that last year his printer broke down. He reported it. It took six months for a replacement to arrive. When it did, the machine sat in its box for three months because it did not have a cable. The doctor is still waiting.

A year into his second term, the Prime Minister declared himself happy to be held to account if the NHS was not fixed by the next election. For all the bullishness of Ministers, for all the taxpayers' money, for all the dedication on the part of those who work for the health service, we are still a long way off the point at which we can call the system fixed. I have never doubted that the Government's heart is in the right place, but only the voters at the next election will be able to tell us whether that is enough.

7.58 p.m.

The Parliamentary Under-Secretary of State, Department of Health (Lord Warner)

My Lords, I congratulate my noble friend Lord Hunt on his choice of topic for debate and on an excellent and rousing speech. I know the contribution he has made personally to our changing and, if I may say so, vibrant NHS.

This has been a well informed and stimulating debate although, like my noble friend Lord Winston, I note a conspicuous absence of Conservatives participating. But my noble friend should not take his compassion too far in helping the Conservatives construct a policy, although I recognise that they are struggling a little and will need all the help they can get. I have to disagree with him about the NHS not being a political issue. I think that I will make it clear during the course of my remarks that we disagree fundamentally with the Conservatives.

I congratulate my noble friend Lord Drayson on a thoughtful maiden speech, drawing on his personal experiences. Like other noble Lords, I very much look forward to hearing many more contributions from him.

I shall, like a number of other noble Lords, miss the contributions of the noble Lord, Lord Clement-Jones, from the Front Bench. He generously offered the Government help by giving us an end-of-term marking on various aspects, and I would like to give him an end-of-term marking as well. In figure-skating terms, I would give him 9 for style, but about 3 or 4 for the ambition of his manoeuvres.

Many noble Lords have shared their personal experiences of the NHS. Those experiences have reminded us that there are dedicated skilled staff at the heart of the NHS and of the long-established value that there should be equal access to healthcare free at the point of need.

The Government's 2000 NHS Plan reaffirmed those values and provided a plan for investment and reform. I can reassure my noble friend Lord Jones that the NHS is not in a situation faced by the late Lord Wilson and the late Lady Castle. I can say that because, as principal private secretary to Lady Castle, I witnessed what I can only describe as the free and frank discussions that took place between the government and the medical profession in the late 1970s.

We have made a lot of progress since then and we have made the investment and reforms that the NHS needed and delivered real improvements to the health and health services of the people of England, as my noble friends' contributions today recognised. I fear that I will not be able to respond to all the points raised in the time available to me, but I will write to noble Lords if I have not dealt with the points that they raised.

As my noble friend Lord Hunt said, by 2008 there will be a record sustained investment in the NHS—with 7.3 per cent average real terms growth over five years. In 1997–08, the NHS budget was £34.7 billion. In 2007–08 it will be £90.2 billion. What a contrast with what happened before this Government. Look how far we have come since the sixpence a week funding by the miners of the Tredegar Medical Aid Society. The granddaughter of one those miners has been sitting beside me during this debate.

The proportion of our GDP spent on health will rise from 6.8 per cent in 1997–98—at the time the third lowest in the EU—to 9.4 per cent in 2007–08. As my noble friend said, the result is that the NHS is now getting the staffing it needs. Despite what was said earlier in the debate, there are over 67,000 more nurses, who are providing the high standards that we have come to expect from nurses in our NHS. There are over 19,000 more doctors including nearly 8,000 more consultants and about 2,500 more GPs.

My noble friend Lord Rea raised the problem of the limited growth in health visitors. I understand his position, but draw his attention to the fact that there has been an increase of over 60 per cent in community services nurses—nearly 12,000 more than when this Government came to office. Overall, there are 224,000 more staff in the NHS in England since 1997, and 84 per cent of all NHS staff—about 1.1 million—are involved in direct patient care.

