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Lord Boyd-Carpenter: My Lords, I wish to express the view that the Prime Minister's handling of the matter greatly increases the admiration which many of us feel for him. We would like respectfully to send our congratulations to him that, despite many other manifold problems, he has handled the matter in a courageous and masterly way. I am sure that all elements in this country are profoundly grateful to him for it.

Viscount Cranborne: My Lords, I am grateful to my noble friend and, with his permission, will, with the greatest pleasure, pass his sentiments on. I also associate myself with them.

5.15 p.m.

Lord Marlesford: My Lords, does my noble friend agree that: given the fact that Sinn Fein and the IRA are one and the same organisation, that membership of that organisation is both tiny and wholly unrepresentative of the people of either Ireland or Ulster, that it has four components: first, a few genuine Irish Republican Nationalists; secondly, a few committed Marxists whose long time desire has been for a united Ireland (Gerry Adams having been a long-term member of that persuasion); thirdly, a small number of dangerous psychopaths who enjoy the process of killing and maiming; and, fourthly and overwhelmingly, a group of criminal extortionists who for years have been making a very satisfactory living out of this form of crime, there is a certain conceptual contradiction in trying to arrive at a political agreement with Sinn Fein/IRA? Indeed, is it not rather like trying to arrive at a political settlement with the Mafia in the United States?

Does my noble friend agree that for the vast majority of the active members of the Sinn Fein/IRA a political settlement in Northern Ireland would represent a terminal threat to their chosen way of life, and that is precisely why the Governments of the United Kingdom, Ireland and the United States must continue to strive for such a settlement?

Viscount Cranborne: My Lords, I am grateful to my noble friend. As negotiations begin, we shall see whether Sinn Fein is able to change its spots.

National Health Service

5.17 p.m.

Debate resumed.

Baroness Masham of Ilton: My Lords, we now go back to the National Health Service. I thank the noble Lord, Lord Winston, for initiating the debate. Having been a member of a health authority for many years I have seen numerous changes. One is how the current competition among hospital trusts has not always been as happy as it might be. I have heard the saying: "Trusts no longer trust each other".

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I have nothing against competition which will raise standards for everyone, most of all the patients. But now trust hospitals are pinching each other's staff and working under the stress of always having to save money. So the pressure throughout a hospital penetrates down to patients. Efficiency is not always about direct money. It should also be about the standard of care at patient level where time can be wasted with inefficiency.

A friend of mine with whom I had lunch last week told me that he had just been to a London teaching hospital for a stomach investigation under anaesthetic. Just before he was given the injection the doctor checked his notes and asked whether he had stopped taking the tablets which he had been on so that the investigation was viable. He had not; no one had told the patient. The doctor used two words which I could certainly not repeat in your Lordships' House and the operation had to be postponed for a month, wasting everyone's time.

So often, the staff making the arrangements with the patients are very junior or, as happens nowadays, are agency staff brought in to fill the gaps. They may not know the procedure for different investigations. Surely there should be a checking system so that the patient knows exactly what to do.

Living as I do in the rural part of north Yorkshire, I know how important it is for everyone to have a first-class GP service. Hospitals can be a long distance away. We are lucky to have many good GPs in north Yorkshire.

My GP and his wife trained at St. Bartholomew's Hospital and have been greatly affected by the saga of Bart's. His loyalty to his teaching hospital has been steadfast, but his commitment to being a GP in England is wavering. After a visit to Australia, he keeps talking about it. Speaking as an FHSA member, we in north Yorkshire are concerned about the lack of general practitioners coming forward for selection when a practice vacancy occurs. A few years ago there might have been as many as 200 applicants. Now we are lucky to have five--and most of those will not have reached the standard required.

There needs to be careful consideration as to why there is a shortage of general practitioners. There are many reasons: too much paperwork; drugs and alcohol violence; demanding patients; out-of-hours working; isolation; too many sick patients in the community who a few years ago would have been treated in hospital; a feel for working in developing countries on the part of many young doctors, and many other reasons. But perhaps also it has something to do with our restless society, which brings with it a lack of long-term commitment. That is reflected not only in the medical profession but in many other professions.

I am president of the Spinal Injuries Association. Since our formation 22 years ago we have always pressed for all patients with damage to their spinal cord resulting in paraplegia or tetraplegia (paralysis from the lesion down) to be treated, whenever possible, in a specialised spinal unit. If you do not feel your paralysed

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parts there is a serious possibility of developing pressure sores, especially while a patient is in spinal shock during the first 24 hours after injury.

I raise this matter today as it is of great concern to the medical staff of spinal units, and of even greater concern to the patient and his family, if a patient develops a pressure sore before he comes to a spinal unit. It is one of the biggest problems, holding up rehabilitation and unnecessarily costing the NHS an immense amount of money. In spinal units there are procedures for turning patients regularly to relieve pressure, with special equipment and nursing expertise.

Patients who are treated in general trust hospitals are still developing pressure sores. In the south of England there are some excellent, up-to-date spinal units; and the one in Scotland which I visited recently must be one of the best in the world. I ask the Minister: what is happening in the north of England? There is concern about the Hexham and Wakefield units.

It is so important for spinal patients to have the correct treatment. Would it not be of great benefit to everyone if there were a central reference point in finding beds? Is there not also a request for this from neurosurgical departments? It seems that the Department of Health could do much more to help these critically ill patients and the doctors who need to find specialised beds for them. Surely it is possible to have a national database linked with A&E departments. If department stores can do that when one goes to buy a dress, surely the National Health Service must be able to do it too?

In recent weeks throughout the country there has been great concern over the lack of intensive care beds both for adults and for children who need critical care. These patients do not come in regimented order. Serious illness and traumatic injury is spasmodic. Would it not be possible to have multi-disciplinary training in critical care for all ages, and nurses who could be used more flexibly and moved to other departments should the critical care beds not be occupied? These beds are very expensive to fund, but they are an insurance policy for everyone who may need them. It is frustrating and tragic for everyone when lives are lost that could have been saved had such a bed been available.

I have heard that social workers have been withdrawn from hospitals in Buckinghamshire by social services, so that links between hospital and the community have been cut. That has caused great concern to hospital trusts such as Stoke Mandeville, which now has to fund its own discharge co-ordinators. Making community care work, especially with elderly patients, is very important. It is a difficult problem. It will mean that hospital beds will be blocked if patients cannot be got back to the community. There seems to be a problem, and I hope the Minister will look into the matter.

There are many needs in this vast health service. Many people work hard to raise money to help provide equipment and keep it up to date. When a scanner to diagnose a critical patient does not have a 24-hour on-call person to work it, there is dismay and disbelief. I hope there will be ways to provide what is needed to

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save as many lives as possible and to rehabilitate those who need it, so that they can have the quality of life that they are able to attain.

If you ask doctors and dentists in the health service these days how they feel, many will say that bureaucracy is swamping them. They have so much pressure on them to use cheap products that at the end of the day job satisfaction is not as good as it should be.

5.27 p.m.

Lord Desai: My Lords, I rise to speak not as anyone who has managed a trust, has been a doctor, or is active in the National Health Service. I take the opportunity to ask this question. If so many extra resources have gone into the health service--as the noble Lord, Lord Clark of Kempston, emphasised and as we all acknowledge--why is there such a high degree of dissatisfaction with the service?

The noble Lord, Lord Clark, said that we were denigrating the National Health Service. I do not think that is the case. Every morning I buy six newspapers: the Sun, the Daily Mail, The Times, the Independent, the Guardian and the Financial Times. I read the Sun first, and then the Daily Mail. I tell the noble Lord: read the tabloids every day. There is always a national health story in which people are complaining. This is not made up. As the noble Lord, Lord Walton, said, perhaps these are events on the margin, whereas the broad flow of service is satisfactory. However, I do not think it can be said that the Motion tabled by my noble friend was somehow concocted from his imagination, or that it merely represents Labour Party denigration of the Government.

The National Health Service is in trust to all the parties. We agree with that. All the parties have helped to make it what it is. It is a valuable asset to us. We are discussing this matter now because in our various ways we care about it. It is in that spirit that I wish to address the subject today.

I believe that there is a problem with the internal market. In my view, the problem is that the internal market does not work like any other market. In the recent past I have had occasion to speak on the Broadcasting Bill, the issue of student loans and several other issues. I have pointed out again and again that this Government say they believe in a free market but do not understand how a free market works. Unfortunately, what turns up is a series of bureaucratic pricing rules and contractual arrangements which make work rather than reduce it.

My noble friend Baroness Hayman was entirely correct. Managers should be there to manage. Of course they have very important things to do. However, they cannot manage but have become bureaucrats. They have become bureaucrats, for the very simple reason that since the introduction of internal market reforms we do not have a market which prices services or commodities, but a series of centrally set prices and contractual arrangements.

What is the temptation of central government? Ultimately, in their search to emulate the market they make more and more pigeonholes, as my noble friend

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has described: fund-holding GPs, non fund-holding GPs, what the patient's history is, which hospital he or she has been to, the length of stay, and so on. Each carries a different price. Those prices are bureaucratic and do not allow for any adjustment.

The welfare state is run in the same way. We create lots and lots of categories just to make a difference of 50 pence to how much we pay somebody each week. If one has so many categories and prices to worry about they are not prices at all. They are what may be called "soviet" prices. Such prices lead to bureaucratic work. A hamburger will cost a different price in a town versus a city, in different parts of a city and in different kinds of hotels and restaurants. Why is that? It happens because the market offers a variety of different prices and lets matters adjust. What we are doing is setting the same price across the country for each separate category rather than allowing local managers to manage. I am not saying that it is easy, because health is not a simple commodity. Health is a bundle of commodities. One does not have to take my word for it. Professor Alan Maynard, who is a more fervent believer in the free market than I shall ever be, is critical of the internal market precisely because it is not a free market.

I was briefly responsible for the health portfolio and spoke from the Front Bench. During my brief tenure the Tomlinson Report came out. That report identified a very simple problem. If you impose on inner city hospitals the same costing rules that you impose on other hospitals, especially if you include the price of land as one of the costs to be met, they will end up as high cost hospitals. If one has the same price across the country for a hip operation they will price themselves out of the market. One does not require a sophisticated diagram to show it. Therefore, one has a single price and bureaucratic rules which say that costs have to be met, with the result that inner city hospitals are shut down. With the finest of intentions, it was said that there were too many inner city hospitals, that technology was changing, that people liked treatment at home and that there should be more primary health care in London. That is fine. But if one does not put primary health care in place long before one shuts down hospitals, if one does not educate people who are used to going to hospital for their problems that alternatives are available, and the transition will be as costly as I have said that it will be--to shut down hospitals does not save money but costs money--one will have a little bit of pinching here and there.

We have not properly thought through the internal market. How to price differentially a hip operation, or anything else, across regions, hospitals and age and gender is not an easy thing to do, but I believe that a lot more flexibility can be allowed. What we have is a system of soviet pricing and decentralisation and, even at a time of a growing budget, budget restrictions. Therefore, a lot of time has to be spent filling out forms.

My experience as an inner city academic is that as money gets tighter there are more forms to fill out. As money gets tighter we have not learned any way of allocating money except bureaucratically by filling out forms. The Government will not allow us to charge any

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particular student fee that we want to charge because that will be too much of a free market. They cannot stand it. It may also antagonise the middle classes. Therefore, we have no free market in student fees and restrictions on the number of students we can take, but we are supposed to behave like an internal market. It does not make any sense. All it does is to make us do things that we are no good at: filling out forms.

I have nothing against managers, but a tremendous amount is spent on them. If they have not been able to solve this problem it is because they have not been given the freedom to do so. They operate under constraints which are unreasonable. Until those reforms are properly implemented we will go on having problems, regardless of which party is in power.

5.36 p.m.

Viscount Bridgeman: My Lords, I should like to thank the noble Lord, Lord Winston, for initiating this debate. I must declare an interest. First, I had the privilege of playing a small part as a special trustee in the noble Lord, Lord Winston's hospital, the Hammersmith. Secondly, until the end of 1994 I was director of a PLC medical services group which included the provision of agency nurses.

Of one thing we ought to be clear. Some of the more uncritical supporters of the purchaser/provider regime may give the impression that we moved straight from stagnation in health care management to the broad sunlit uplands of the Griffiths reforms. It was not like that. Many of the developments that we now see were already under way. It was just that the new climate enabled them to happen more quickly. That having been said, on the whole we have an exciting and motivated National Health Service which is not without its attendant problems, several of which have been articulated by noble Lords this afternoon. At the root of it all, the health service is becoming more patient-responsive. Waiting lists are down and the Patient's Charter has some meaning to it. I suggest that that derives from better management and use of resources; in particular better management in the difficult areas of cross-discipline problems such as mental health and chronic diseases. Lest it should be thought that I am seeing all of this through rose-coloured spectacles, I should add that there is a danger of over-efficiency. A drastic cutdown of beds probably results in a lack of surgical beds when there is a crisis in acute wards, but they are developments that are capable of adjustment in the light of experience.

The success of the new service owes a great deal to that much maligned body of men and women, hospital administrators, for whom, contrary to much that appears in the media, I have found widespread appreciation on the part of the medical profession. I take issue with the noble Lord, Lord Desai, and the noble Baroness, Lady Hayman. There may be bureaucracy in the health service, but in the vast majority of cases managements across the country are very effective. There is also a perception that there is better local planning and welcome delegation of responsibility from central government to the health service and, within the health service, to a level close to local communities. At this

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stage there is perhaps more promise than delivery, but the groundwork is in place. Per capita funding is to be welcomed where the resources follow the population, though I know some inner-city trusts feel disadvantaged under the department's current formula vis-o-vis those in suburban and rural areas. Should not weighting for deprivation be applied to all health authority funding without exclusion of some elements as at present? I hope that my noble friend the Minister will look at that afresh.

One hears of a release of enthusiasm for innovations. GP funding is a high profile and successful example. But initiatives can be found in many areas of the hospital and community services and indeed in collaboration with the voluntary sector. But let us not be blind to problems which radical developments of this nature bring in their train. The trusts and authorities must be sensitive to a fault that extra responsibility is not forced on those who do not want it, whether for reasons of age or innate conservatism, or quite simply because they just want to get on with the job of treating and caring for the sick for which they joined the service. Those people must be left to get on with their chosen line. But at the same time, it is good to know that in the current climate it is the young Turks, too, who are being given their head.

Lastly, let me say a word about nurses. Mistakes have been made in the past. Nursing training schools were closed down to a far greater extent than they should have been. It can never be said that nurses are adequately paid, despite the very telling statistics produced by my noble friend Lord Clark. The nurses' case always seems to me to be less well articulated than--dare I say?--that of the junior doctors. But nursing directors speak of the motivation that nurses now have. They arrive with, if not a degree, at least a university standard of qualification. They are ambitious to get on. Trusts now provide a wide range of in-house training and there are management opportunities for those so inclined. A good example is the present chief executive of one of the three largest Manchester trusts, who is herself a qualified nurse. The significance will not be lost on the profession.

At a lower level, nurses are increasingly involved in consultations affecting every aspect of their work. The development of the role of nurse-practitioners, to do work previously done by doctors only, is an enormous step forward, not--one nursing director pointed out to me forcefully--because it enables junior doctors' hours to be reduced, desirable though that is, but quite simply because the patient gets better service, often by the elimination of lengthy delays. The increased practice of named nurses to accompany patients through different departments of the hospital is another small example of improving care for the patient.

The reforms of the National Health Service are far from complete and inevitably there will be frustrations and mistakes. But I suggest that the omens are good

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for the twin goals of better care for patients and occupational fulfilment for all those committed to their well-being.

5.43 p.m.

Lord Dubs: My Lords, I welcome the opportunity for debate given by my noble friend Lord Winston and also his very interesting and purposeful comments when introducing it. I should declare an interest. I am a non-executive director of an NHS trust in south London which deals with mental illness. Some years ago I was on the Kensington, Chelsea and Westminster Area Health Authority.

I note from the debate that there seem to be two health services in this country. There is the one described by some Conservative Members opposite as a system which is working perfectly, with which nothing can go wrong and in which all is ideal. Then there is the National Health Service which we on this side of the House describe. That is based, I suggest, on fairly broad experience and it tells us that there is quite a lot amiss with the National Health Service. We have to note that over the years since the Conservative Government were elected there have been repeated statements made by Ministers about their wish to have an increasingly large private sector of healthcare in this country. There have also been other comments which may have made some of us wonder whether there is a total commitment to the National Health Service. I totally exempt from those remarks the noble Baroness, Lady Cumberlege. I know her very strong commitment to the health service. But over the years, there have occasionally been other signals.

I believe that in this country we are getting our health service on the cheap. As a country, we spend far too little of our gross domestic product on healthcare. Compared with every other advanced industrial country, the percentage of our GDP spent on the health service is less. The latest figures that I have are for 1994. In the UK we spend 7.1 per cent.--that is for all healthcare, private and public; in France the figure is 9.8 per cent.; in Germany it is 8.6 per cent.; in Canada it is over 10 per cent. and the United States spends over 14 per cent.

I believe that part of the reason is that over the years the National Health Service has been extremely cost-effective in delivering healthcare. All the evidence suggests that a state-financed health service, financed from the centre, is a better and more effective way of providing healthcare than the whole range of private and insurance-based schemes that we see in other countries. But there is a price to be paid for that. Because it means that the Government have to make one decision every year about how much money goes into the National Health Service, it is all too easy for a government to provide less than they should. Therefore we spend the low percentage of GDP to which I referred.

I turn to the subject of managers. I believe that one of the regrettable consequences of the purchaser/provider split and moving on to a market-based system has been a proliferation of managers of various levels in the health service. On the

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other hand--I speak from my experience of the health service to which I referred--there is a need for good and effective management in the health service. I should be very disappointed if the arguments about the first point--namely, the need for additional management simply to have an internal market--were to distract attention from the need to have good, effective and adequate management, so that in turn we can provide better and more efficient healthcare for patients. My fear is that in these arguments the second point will not come out so clearly.

The Pathfinder Trust, of which I am a non-executive director, in my experience has an extremely dedicated staff who often are working against difficult odds. There are some excellent non-executive directors and indeed executive directors to manage the trust. It is a pleasure to be there with them. The trust also provides a number of national or wider-than-regional services, such as a specialised service for the deaf mentally ill. That is all very positive. But I believe that the context in which we and other bodies in the health service are working is often a difficult context, which is made more difficult by some of the activities of the Government.