The Conservative propaganda—which has been rather unrelenting in recent months—that the NHS is awash with managers is a complete lie. Out of the total increase in NHS staff of 224,000, 13,000 have been managers. That is about 5 per cent—par for the course in most well run public and private complex organisations. I can reassure the noble Baroness, Lady Masham, that NHS management costs have fallen from 5 per cent of NHS expenditure to 3.9 per cent in 2002–03. I can tell the Benches opposite that the Tory internal market was extremely bureaucratic, with high transaction costs, which was even recognised today in The Times by the Conservative's health spokesman, Andrew Lansley. We do not need lectures on bureaucracy from those on the Benches opposite.

More staff means more beds. Between 15 January 2000 and 16 July 2003, the number of open and staffed critical care beds increased by 32 per cent. We have under way the largest hospital building programme in the history of the NHS. Nearly 120 new hospital schemes are going ahead. By contrast with the past, these hospitals have tended to open on schedule or early. I can reassure my noble friend Lady Jay that 99 per cent of the 10,000 or so wards in the NHS have single-sex sleeping arrangements and 97 per cent of trusts provide properly segregated bathroom and toilet facilities. Those that do not are building new hospitals that will address the few places without proper facilities.

We have also re-equipped our hospitals after the famine years of the past. As of the end of May 2004, we have delivered 59 new magnetic resonance imaging scanners, 76 linear accelerators, 159 computerised tomography scanners and more than 690 items of breast screening equipment. That means 49 per cent of MRI scanners, 66 per cent of CT, and 53 per cent of linear accelerators now in use in the NHS are new since January 2000. That has never happened in the history of the NHS. We have the largest public sector IT procurement programme that will deliver transferable patient records, online booking and rapid information flows. I hope that that reassures some noble Lords who raised the issue of records. We have more staff, more hospitals and more and better equipment. That is this Government's record, as a number of noble friends have said during this debate. There has also been better access to drugs. Several noble Lords have drawn attention to the work of the National Institute for Clinical Excellence, which has improved access to the latest treatments.

To put our values and vision into practice, we need this current expansion of capacity. Without these additional doctors, nurses and other staff, without the equipment, the IT, the drugs and the hospitals, we could not have delivered the outputs and the improved outcomes that have been achieved. We have recognised the need to invest in the NHS, which the party opposite singularly failed to do when they were in government. It is difficult to see that they have learnt the lesson since. Under their proposals, they want to take £1 billion out of the NHS with their passport or voucher scheme—or whatever they decide to call it the next time it is re-launched. However, we have matched the new resources with reform to ensure delivery. That is why we have been able to deliver faster treatment. We have now all but eliminated waits of over 18, 15, 12 and nine months. In other words, we have halved the maximum wait which we inherited in 1997. Around seven in every 10 patients are admitted within three months of going on an inpatient waiting list. The average wait is just 2.7 months. At the end of March 2003, more than 90 per cent of patients in accident and emergency departments were seen and treated within four hours. As I understand Conservative policy, especially in the light of the remarks of the noble Earl, Lord Howe, it is to scrap all targets and so, I would suggest, let waiting times increase, ensuring that the public do not know what it can expect from the NHS.

We have delivered easier access, not only to hospitals but to GPs, to walk-in centres and to NHS Direct, including NHS Online. In April 2004, 97 per cent who wished to do so saw a GP within 48 hours, and 97 per cent were offered appointments to see a primary care professional within one day. NHS Direct has handled more than 23 million calls since its launch in March 1998, and has users regularly reporting satisfaction ratings of 90 per cent or higher.

Alongside those changes, we have seen the development of 350 healthy living centres, funded through the New Opportunities Fund, so skilfully chaired by my noble friend Lady Pitkeathley. Those new forms of service delivery have raised NHS productivity. Our reforms have also produced better outcomes for patients, with sustained reductions in death rates in cancer. There has been a 10 per cent fall in the rate of premature deaths of those under 75 from cancer since 1995 to 1997. Let me also pay tribute to the work of Professor Mike Richards, who has done a splendid job as the noble Baroness, Lady Finlay, remarked. Death rates from heart-related disease in those under 75 fell by more than 23 per cent from 1995–97 to 2000–02.