I turn briefly to care in the community, to which we paid some attention in this House only a few days ago. Traditionally, the expression "care in the community" seems to have been applied to resettling long-term hospital residents into supported places in the community. But the definition has now become wider. We are speaking about an approach to mental healthcare which has as its aim the avoidance of care in institutions whenever possible. That is not an easy or inexpensive option. In fact, it might be a more expensive option because providing intensive support in the community may indeed cost the provider of the service rather more than long-term stays in hospital. So it seems to me that we must not regard community care as an inexpensive option but as one which is right and proper when handled well and in the interests of patients.

There is one other aspect of our mental illness services to which I shall refer. I have noticed at Pathfinder that there is a disturbingly large proportion of black people in Springfield Hospital. It is even more disturbing that, when one asks how they have been referred to the hospital, they seem to be referred by different means from those for other patients in the hospital. In other words, fewer of the black people in the hospital are referred by GPs and therefore picked up early in the process when they become ill; but, alarmingly, a larger proportion of black people are referred by the police when their illness has become very severe. There must be something wrong in that regard. I do not know what the answer is, but it is right to draw attention to the problem. It is widely understood by those who have studied it; nevertheless, it is a matter of some importance and concern.

We recently had to move to determining pay at a local level. I am bound to say that I find that process difficult. One trust alone negotiating pay--we have not yet started this year's negotiations; we are about to--is in a difficult position. We have to look to see what others are doing and wait. That is not a sensible way of moving

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forward but the resources and options are limited. I question the idea of local pay rather than utilising the old system, which seemed to me to work well.

Perhaps I can refer to one aspect of preventive health care, or the lack of adequate preventive health care related to teenagers who smoke. It is disturbing that smoking by 11 to 15 year-olds increased by 12 per cent. in the last year for which we have figures. That means that 280,000 regular smokers are aged between 11 and 15 years. If one adds the occasional smokers, it means that over 20 per cent. of that age group, none of whom should be allowed to buy cigarettes and tobacco, are smokers. It is also disturbing that girls feature more prominently in those figures than boys. The consequences to the National Health Service will be that at some future time it will have to deal with the increased severe illness that arises from people who begin smoking at an early age.

The Health Education Authority has had less money available to deal with the problem of teenage smoking. In 1991-92 it had a budget for that purpose of £1.7 million and in 1995-96 it was reduced to just £850,000. It is an extremely serious problem with long-term implications for the health service. It is being made worse by the fact that, though television advertising of cigarettes is not permitted, there is so much sport sponsorship, all of which feature the tobacco companies, that many teenagers in surveys still think that cigarettes can be advertised on television. That is undesirable and I urge that more effort is made in promoting health education for young people in order to reduce the number of teenagers who smoke.

5.53 p.m.

Baroness Cox: My Lords, like other noble Lords, I am grateful to the noble Lord, Lord Winston, for initiating a debate which allows so many important issues to be addressed. I declare an interest as a vice-president of the Royal College of Nursing. In that capacity I shall address some of the problems facing the nursing profession in Britain today.

I appreciate that the Government have introduced many reforms which have offered nurses many new opportunities and some of those were identified by my noble friend Lord Bridgeman. However, this afternoon I speak with a heavy heart. I fear that my contribution will sound negative, but that is because it is born in the concern experienced by so many members of a profession which is staffed by dedicated people who now feel undervalued by the Government and by a review body which recommended so much less remuneration for them than for other professions, including junior doctors.

I shall address four interrelated problems: shortages of nurses; morale; recruitment and pay. In each of those areas I shall refer back to answers given by my noble friend Lady Cumberlege in response to questions asked in your Lordships' House on 21st February. I hope that she will be able to give rather more reassuring responses today to a profession on which the National Health Service depends for 80 per cent. of the care it gives to patients.

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I turn first to nursing shortages. My noble friend referred to an excerpt from the review body's report, asserting that there is no general shortage of nurses, though the report admits that there are difficulties in some areas. It also points out that there are signs of more shortages to come. My noble friend also claimed that local pay negotiations are the best way of meeting such shortages. Can my noble friend say whether that principle is being applied to other professions such as doctors, teachers and social workers? If not, why are nurses singled out for that treatment?

Is my noble friend aware also that the principle of local pay negotiation is quite invidious? Trust executives are making the point that salary increases for nurses can only be made at the expense of resources available for patient care, and that has an inhibiting effect on a profession manifestly dedicated to promoting the highest possible standards of care. It therefore feels uncomfortable in competing for resources which would otherwise go to patients.

I also fear that my noble friend's confidence in local pay negotiations for reducing nurse shortages may prove unfounded. For example, there is only a small pool of nurses available for recruitment to the NHS. The unemployment rate for nurses is now only 2.5 per cent. compared with a figure of 8.6 per cent. unemployment rate for the general population. That small pool of available nurses also needs to be seen in the context of expanding demands for nurses. According to Department of Health statistics, the demands for nurses in the NHS, in the independent sector and in GP practices expanded by over 20,000 whole-time equivalents in the five years between 1989 and 1995. Since one-third of nurses work part-time, that probably means a net expansion of at least 27,000 nurses in the past five years.

That expansion occurred at the same time as a sharp cut-back in the number of students in training. In 1983, 37,000 nurses qualified. In 1986, the figure dropped to a mere 14,000. Though the Government announced recently a proposed increase to 17,000, that is still a far cry from earlier years. Taking retirements into account, the prospects are that the pool of nurses available to meet the expanding demands of the NHS will shrink; that shortages will increase, and that patient care will suffer.

Perhaps I may give a few examples of current shortages from the many which I could have chosen. Glasgow Royal Infirmary delayed opening its winter medical ward by two months because of problems in recruiting nurses. Leighton Park Hospital in Crewe, where there were 76 unfilled vacancies, issued a public appeal for nurses. I have just heard that the Maudsley Hospital, a Mecca for psychiatric care, has around 100 unfilled places for nurses. In November 1995 Whipps Cross Hospital had to close to emergencies for 15 hours because of a shortage of qualified staff. In January this year Great Ormond Street could use only 11 out of 19 paediatric IT units because of staff shortages. A survey by the Royal College of Nursing's journal, Nursing Standard, found that two-thirds of trusts are finding difficulty in recruiting qualified nurses; one in five nurses believes that staff levels are

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"dangerously" low and 70 per cent. said that they thought staffing levels were too low to provide adequate care to patients.

From my experience of nursing I know that one of the most potent sources of low morale is the inability to provide the quality of care for patients and their families which professional standards require. If one spends a shift run off one's feet without a proper meal break, it is not the hard work, the long hours, the physical exhaustion or the lack of a meal which gets one down; it is the care one could not give because the ward was too short-staffed; the patient one did not have time to talk to when he was lonely or depressed; the relatives one could not spend time with when they needed reassurance; the students whom one could not supervise and teach, or the personal care of a patient which had to be rushed, for example, because so many patients were coming and going to theatres and life-threatening responsibilities had to take priority over other kinds of care.

One shift like that is not only physically and mentally exhausting; more seriously, it creates frustration and a lack of job satisfaction over the shortcomings of the quality of care you could not give to your patients. But shifts like this, day after day, week after week, create demoralisation and may well lead to resignation from nursing.

It is perhaps not surprising that the Royal College of Nursing has analysed new evidence from the Department of Health, which confirms a worsening picture of rising demand and falling recruitment. Turnover and wastage in nursing have been increasing steadily over the past three years, with turnover rising from 11.1 per cent. in 1992 to 14.7 per cent. in 1995; and wastage rising from 7.5 per cent. to 9.3 per cent. over the same time. I believe that this evidence was excluded from the Government's own evidence to the review body. These are the hidden costs of shortages behind statistics and are closely related to morale.

As part of its evidence to the Nurses' Pay Review Body, the RCN commissioned the largest ever survey of UK nurses. It found dissatisfaction with pay, career prospects and job security had reached record levels. Among reasons given by nurses for leaving the NHS, almost one-third cited low job satisfaction or concerns about career prospects or pay; nearly 40 per cent. said that they would leave nursing if they could.

Another aspect of my noble friend the Minister's reply last week indicated satisfaction with the number of applicants wanting to come into nursing. But these figures must be seen in context. I am happy to say that there has always been a pool of idealistic, young and not so young, people prepared to enter nursing despite the relatively low pay, anti-social hours and life and death responsibilities, making personal demands which add incalculably to the stress of professional responsibilities. But these figures must be seen in the context of reductions in the number of student places and in newly qualified nurses to the extent to which I have already referred. Moreover, the fact that nearly 40 per cent. of qualified nurses are considering leaving the profession can hardly be encouraging for new recruits.

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Probably the most discouraging development of all is the last point I want to address--the level of pay relative to other professions and the derisory 2 per cent. recommendation by the review body. I ask my noble friend what encouragement she can give to nurses concerning this recommendation of a 2 per cent. pay increase, when a qualified nurse already earns 23.6 per cent. less than a police constable; 21.4 per cent. less than a teacher and 31.2 less than a social worker? And what explanation can my noble friend give for the disparities in recommendations for the 2 per cent. for nurses compared with between 4.3 per cent. and 5.8 per cent. initial increase for junior doctors, with a further 1 per cent. from December?

Will my noble friend understand that these discrepancies are extremely demoralising for a very hard-pressed profession? Does she appreciate that a relatively low salary structure already exists? A newly qualified staff nurse with major clinical responsibilities earns a mere £11,895. A small percentage on a small salary is a very small increase indeed and cannot be seen as fair or encouraging.