Let me reassure the noble Lord, Lord Patel, that we have not neglected mental health. We have established 240 assertive outreach teams, 33 early intervention teams, 150 crisis resolution teams—more than doubling that further during this year—and 12 programmes for training 1,000 graduate primary care workers. That is a major increase in capacity, although I accept that we shall need to continue to work on that area.

I am grateful for the recognition given by my noble friend Lady Pitkeathley to all that the Government have done to assist carers, but we know that we can do better by investing more in research and bringing discoveries to the patient faster. The Chancellor announced in this year's budget an extra £200 million a year for health research, a half of which my department will invest in new collaborative translational networks, building on the report of the Biotechnology Innovation Growth Team mentioned by the noble Lord, Lord Drayson. Let me say, by way of reassurance to my noble friend Lord Turnberg, that that work will have a public health element as well. I shall shortly make an announcement on that collaboration.

The Government have invested £40 million in a new UK stem cell bank, and we have a £50 million genetics programme to help to harvest the new genetic discoveries for the benefit of patients. In addition, we established in 2001 public career scientists awards, the fifth round of which is under way. With the MRC, we are funding more fellowships at doctoral and post-doctoral level. That will go some way to meet some of the concerns rightly expressed by my noble friend Lord Turnberg about academic medicine shortages in public health.

Our reforms have enabled staff to work differently to achieve more. The new contracts enable this through offering greater opportunity and reward for greater responsibility. We have devolved power to the frontline, through new freedoms. The development of foundation trusts will be a successful innovation. We are devolving 75 per cent of the budget to primary care trusts. There are some noble Lords who cannot have it all ways. They cannot say that we have command and control and then complain when we devolve money to local commissioners to make decisions on the basis of their local priorities.

New methods of working, such as treatment centres, provide better and quicker services to patients. We know that we need to go on increasing the number of NHS staff. That is why we have a range of recruitment, retention and return schemes and why we are expanding our training programmes. I gladly recognise the contribution made by UK universities as my noble friend Lady Warwick said. I can assure her that we are working hard on the complex issues involved in a benchmark price and a standard national contract for nursing and allied health professions.

I can also tell the noble Lord, Lord Colwyn, that we have improved funding for NHS dentistry consistently, and new arrangements have been put in place that will deal with many of the problems that we inherited. However, we do need to negotiate those agreements with the profession, and my honourable friend Rosie Winterton will make a further announcement shortly.

We have had to put right the neglect of the previous administration by increasing capacity, but we know we need more than increases in capacity. Provision of healthcare needs to be made more personal, as several noble Lords have said. We need to provide people with information about their healthcare and more choice over their treatment, as my noble friend Lord Harris so eloquently advocated. I assure my noble friend Lord Desai that we agree with him that patients need more empowerment and choice, although whether we take up his air miles card is another matter. But our increase in capacity now makes it possible to increase choice as we pledged to do in our 2001 manifesto.

Following an extensive public consultation last December, we published Building on the Best: Choice, responsiveness and equity in the NHS. This sets out how we need to make the NHS more responsive to patients by offering more choice across the spectrum of healthcare. There is, of course, already good practice locally and many schemes where service users are becoming more involved in their care. A national initiative offering choice of hospital is already being implemented for those waiting over six months for elective surgery. From December 2005, choice of hospital will be offered at the point of referral by general practitioners. Despite the scepticism mentioned by a number of noble Lords this afternoon, commissioning itself is improving and we are strengthening those arrangements. Let me assure noble Lords that this will play an important part in the choice agenda.

I shall try to give my noble friend Lady Jay some brief insight into our approach on choice. Choice needs to be extended to everyone, regardless of where they live, what they can afford, their educational status, age, disease or condition, or their cultural background. Redesigning services around the wishes and choices of different groups of service users will improve access to care and treatment and reduce health inequalities. We know from our experience that we can combine equity and choice, just as we have successfully achieved full employment and low inflation.