Finally, my noble friend Lord Clark claimed that the Government had treated nurses very generously. NHS nurses' pay has increased by 6.2 per cent. less than average earnings since 1989. In relation to other professions, nurses would need an 8 per cent. increase to achieve the same level of pay as a teacher. Can my noble friend explain how these developments can be interpreted as encouraging to a profession on whom the National Health Service depends for quality of patient care?

6.3 p.m.

Baroness Nicol: My Lords, I am very grateful to my noble friend for giving me the opportunity to air one of my own particular worries, but also for allowing us to hear the very expert speeches from so many Members of this House, not least that of the noble Baroness, Lady Cox, who has just spoken. I found her speech extremely inspiring in its way because one begins to feel that there is little understanding of the whole problem of nursing. She encapsulated it for us.

My approach to health provision is that, within the National Health Service, there should be no discrimination between patients on the grounds of money, background or influence. That probably now sounds old-fashioned. There should be just one criterion governing the provision of treatment and that is medical need.

For many years it was a matter for national pride that our approach to the provision of medical care was that it should be free at the point of need and available to all without discrimination, within the bounds, of course, of available resources. The introduction of market ethics has changed all that and I wish to devote my few words to the effects of some of those changes rather than reciting the details of the changes with which we are all familiar.

I find that Government Ministers are cynical about cases quoted by Opposition speakers so I propose to quote at some length from a speech made last November

28 Feb 1996 : Column 1500

by the BMA Chairman of Council, Dr. Sandy Macara. This is what he had to say about the internal market in the National Health Service:

    "It was assumed that competition, with the philosophy of 'winners' and 'losers' replacing that of co-operation, would deliver the goods ... It is little surprise that a majority of senior doctors now crave early retirement, and an unprecedented proportion of young doctors are abandoning medicine after many years of gruelling and expensive education. Where, they ask, stands equity, when the cash lottery dictates priority to patients with lesser need? Where stands integrity, when doctors are instructed, as in Deal earlier this year, to conceal from the town's fund-holding general practitioners' patients the reason why their treatment had to be deferred--because their doctors' money had run out? Where stands the theory of money following patients, when patients have no choice but to follow the money or to await the next contract? Where stands patient choice, when bulk contracts unrelated to relative need dictate place, time and person providing care? Where stands management, whose proper function is to care for those who do the caring, when the government's policy forces them to take the blame for inability to meet heightened demands incited by successive patients' charters?".
Surely the Government will not claim that Dr. Macara does not know his facts or that he has a party political viewpoint.

During a recent debate in another place on the subject of GP fundholding, my honourable friends and others, reported evidence of the inequalities of availability of hospital treatment between patients of GP fundholders and non-fundholders. In the long and sometimes rambling answers from the Secretary of State, I could not discover any concern for the patients of the 50 per cent. or so of doctors who are not fundholders. The concern was all for the success of this particular scheme; the patients obviously taking second or even third place.

I agree that all sections of the National Health Service should be expected to take account of the costs of running the service. But I strongly oppose the idea that medical practitioners should be expected to put financial efficiency ahead of the needs of their patients. So does the chairman of the BMA Council and I quote once more from his November speech. In relation to the use of resources, he said,

    "Of course, everyone--manager, professionals and those whom they serve--has an absolute duty to make the best possible use of the available resources, which will always be finite".
He then went on to say,

    "More adequate resources would, naturally, make decisions less painful but, as Kierkegaard observed 'in every choice there is a sacrifice'. But any sacrifice should be minimal and bearable, such as having to wait a little longer for treatment which is neither life-threatening or disabling. The blanket refusal to provide whole categories of treatment with total disregard for the claims of individual patients, as the Berkshire Health Authority sought to do, is not only illegal but totally irresponsible".
Those are strong words from someone in a very senior position. I hope that the Government will take them on board.

For me there is something deeply offensive about any system which discriminates against someone in medical need, in favour of someone in less medical need, but for whom money is forthcoming, whether that money is from the GP fundholder or any other source. Where medical services are rationed for whatever reason, there should be only one criterion for priority in treatment--medical need. That used to be the ethic by which the

28 Feb 1996 : Column 1501

health service was run and the sooner we can return to it in the health service, the better it will be not only for the health of the nation, but for the confidence of people in the service and for the morale of both patients and health service workers.

6.10 p.m.

Baroness Brigstocke: My Lords, like the noble Baroness, Lady Nicol, I feel privileged to be taking part in this debate in which there have been so many informed and fascinating speeches. I speak as a non-executive director of the Health Education Authority but, more importantly, as a mother of someone who has been a nurse and, for many years, a sister in a busy accident and emergency department in a well-known inner-city hospital.

I turn first to the Health Education Authority, which is a key player in implementing the Government's health of the nation strategy. Its health promotion work is recognised nationally and internationally. I should like to make it clear that the HEA is not part of the Department of Health. It works not only for the department but for other agencies and organisations on a contract basis. To respond to a remark of the noble Lord, Lord Dubs, I should like to say that the HEA is happy to work with the present funding arrangements.

By helping to educate the public, the potential patients, not only during their school days (regrettably, there has been an increase in the number of teenage girl smokers) but also later in life by encouraging a healthier lifestyle, such as encouraging the elderly to take more exercise, to get more fresh air and to have a better diet, the HEA plays some part in making us all fitter and thus less likely to overload our GPs, hospitals and health professionals with trivial complaints. How we get the middle-aged to be more thoughtful and less self-centred is, I fear, beyond the powers of the Health Education Authority.

My two points relate to abuse of the National Health Service and to its management style. There are difficulties in the NHS--no huge organisation is without them--but they do not arise only from, to quote from the Motion,

    "current developments in the National Health Service".
Many are the result of gross abuse by the public, as voiced this very day by many strained and overworked GPs. The notion of care as expressed in the Health of the Nation should apply not only to patients, but to doctors and nurses also. The public--the potential patients--have a duty to behave responsibly. How can we prevent patients from abusing the service?

I speak now entirely on my own account and from a personal point of view. I respect and admire the high quality of so much in the National Health Service, but I do have some concerns. What I say is based on what I have learned from my daughter who, as I have already mentioned, has over 10 years' experience in an accident and emergency department. She has seen many examples of abuse of the National Health Service, especially on Thursday nights when the dole has been handed out and abuse comes from drunken louts using unimaginably disgusting language. Last

28 Feb 1996 : Column 1502

week, for instance, two men came in, escorted by the police, having attacked each other in a pub with an axe.

I was delighted to hear my noble friend the Minister refer in answer to a Question earlier this week to the accident and emergency department at the Royal London Hospital, which could deal with three times the number of emergencies that it sees. Unhappily, that is not the position in my daughter's hospital. I shall not enumerate the problems for nursing staff and patients which she has encountered when there are simply not enough beds or nurses available. Both she and I realise the financial constraints, but it is demoralising to a responsible professional when nurses in the department are not asked for their advice or to give an answer to even the simplest of problems, such as what colour to paint the accident and emergency department. In come the engineers and they decide the colour. It will certainly be the cheapest paint. They do not ask the staff who have to work in the painted area, yet colour can have an enormous effect on patients and staff, their well-being and behaviour. Soothing colour is very important in casualty.

Now that the overall necessary restructuring of the National Health Service has taken place, could the management style be looked at again? I know that there are many good examples, but I want all hospitals to reach the same high standards. It seems to me that the overall management style is still inappropriate. A command-and-control management style is more suited to the running of an old-fashioned car factory. It is the managers and the senior consultants who could improve that and thereby improve the morale not only of the nurses, but also of the junior doctors. They are all skilled professionals and should be consulted and have the opportunity to contribute to decisions on all matters relating to their work. One cannot blame the Government or a shortage of money for everything. Let the managers and the senior medical staff sort this out. They are the ones who can improve the morale of the nurses.

Managers and senior medical staff are responsible for considering major incident procedures. That has been particularly important in the past few days in the light of the recent bombings with the threats of even more. Here is a perfect opportunity for managers and senior and junior medical staff to work together. It is always easier to talk about the problems than the solutions.

I urge my noble friend the Minister, for whom I too have the highest regard and admiration--I cannot express it as fluently as the noble Lord, Lord Walton--to continue supporting all the education programmes which seek to make people fitter, as outlined originally in the Health of the Nation report. Will she also look at ways to help all managers and senior staff to consult and to use the superb professional expertise of all their staff, especially the nurses who are so often those who really know what is needed on the wards to give even better care to their patients?

6.19 p.m.

Lord Ashley of Stoke: My Lords, I should like to congratulate my noble friend Lord Winston on initiating

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this valuable and important debate, and on the way in which he spoke. He got the debate off to a fine start with a first-class speech, and we are all grateful to him.

As to his reference to the market, I wish to comment on its effect on profoundly deaf people. Their story is a staggering one, and I use that word advisedly. I am concerned about profoundly deaf people--adults and children--who are being deprived of something which can magically transform their lives. I refer to a cochlear implant; an electrical stimulation of the ear which introduces or restores the perception of sound. It is totally unacceptable that any adult or child should be deprived of this wonderful device.

On a personal note, after 25 years of total silence, when I could not even hear my own voice, I have benefited from a cochlear implant, and it has transformed my life. I can now participate in conversations whereas I could not do that before; I can hear all kinds of ordinary sounds. It has transformed the lives of some 15,000 people throughout the world, and will transform the lives of many more millions in future.

Let me remind the House of the words of the Minister, whom we all respect and expect to give a positive answer to the many speeches we have heard tonight. On 9th December 1993 she said,

    "I would be very surprised if there are people being denied this treatment".
The Minister also said,

    "Health authorities are required to meet the costs of cochlear implants in all cases where that is the appropriate treatment".--[Official Report, 9/12/93; col. 1015.]

I greatly appreciated what she said, but there is abundant evidence that many district health authorities have been evading their responsibilities. At first their very limp excuse was that the cochlear implant was unsafe and unproven. That was said after it had been in use for years and years and before the official report of the Medical Research Council's Institute of Hearing Research which said that cochlear implants were "safe and effective". Some district health authorities then changed their tune and their excuses. They then said, "Well, these are too expensive." Either way, whatever the excuse, the patient suffered.

How has it come about that profoundly deaf people are deprived of cochlear implants? It is because of the market system. Some health authorities are instructing the local ENT surgeon, or even the local medical officer of health--neither of whom are specialists in cochlear implants--to decide whether or not a deaf person should be considered for a cochlear implant. That is ridiculous, is it not? Health authorities acting in this way are doing so because of limited budgets and a need to have priorities. I recognise that, but some DHAs fail to appreciate the profound significance of total deafness.

One of the most staggering examples of this ignorance was shown by the Dudley Health Authority and its director of public health. She questioned whether a woman who was totally deafened by meningitis should have a cochlear implant operation. She wrote in one letter to a surgeon,

28 Feb 1996 : Column 1504

    "this lady's GP tells me that she leads an active and virtually normal life with no detrimental effects from her deafness".
"No detrimental effects" from total deafness--how irresponsible can you get? How can deaf people hope to have the medical treatment promised by the Minister if that kind of attitude is shown by district health authorities? We need a much greater appreciation of the problems of total deafness and a greater willingness to make treating it a priority.

A disturbing aspect of the behaviour of some but not all district health authorities--there are some great district health authorities--is that they react in different ways to total deafness. They are not really making available their criteria for funding or not funding cochlear implants. As a result, it is a lottery for deaf people. That cannot be right given the ethics and the basis on which we believe the National Health Service is run.

I shall quote the case of the Lincoln Health Authority. In a letter dated 26th October 1995, that health authority told a deaf woman's Member of Parliament that it had not funded any cochlear implants at all that year. It was oblivious to the fact that cochlear implants had been available on the National Health Service since 1990. Instead the health authority had commissioned an internal report into the costs and benefits of cochlear implants. There was no need to do that because of the official report of the Medical Research Council which was already in hand and which was published a month or two after the local authority report.

When the notable surgeon, Mr. John Graham, asked the district health authority for that report, it refused to disclose it. He was entitled to know the criteria for allowing or not allowing cochlear implants, but the health authority simply refused to disclose the report. That, too, I find unacceptable.

Will the Minister appeal to that district health authority to state its criteria for agreeing or refusing cochlear implants, and place its response in the Library? I also urge that all district health authorities should report annually on the number of cochlear implants that they have authorised.

Some district health authorities are saying that they will only do one or two operations per year, and those will be for children. Of course I strongly support implants for children--they are the most important of all--but it would be unfortunate if ageism began to creep into the cochlear implant programme; adults are as entitled to them as anybody else.

The real problem is that there is a backlog from before this operation was invented and perfected, and that backlog will be neglected if the district health authorities insist on a children only policy. More funds must be found by the Government¬--they are the only source of funds--for operations for adults. The backlog must be tackled otherwise some deaf people will be left in limbo for ever.

We are discussing an operation which costs £39,000. That is what the operation costs with the concomitant rehabilitation. If it were a case of an operation costing £39,000 which could restore the sight of blind people, and they were denied that operation, there would be a

28 Feb 1996 : Column 1505

great outcry and people would march on Whitehall--and rightly so--because that would not be considered acceptable. But the same thing does not happen when deaf people are deprived of an operation which can restore their hearing, or give hearing to people born congenitally deaf. This is a situation which cannot be tolerated in a civilised society, and I hope the Minister will do her best to resolve it by appealing to and pressing the district health authorities on this matter.

6.29 p.m.

Baroness Flather: My Lords, first, perhaps I, too, may thank the noble Lord, Lord Winston, for initiating the debate; and, secondly, take issue with one statement that he made when he said that his speech was going to be non-political. All I can say is that I am greatly looking forward to hearing a political speech from him so that I may have a chance to compare the two.

My first question is: could the health service have continued in the same shape and form in which it existed before the reforms? I am sure that different people answer that question differently. I do not believe that it was possible for the health service to continue as it was. There have been such advances in medicine, about which we all know. They are not new. We have also to remember that we are giving more and more people more and more expectations. I do not believe that any amount of money will, in the end, meet all expectations. There will never be a government who will not be accused of underfunding the health service. It is true of every country. It is happening all over the world.

This country still has one of the best, if not the best, health services. I know that it has been said that we spend less money on it than other countries. All I can say is that we must be receiving better value than other countries. I saw a programme on Monday about Wheeler's "America", which I am sure many other noble Lords saw. What we saw in that programme about the richest and most powerful country in the world should make us realise that we are not as badly off as we think we are. We have got into the habit of continually running down this country. I do not understand that. It is my adopted country, so perhaps I do not have the British psyche after all. On this occasion, I am pleased that I do not have it.

Whenever I go to the countries of our European partners or to the USA all I hear is, "What a great place this is. Look at what we are doing and what we are achieving. Look at the structures we have put into place. Look at what we have done". As soon as one comes here all one hears is that everything is dismal, everything is negative and everything is doom and gloom. That applies also to the health service.

We heard from the noble Baroness, Lady Hayman, that staff morale is low. If one awoke every morning to read in the press that one's morale is extremely low, and everyone spent their entire time saying that one's morale is low, I doubt very much that one could raise one's morale. One would be completely confused about what is going on within one's area of work and about what one is being told is going on. Everyone has heard of the self-fulfilling prophecy. I believe that in this case it is a question of a self-fulfilling prophecy.

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I am a non-executive director of Hillingdon Hospital Trust. It became a trust in the first wave of trusts. It was one of those general hospitals which was grossly neglected and badly run. It was dirty and uninviting. When one went into the hospital one could find no one to give directions. As a non-executive director, I experienced that. I am pleased to say that I was never a patient in that hospital at that stage. I should not have liked to go there. The place was confused. One could not find one's way around and there was no structure to the place.

It has been transformed in the years since it has been a trust. The waiting list has decreased by almost 1,000. The workload has increased by about 20 per cent. Hillingdon is situated in an area with a high ethnic minority population. There was a beautiful policy document, but no one had ever bothered to open it. We now have a substantial action plan in place to meet the needs of ethnic minority patients and ethnic minority staff. That in itself is extremely important.

There are new developments in areas of sensitive service such as a women's unit for surgery and consultant clinics which have moved to become community clinics. They are not just for fundholders. They are specifically for non-fundholding GPs.

A great deal has been said about there being too many managers. I do not believe that we have too many managers. I do not believe that we have enough. The hospital's turnover amounts to £53 million a year. We have five managers. One of them is at the lowest grade. That is not too many managers for that size of turnover. Their salaries would not be acceptable anywhere except in the NHS. It has become a habit to knock managers. I am sad about that, because many of the managers work extremely well and hard.

I should mention also the continual harping about there being no beds. We have never for any reason shut our A&E department. We have always found a bed for every patient. There is a detailed protocol in place at the hospital, agreed by the RHA, as to what steps should be taken. I urge my noble friend the Minister to ensure that all hospitals plan carefully what to do in case they are under pressure, so that it is not said that they are being lazy, but are trying to find a suitable bed for everyone who needs one.

One swallow may not make a summer, but we have heard that there are many trust hospitals which have improved beyond all recognition as a result of the reforms. Let us at least be optimistic about the chink of light and not dwell constantly on doom and gloom.

6.37 p.m.

Lord Haskel: My Lords, perhaps I may start by saying that I have no interests to declare. I have never served on a health authority, on a hospital board, or, indeed, on any quango. I would describe myself as a user of the health service. As such, I should like to record my debt of gratitude to all the people who work in the health service--the staff, the doctors, the nurses, and, yes, the administrators. I too should like to thank my noble friend Lord Winston for giving me the opportunity to express my gratitude.

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My experience is in industry. From what I read and observe, I must agree with my noble friends Lord Winston and Lady Hayman that the health service seems to be suffering from low morale. All the signs are there. We have heard about high staff turnover, unfilled vacancies, dissatisfaction over pay, excessive paperwork, early retirement, and all kinds of grumbles. Other noble Lords have suggested that the cause of the low morale is not just underfunding but too much management. Even the Government have become alarmed at that. I understand that Mr. Stephen Dorrell has said that he hopes to cut management costs by some 7 per cent. during the current financial year.

However, a 7 per cent. cut in management costs is only a small part of the solution. It seems obvious to me that the solution is not just less management; it is more leadership. The difference between management and leadership is a matter in which I have taken an interest for a number of years. But the Minister does not have to take my word for it. She can get it from her own colleagues. Just down the road, at No. 1 Victoria Street, at the Department of Trade and Industry, one will find one of the Government's more imaginative schemes. It is called "The World Class Companies Scheme". This scheme is designed to assist our better companies to become world class.