Let me try to reassure my noble friend Lord Winston that we are bringing the private sector into serving the needs of patients within the NHS, not pushing patients into the private sector. That, if I may remind him, seems to be the policy of the Benches opposite. We will be going further. My right honourable friend the Secretary of State will be making further announcements in this area very soon indeed.

But one thing is clear. The Government's idea of choice is fundamentally different from that of the Benches opposite. When we offer choice it is equally accessible to all people, irrespective of their ability to pay, whereas the party opposite—I say it again—wishes to take £1 billion out of the NHS to subsidise those who can afford it to chose an alternative to the NHS through what I suggest is a spurious patients' passport or voucher scheme. Their notion of choice would damage the NHS. There should be no misunderstanding about that. It will reward the few who can afford to make a contribution. Our version will enhance the NHS and provide choice for the many.

But we are not complacent about our record on public health. Even with the 10 per cent drop in cancer deaths and the 23 per cent fall in heart-related deaths, there remain challenges to be tackled, as many noble Lords have indicated in this debate. For example, it is totally unacceptable for one in five children not to eat any fruit in a week. There is an excessive consumption of alcohol by some people. Men in Manchester are likely to die on average 8.5 years earlier than men in Rutland. The incidence of obesity has trebled in just 20 years. One in 10 sexually active young women is infected with chlamydia. The Government share the concerns expressed by my noble friend Lady Gould and I pay tribute to the work she is doing in the area of sexually transmitted infections. We accept that there is a need to give priority in this area.

We will continue to tackle health inequalities through our programme of action, launched by John Reid last July. But, as my noble friend Lord Hunt has said, we have done much through measures such as the minimum wage, Sure Start and tax credits to reduce inequalities. We know that it is vital to improve the health of our children, as many noble Lords have suggested. My noble friend Lady Massey has raised many important preventive issues and I pay tribute to the work she has done as chair of the National Treatment Agency.

The noble Baroness, Lady Masham, raised the very important issue of MRSA and healthcare-acquired infection. Of course, MRSA is everywhere including, dare I say it as delicately as I can, on many noble Lords' hands and probably up a number of nostrils as well. That is a fact of life. It is in the atmosphere. It is everywhere. There is no problem for most people who are fit and well. The problem is for people whose immunity is low, who are seriously ill when they are in hospital. The CMO has produced an action plan, Winning Ways, which was published in December last year, showing how we are tackling the problem. Further action will be announced soon. Hand hygiene is critical and the NPSA, chaired by my noble friend Lord Hunt, is piloting an approach to improve hand hygiene, which we hope to roll out nationally.

Many people are now better informed about and more involved in their health and well-being than ever before. Health is an issue for us all, not just the Government. We cannot force people to be healthy. My right honourable friend the Secretary of State has been trying to get that message across. In public health, there are few quick fixes but we are seeing new ways to manage chronic disease, developing them with the patient centre stage and more involved in their own care rather than waiting for crises to happen. Although we are often aware of steps that we can all take that will improve our health—eating a healthy diet, stopping smoking, curbing drinking and being more physically active—we do not always act on our own knowledge.

I suppose that the noble Earl, Lord Howe, has to find something on which to criticise us, so he focuses on public health and chides us for not doing enough. I admired his elegant speech on that. However, I do not find many echoes of it in the speeches of his leader and shadow Front-Bench spokesmen in the Commons when they talk about health policy. By contrast, on 3 March, my right honourable friend the Secretary of State for Health, John Reid, launched the biggest consultation exercise of its kind about how to improve everyone's health and well-being. We wanted to hear from people across the country—from the NHS, the local authorities, industry, the media and, most importantly of all, individuals in the public.