My proposal is simply that the National Health Service takes their advice: the Labour Party has. The party is busily introducing facets of the scheme into its headquarters at John Smith House. What is more, the Labour Party has appointed a person to introduce this and other schemes into the local authorities controlled by Labour.

As other noble Lords have said, it is of course management's role to manage, but it is also management's role to lead. What is the difference? Management deals with important practical matters, such as organisation, budgeting, finance, technology and marketing. It also spends time at the centre monitoring activities at what my noble friend Lord Winston called the coalface. Incidentally, as it is made easier by centralised decision-making, perhaps this is the real reason why the regional health authorities are to be abolished in April and not, as the noble Lord, Lord Clark, suggested, for financial reasons.

Leadership is less practical. It deals with vision, progress, ethos, cohesion and, yes, morale--and despite the warning of my noble friend Lady Hayman, I would like to speak about morale. I would like to start with trust. I have had occasion to quote in your Lordships' House on earlier occasions from Professor Fukayama's recent book. His point is simple: that trust is an important element of leadership: trust that contracts will be honoured, trust that the truth will be told, trust that institutions are responsive and accountable and trust that people's words are their bonds. From what I have heard today, a little less management and a bit more trust could work wonders for morale in the NHS.

Down in Victoria Street they will tell you that leadership matters a lot in "people businesses". If ever there was a people business, it must be the National

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Health Service, which employs 1 million people. Other people businesses, such as advertising or research organisations, flourish under a light management touch and react to leadership because most people prefer to work that way. Directors know that low morale means low profits. This is the direction in which business in general is moving, encouraged by the DTI, I might add.

It seems to me that the NHS is moving in the opposite direction, having recruited 20,000 managers since 1981; and they are now trying to reduce that number. Mr. Marco Creste, chairman of the National Health Service Trust Federation, agrees.

    "What needs to be done first is to reduce the administrative burdens put on trusts",
he says. Neither he nor I are suggesting that financial controls should be reduced, and of course trust executives must be accountable to their boards. What I am suggesting is that world-class companies have learnt that staff perform better if they are managed less and trusted more.

We have been told by noble Lords that the health service keeps down costs by being market driven. What do the Minister's colleagues down in Victoria Street say that world-class companies should do about this? They acknowledge that cost cutting and tight budgeting are necessary, but that it is not enough. If your Lordships will excuse the jargon, you also have to create value in the marketplace. To create this value in a people business you need your employees to become better trained, better skilled, more conscientious and better informed, and to be willing to educate and improve themselves. Nowadays people understand that to achieve this it is sometimes necessary to work longer hours and under more pressure. In an organisation such as the National Health Service, where people see their work less as a job and more as a vocation, I am sure it is easy to achieve this result.

The reward for all this effort should be more meaningful employment and a greater value put on employees. The noble Baroness, Lady Cox, described this for nurses, and in this way people perceive fairness in the organisation and have an incentive to co-operate. This is what keeps morale high. Sadly, in the National Health Service the reward seems to be insecurity, with short-term contracts, frustration from unfilled vacancies and divisiveness from competition for resources. With this low morale, no army of managers will get employees to lift their performance. Money incentives alone will not do it.

Another lesson the Minister could learn from businesses striving to become world class is that management development is the key, not imposing management. By adding management to the skills of engineers, salesmen and accountants industry has made them more accountable. I think the noble Baroness, Lady Brigstocke, was trying to suggest this. If you do not involve medical staff in management how do you fully measure the success or failure of their work? Without this measurement management becomes administration; and this is why I think my noble friend Lord Winston told us that there is no serious audit.

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One final point: to a businessman it has always seemed to me rather naive to think that money will follow the patient. Experience tells us that the patient will follow the money. The management philosophy in the NHS to me still seems to be stuck in the 1980s, when the market was considered to be little more than the law of the jungle. Better companies in the 1990s have found that they can become world class by taking wider considerations into account.

At the same time it will not have escaped people's attention that generally better companies pay better wages. This is the way they share out success. My noble friend Lord Winston spoke of unnecessary competition. World-class companies now co-operate with their suppliers and get better results than they did with the old adversarial relationships. Surely it is time for the National Health Service to learn this lesson instead of opposing it on the grounds of "collusion". The price of failing to deal with these issues is a low-grade NHS, which in my view is too high a price to contemplate.

6.46 p.m.

Baroness O'Cathain: My Lords, the wording of the Motion is very specific and I will keep my remarks specific to that wording; namely, dealing with the level of the concern among Health Service staff. Before I do so, perhaps I should declare an interest. My interest is that the National Health Service impinges upon my life through the wonderful, unstinting and efficient service given to my husband by our local general practise which, despite many and deep-seated concerns about fund holding, now finds that it is workable and much more efficient in dealing with patients.

I would add another interest. I am a taxpayer and a contributor to national insurance. Both of these are probably not specifically the types of interest that one would expect to be declared, but actually unless a business--and the National Health Service is a huge business: a £41 billion per year business--takes the needs of its customers, like my husband, and shareholders, as I feel I am, into account that business will not thrive.

The National Health Service is an internationally respected and admired business. What we must do is to make that business even more efficient and more effective. I know from personal conversations with employees of the National Health Service that one level of concern among them is the rapid development of what are called business management approaches to the service. Those who work in the National Health Service have as their main objective the provision of the best possible health service to the population as a whole. But probably because of less-than-perfect communication processes they have not been convinced that some of the proposals currently being put forward are in the best interests of the patients and of those who work in the service.

My specific point relates to the non-espousal of the concept of local bargaining of pay and conditions of employment for nursing staff, midwives, health visitors and professions allied to medicine. The National Pay Review Body in 1995 recommended that an element of

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local pay negotiation should be contained in the annual settlement of pay and conditions. That was recommended for several reasons, not least because local pay determination is an inherent part of the Government's National Health Service reforms. That might be greeted with scepticism or even derision, but before it evokes that response, perhaps I may, as someone who has had a long career in business, put forward some facts--and I mean facts--about local pay determination.

Those of us in business know that local pay determination provides for flexibility in both organising the provision of labour to meet the needs of the local conditions and flexibility in employing staff to meet the staff's own needs. It is a partnership between serving the customer and serving the special circumstances of those who wish to be employed in the serving of that customer.

I give your Lordships an example. In the retail business some staff want the flexibility to be at home when the children arrive from school; and some staff who have retired early from their full-time career want to continue some sort of economic activity and feel that they wish to get out of the house on a regular basis and get involved once more in paid work--not necessarily on a 35-hour per week basis, but perhaps on a 20-hour per week basis. Neither of those groups of people is being exploited; those people are getting annual salaries with adjustments made for the work patterns that they have requested and that they have seen as best suiting their own specific needs and wants.

From the employer's point of view, the flexibility offered by that type of arrangement permits greater flexibility in scheduling staff cover for peaks and troughs of activity; flexibility to cover what many would think of as being "unsocial hours" but which the staff in question welcome because it has been their choice.

They are but two of the advantages. Logistics must also be considered. Is it realistic that pay and conditions for 430,000 nurses can be dealt with centrally? How can that be efficient? How can the differing needs and wants of both patients and nurses be assessed at long distance? I suggest that both groups would be much better served by local bargaining on pay and conditions if it were espoused because it would, in effect, result in what is currently known in management terms as empowerment. Empowerment implies trust and that really goes along the lines supported by the noble Lord, Lord Haskel.

We keep on talking about educating our workforce to take its place in the constant struggle to improve competitiveness. All young people must be aware of this now--there are so many statements made to that effect. In the course of such education we emphasise the need for decision making. We raise expectations that when young people enter paid work they will be able to contribute to the decision-making process. Greater autonomy is seen as the method by which a business can and will flourish. Smaller units which can make decisions on the spot to deal with particular local needs and wants of the customer are at the root of the most successful businesses in this country. Greater autonomy demands greater control over resources, and one of the most important of those resources is staff.

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The latest report of the National Pay Review Body makes somewhat sad reading on the issue. In effect, it describes how, despite signalling the change in 1994, little progress has been made. The Royal College of Nursing did little to counter the impression that the basic rate of the national agreement was all that the staff would get. Even my noble friend Lady Cox stated that nurses were offered only 2 per cent. That is the national salary scale. On top of that, it is expected that local pay increases will be granted. Sadly the whole concept of the two-part approach--a basic national rate plus an element of local pay--has been interpreted as a one-part approach; namely, the basic national rate.

Last year, a big communication exercise was not effective in countering the widespread belief that only a minimal pay rise was offered. As an outsider I have to say that it appeared that there was a deliberate campaign to obfuscate the issue; in other words, as I have already said, there existed a "less-than-perfect communication process".

There was actually a campaign by the Royal College of Nursing to seek offers from the trusts of a certain universal rate--the same rate whether one lives in Aberdare, Brighton or Cirencester--without any conditions as a requirement for accepting any local offer. The trusts' freedom for action was limited by the refusal of the staff side to sanction any local pay negotiation. However, some seven months after negotiations commenced, the Department of Health and the Royal College of Nursing reached an agreement on a national framework within which local pay arrangements could be implemented. Some progress has been made and I hope that more progress will follow.