We are asking for views on questions such as, "What support do individual communities need to be healthier? What would make the big differences to the choices people make about their health and how to prioritise actions? How do we balance individual choice against good health for others in terms of, for example, smoking in enclosed public places?". Responses to the consultation will feed into the production of a White Paper setting out next steps, to be published later this year. The consultation is the next step towards better health, a process that will involve people at every level and in all walks of life. It will meet the needs of the black and ethnic minorities as well, which were so eloquently described by my noble friend Lady Howells, who has had to leave, and the noble Lord, Lord Chan. I shall certainly investigate whether work is in hand on stress—she inquired about that—and shall write to her.

We have had a good debate. It has shown the Government's commitment to the NHS—a record of which we can be proud. It has also shown our commitment to going further and building on that huge investment in extra capacity by taking forward the choice agenda for patients, producing patient empowerment, and providing a more personalised NHS. That will be done without breaching the fundamental principles of the NHS—services available to all, free at the point of delivery. Our version of choice is very different from the privileged version proposed by the Opposition. Alongside choice, we will take forward a reform agenda on public health, building on a wide-ranging public consultation and trying to take people with us on a consensual basis wherever possible. We recognise that public health can be improved and intend to work in partnership to achieve improvements, especially in the health of our children.

At the next election, the electorate will be faced with a clear choice on health—a Government with a strong record of NHS investment and reform and with clear plans for expanding choice, personalisation of health and better public health for all, or an Opposition whose policies will take money out of the NHS to subsidise health choices for the better-off.

Lord Selsdon

My Lords, as the only Baron on these barren Benches, I feel that the Minister's remarks might be a bit unfair, because one thing that my noble friends were trying to do was to get greater efficiency in the National Health Service. Will he remind me, from the Government's own statistics, how many employees there are per acute bed in the United Kingdom, compared with our friends on the continent of Europe, particularly Germany, Switzerland and France?

Lord Warner

My Lords, I do not remember the noble Lord participating in the debate. If he is curious about such matters, he can ask the Library for that information.

8.24 p.m.

Lord Hunt of Kings Heath

My Lords, we have had an excellent debate and I wish to thank all noble Lords who have taken part in this five-hour session. In particular, I pay tribute to my noble friend Lord Drayson, who made a magnificent maiden speech. I am sure that he will make a great contribution to this House in future. I also thank the Minister for his skilful and comprehensive summing up. He did not go quite as far as I had wanted in relation to the NPSA's "Clean your hands" campaign by announcing the allocation of lots of extra money, but I am ever hopeful.

I should also pay tribute to the noble Lord, Lord Clement-Jones, who has been a fine Front-Bench spokesman for the Liberal Democrat party. He will be much missed and I hope that he will contribute to debates on the health service in future. I notice that, in castigating the Government for their restructuring of the NHS, he failed to defend at all his party's own policy, which is aimed at a further restructuring. I hope that before he gives up his post he might table an Unstarred Question on restructuring to allow us to debate the matter further.

The noble Earl, Lord Howe, accused me of making a speech more fitting to the 15th plenum of the Supreme Soviet. That will not commend me to my party, although it will come as a pleasant surprise to the members of the Kings Heath and Moseley branch of the Labour Party. I was somewhat disappointed at the noble Earl's pessimistic tone, although he acknowledged some of the advances that the health service has made.

I was glad that two former health Ministers spoke in the debate—my noble friend Lady Jay, who contributed so much at the beginning of this Government's programme and my noble friend Lord Jones. In his story of Barbara Castle's handbagging of the esteemed pinstriped presidents of the Royal Colleges, I noticed a sense of angst among two former presidents of Royal Colleges. They brightened up considerably when my noble friend Lord Dubs then referred to 5 July 1948 and to the patients who were lying to attention as consultants marched around the wards.

Life changes and so must society and the NHS. At the end of this debate I am left with a sense of considerable optimism. Of course there are many pitfalls and challenges. We have heard about many of the critical issues in relation to public health. But is there any doubt that the NHS is in good hands? Is there any doubt that it is making good progress? I believe that it is in a very fit condition to continue to serve the nation for many more years to come. I beg leave to withdraw the Motion.

Motion for Papers, by leave, withdrawn.