The whole new system proposed contains strong safeguards for equitable treatment and for the appointment of local representatives of staff to carry out negotiations. It is not a recipe for bulldozing the staff to accept pay cuts or any such devious plan: it is the devolution of power to local level; it is at the local level that patients are treated; it is at the local level that staff are employed; and it is at the local level that intelligent, hard-working and committed staff should be empowered to have a much greater say in the application of the great strengths of the National Health Service to the improved level of local service--and, indeed, even empowered to choose the colour of the paint in the working environment, as required by my noble friend Lady Brigstocke. That is what local bargaining on pay and conditions achieves. That is what business has discovered.

The NHS business is one of the biggest businesses in the country. I suggest that the time has come for it also to discover the benefits. Like the noble Lord, Lord Haskel, my experience is in industry and business. I am sure that he would agree with me that, in the case of efficiency and effectiveness, the central bargaining on behalf of over 400,000 staff cannot be efficient.

I return now to the word "concern", in respect of which morale has been quoted. We have heard of the shortage of nurses. However, in the report of the National Pay Review Body, I was interested to see that,

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on 31st March 1995, total vacancies for nurses which had lasted for over three months as a proportion of total establishment was 1.4 per cent. In business, that would actually be welcomed as a very low figure.

Concerns are often fuelled and the flames fanned by the supporters of the status quo. Nothing stands still; nothing is unchanged in our ever-changing world, particularly in the health sector where I have been reliably told that some 90 per cent. of extant medical knowledge is 10 years old or less. Indeed, a graphic account of the scale of recent developments has already been given by the noble Lord, Lord Walton of Detchant. We cannot have a lopsided National Health Service where the technology has surged ahead, yet there are attempts to fix the issue of pay and conditions in some "time warp" which has long been deemed to be past its sell-by date by the rest of the business and commercial world.

6.59 p.m.

Lord Rea: My Lords, as someone who has spent most of his professional life in general practice, I shall concentrate on the current situation as it affects GPs. For a number of years, until about 1990, general practice was a popular choice for medical graduates. With vocational training, as other noble Lords have pointed out, standards have risen and the importance of primary care has been recognised by the Government to the extent of coining the phrase, "a primary care-led National Health Service". That concept has been cautiously welcomed by the General Medical Services Council of the BMA which represents the interests of GPs and the Royal College of GPs which is the academic arm of general practice, provided that the necessary resources are made available.

The Royal College spelt out what is required in a recent statement. On resources, it said that,

    "shifting resources from secondary to primary care at least equivalent to the shift in the balance of work,"
is necessary, as are "adequate funds" for,

    "the training and continuing education of general practitioners to ensure they have the skills necessary to undertake an extended role".
The college also asks for the development of:

    "structural and financial mechanisms to support the delivery of high quality patient care".

To run down or trim hospital services and to discharge patients early before the necessary community and primary care services are up and running will lead, as my noble friend Lord Dubs said, to overstretching of health workers in the community, a fall in standards and a fall in morale. That is already happening to some extent, and is one reason for the rise in emergency admissions. Some patients have to be readmitted because they have been discharged too early, in too unstable a condition for community health resources to handle them. That is especially although not entirely true with regard to mental health problems.

While I recognise the increased and even pivotal role of primary care, we must not allow developments there to follow the pattern of community care for the mentally ill in the mistaken belief that it will save money. As

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noble Lords are only too well aware, and as has been mentioned, community care for the mentally ill, however laudable the objective, is not adequate at present to cope with the caseload of mentally ill patients needing care. That will be the case even after Mr. Stephen Dorrell's recent emergency injection of some £90 million.

Just as the idea of a primary care led NHS has been taking shape, the GMSC of the BMA has come up with a rather disturbing report. Under the heading:

    "Where have all the doctors gone",
it states that

    "general practice faces a deepening workforce crisis"

    "there are insufficient doctors to meet the increasing demand and the changes in the roles and responsibilities of GPs working in the NHS".
That report is a warning of trouble ahead.

Until 1994 the total number of GPs was rising. However, since 1989, as the noble Lord, Lord Walton, pointed out, the number of newly qualified doctors entering training schemes for general practice has fallen by 18 per cent. That is my calculation; the noble Lord, Lord Walton, said that it was 14 per cent., but I have checked and I believe that 18 per cent. is the correct figure. That is an early warning sign that doctors are turning away from general practice.

More GPs are retiring early before the age of 65. The total number of male GPs has already started to fall. Luckily, the number of new women GPs has been increasing sufficiently to keep the total rising. Many of us would say that is a very good thing. I certainly agree. However, it is well known that the majority of younger women doctors will need to take time off to produce and care for children. Therefore, more are needed to provide the equivalent number of full-time doctors. Already the proportion of doctors working part-time has increased from 5 per cent. to 11 per cent. of the total in the past five years.

One reason for the decline in the number of male entrants to general practice is that more consultant posts have been created--18 per cent. more since 1988. That is another welcome development, which no one would want to see reversed. However, the hospital service also suffers from the fall in recruitment to general practice training schemes, because two out of the three years in those schemes are spent in hospital SHO posts. Already, because of manpower needs, some of the training programmes are having to recruit from overseas. Those doctors--from Spain, Holland or wherever it might be--will return home after they have received their training at our expense. Of course they will have worked here during their training period and nearly always given very good service, but we lose them in the end.

As the noble Baroness, Lady Masham, said, there are often very few applicants for some practice vacancies. To cope with the problem, the GMSC recommends that at present no more healthcare activities are transferred from hospitals to primary care. I am very sad about that, but it may be necessary. It also recommends that medical school intakes be reviewed urgently, both because of the falling number of GPs and the increasing

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number of consultants. The GMSC says, logically enough, that a primary care led NHS cannot exist without an adequate supply of properly rewarded GPs. It also states, among other suggestions, that

    "support must be provided in the form of additional resources to provide staff, premises and technical assistance",
and that

    "additional incentives will be required in those areas where there are particularly acute recruitment problems".
Those are usually deprived, inner city areas.

Deprivation payments to GPs have been made since 1990. The scheme has been of help in keeping some GPs in inner city areas and raising the income of some of them to an average level. It used to be lower. However, it is an inadequate system, both in terms of the extra workload which deprived patients cause and their additional health burdens, and also because of the high level of deprivation which a community has to reach before the doctors there qualify for extra payments. I believe that the system should be reviewed urgently and more appropriately targeted. Discussions should reopen with the profession on the best methods of achieving that.

General practitioners feel that the additional tasks required of them through the 1990 contract, which include much preventive medicine and health promotional activities such as reaching immunisation and cervical cytology targets, and so on--which are aspects which are not fully covered in their training--have diverted them from their highly valued task of providing high standards of continuing personal clinical care. Many of those tasks can be delegated to nurses and other workers, who do them better and more methodically. However, for that to be achieved proper premises and facilities must be available. The procedure by which the contract was virtually imposed on the profession has left a lasting distrust of the Government among general practitioners.

Several noble Lords opposite have praised the GP fundholding scheme. It is now fairly clear that, despite enthusiasm by some fundholding GPs, the scheme has caused more problems than it has solved, quite apart from its divisive effects. Recent research based reports have shown little long-term change in referral patterns or prescribing by fund holding GPs.

Other noble Lords have mentioned increasing expectations of patients, such as the increased number of calls for night visits. That is a manifestation of a socially fragmented society--which has been getting worse during the lifetime of this Government.

Those are just some of the reasons doctors have been turning away from general practice. To make a primary healthcare led NHS a reality a real injection of resources into undergraduate and postgraduate training and increased support of GPs in their work is needed. The details should be the subject of immediate negotiations between the profession and the Department of Health.

7.8 p.m.

The Earl of Clanwilliam: My Lords, if there were not concern in the NHS about developments it would be remarkable in such a large organisation. Noble Lords

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have spoken both in the general and in the particular. I shall speak in the particular, as no doubt the noble Lord, Lord Winston, would expect. I take this opportunity to congratulate him not only on his maiden speech but on his opening speech today.

One fact that I find compelling, and which is a development which should be of great concern to the NHS, is that conventional medicine uses modern drugs which are becoming less and less reliable as the viruses they are designed to treat become resistant and the bacteria learn to mutate. Logically, we could eventually reach the point where the pharmacist has been defeated.

Before I am accused of scaremongering, perhaps I may quote from the report of the Parliamentary Office of Science Technology entitled Diseases Fighting Back, published less than 18 months ago. The noble Lords, Lord Flowers and Lord Dainton, and the noble Baroness, Lady Platt of Writtle--whose permission I have to mention her name--were members of the panel. Noble Lords will appreciate that I am encouraged to quote from a report which speaks with such authority. Paragraph 2.2 on page 4 states,

    "As antibiotics became widely used, it soon became apparent that bacteria which were previously susceptible to a particular drug could acquire resistance to it. This 'acquired resistance' stems from the natural ability of bacteria to adapt genetically to a new threat".
As noble Lords know, the body has its own powers of resistance to and recovery from disease. Sometimes that is included, quite wrongly I believe, in the placebo effect. The report continues at page 5:

    "A proportion of the natural bacteria population in the body are capable of defending against an antibiotic ... treatment subjects the bacteria to a 'selection pressure' which will soon lead to the resistant strain becoming a dominant one".
We have recently had a Starred Question on the subject of MRSA; a subject relevant to this point. The report continues at paragraph 4.1 that 9 per cent. of the 5.7 million NHS patients--over 500,000 citizens--acquire infections while in hospital and some 60 per cent. of MRSA infection involves multi-resistant strains. If we solve that problem, the nine cancer patients referred to by the noble Lord, Lord Winston, would soon find beds. Why does the medical profession not do something about this extraordinary scandal, where patients are being poisoned in hospital by medicine presented to them? It is not the fault of the National Health Service, but of the medical profession. This surely must be a development that causes concern to the health service.

But history shows, on the contrary, that herbal preparations are not subject to these self-defeating effects. It is not only our own UK brand of herbalism which makes the point, but Chinese herbalism and its thousands of years of proven benefit with traditional remedies continuing to bring relief to patients in a wide field of therapy. In particular, there is the example of the severe atopic eczema to which I referred in a previous debate.

On the subject of male infertility--currently a subject of great national concern according to the press--traditional Chinese medicine has developed techniques which have relieved that problem over centuries. Studies

28 Feb 1996 : Column 1516

in China cover 13 associated problems ranging from azoospermia to varicocele spermophlebectasia, with 11 other activities which are either unpronounceable or too indelicate to repeat.

Eight different studies involve over 1,500 patients with success rates varying between 71 per cent. and 94 per cent. Indeed, a small number of patients have been treated at the Chiswick Clinic over periods of 50 to 90 days with results of considerable importance. Is all this to be discarded as anecdotal, as all herbal treatment is considered? Even if it is anecdotal, it should be followed up and funds provided for further clinical trials. That would relieve pressure on the NHS.

As regards the concerns of NHS employees and practitioners, a revolution is being brought about by the department to keep up with modern technology of the IT variety and the ever-increasing flood of new technology from medical research. The noble Lord, Lord Walton, and the noble Baroness, Lady Flather, explained that point. It is a revolution which provides more care to more people every day in an atmosphere where there is an insatiable demand for eternal health.

Where is it all to end? Is it not enough that 1 million more patients are being treated this year than in 1991? That is 3,500 new patients every day. Is that not a remarkable achievement? How can anyone carp at the National Health Service when it provides a service like that? Waiting lists are dropping and, yes, I know that there are always some statistics which will indicate problem areas somewhere, especially at a time of such expansion in this huge organisation which is the largest employer in Europe.

Let us imagine the NHS still juddering along in the old way before the Conservative Party started to put it to rights. The miracle is that those waiting lists and problems are dwindling despite what anyone can say, and under extraordinarily difficult circumstances. This is all being achieved at a time when the bacteria are busy with genetic mutation to counter the wonders of modern science-based medicine. There will obviously never be enough money to fund the health service. There never can be. It can only be more efficiently organised.

I hope noble Lords will accept that applying some of the non-conventional systems might relieve pressure on the health service. That is not a total panacea but a help. The noble Lord, Lord Desai--unfortunately he is not in his place--said that not a day went by without some tabloid horror story coming forward. The truth is that hardly a day goes by without complementary medicine being mentioned in the press. In The Times today Donald Lane, vice-chairman of the National Asthma Campaign and consultant chest physician at the Churchill Hospital, Oxford, states that there was little doubt that some complementary therapies helped but they had to be used in addition to, not instead of, standard treatments. Chinese medicine combines them all. That is how treatments should go forward. It is not a question of one or other, but of using all opportunities together.

I congratulate my noble friend on the success of the department in running the NHS in the face of such adversity and carping, and the remorseless advances in

28 Feb 1996 : Column 1517

science, costs, and the demographic effect. Perhaps I may draw the attention of the House to the fact that the NHS will never be in trouble because in this debate 11 noble Baronesses have spoken and only 11 Peers.

7.18 p.m.

Baroness Robson of Kiddington: My Lords, I, too, thank the noble Lord, Lord Winston, for introducing the debate. It is particularly significant that the debate has been introduced by a member of the medical profession actively involved not only in the service but also in the education and training of doctors, and in research. He is someone who really knows what he is talking about. The noble Lord introduced the debate by giving his impression of the impact of the reforms and the problems that have been created through the creation of the internal market. That set the pattern for our debate.

The large number of speakers taking part in the debate and the frequency with which health service Questions appear on the Order Paper is a sign of the deep concern felt on all sides of the House as well as all over the country about what is happening to our National Health Service.

I should like to begin, first, as have many speakers, by thanking all the people, in whatever capacity they work in the health service, for all the work they do and for their dedication, often under very difficult conditions. Secondly, I wish to emphasise how lucky we are in this country to have a system based on the general practitioner service which ensures that everyone in this country has his or her family doctor to turn to in times of need. That is probably the greatest strength of the NHS.

I was born in another country, Sweden, which has often been held up as the shining example of a perfect health service. But for years it had no general practitioners. As a result, the hospital clinics became overcrowded. Sweden has now finally had to start creating a general practitioner service. I believe that that is one of the most important things in our health service. However, we have reached a point where all the dedication of nurses and doctors is not enough. As a nation, we cannot go on expecting people to perform well beyond the call of duty.

I wish to return to the problem of the fall in the number of doctors who enter general practice. Between 1988 and 1994 the number of GP registrars fell from 2,165 to 1,840. At the same time, there was an increase in the number of women GP registrars, which adds to the problem of the lower numbers as women GPs are likely to work part-time during at least some period in their lives and careers because of family commitments. For every 100 GPs retiring, today we need 110 new recruits, not fewer than we had before. So we must ask: What is the reason for the fall in the intake of general practitioners? Many noble Lords have said that it is largely to do with the increased workload because of the increasing shift in the health service towards primary care and also the unsocial hours. Both contribute to low morale in the service. In addition to low recruitment figures, an increasing number of GPs are also considering early retirement. In some parts of the country, I am told, it may be as many as 50 per cent. In

28 Feb 1996 : Column 1518

my family I have a consultant at a hospital and a GP, both fairly young people. They are already seriously considering taking early retirement because of the pressure of work.

In addition, the Government's decision to phase the recommendations of the pay review body has only exacerbated the problem. We need urgent action now to safeguard our GP services. As a first step, there should be a complete halt or moratorium on any further work being loaded onto general practice until the problem of recruitment has been dealt with. I ask the Minister to consider that.

There is also a shortage of doctors in the hospital sector. This was clearly set out in the report of the Department of Health's own medical workforce Standing Advisory Committee last June. Furthermore, we have been told that emergency admissions increased by about 13 per cent., 14 per cent. or 18 per cent.-- I am not sure which is the correct figure--between the years 1990 and 1993. According to NAHAT, the most likely reasons for the increase are: patients are older, there are more cases of some illnesses, patients have higher expectations and GPs feel less able or willing to cope with seriously ill patients. Early discharge has been mentioned, in other words the revolving door of going back into the accident and emergency department. Also, family life is quite different and families are less able to look after their own members. So there is an inter relationship which is clearly visible between the hospital service and the GP service.

We know that the greatest shortage exists in the A&E departments where, because of the closure of a number of departments, bed closures and ward closures, the workload is now almost impossible. That results in long waits on trolleys, departments running out of trolleys and having to borrow them from the x-ray and theatre departments, with treatment having to be carried out in the accident and emergency department which should be carried out in wards. Too often, the standards of the Patient's Charter--of which the Government are proud--for accident and emergencies of a bed within two hours of admission cannot be fulfilled.

The above concerns are echoed by the Royal College of Nursing. The noble Baroness, Lady Cox, told us about her concerns. For two years the RCN has been warning the Government of a growing nurse shortage problem. It is now acknowledged that there is an acute shortage in certain areas: intensive care, theatre nursing and paediatric intensive care. Faced with those admitted shortages, it seems incomprehensible that a number of senior nurses across the country are being made redundant as a result. In the Trent region 32 senior nursing posts are threatened as part of the Government's proposed management cuts. We are all aware that the quality of care in clinical areas depends on the skill and experience of the ward sister. We cannot afford to get rid of our senior nursing staff.

In the present climate, we need a national workforce planning system, not a local one, to identify the need for nurses all round the country. Nurses feel unable to fulfil their tasks in the face of those shortages and, as the noble Baroness, Lady Cox, told us, as many as

28 Feb 1996 : Column 1519

40 per cent. of them are considering leaving the profession. The recent national pay award of 2 per cent. has added to the problem, making morale among nurses at an all-time low. Any extra will have to be negotiated locally. NAHAT itself admits that each trust will need to make its own judgment in the light of its financial position which is bound to vary from trust to trust.

The noble Baroness, Lady O'Cathain, said that the right to remunerate at different levels is not necessarily wrong. I agree with that, but it should be for good performance over and above the basic rate. It should not be dependent on an award of a 2 per cent. increase, which is below inflation. It should not be phased, as it is for doctors. The nurses who, a few years ago, were delighted when they achieved their own pay review body must wonder whether they have achieved all they thought they were going to.

I believe that the recommendations of the pay review body should be altered or varied only with the assent of Parliament. If the Government decide not to follow the recommendations, as they did this year, by delaying implementation, it should require parliamentary approval. That will give parliamentary protection against the actions of any government who want to change what the independent body recommended. After all, both the Government and the staff had agreed to accept the pay review body decision.

I also believe that there should be national criteria for local flexibility. There is need for that flexibility, but there should be national criteria to govern how it is supplied. For example, there should be flexibility to reorganise the staff structure in a trust, to deal with a local recruitment problem or to reward exemplary performances. That flexibility should be used within a pattern established for the country as a whole. After all, we pride ourselves on a national health service, not a local health service.

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