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Baroness Jay of Paddington: My Lords, we have had an extremely informative and rather disturbing debate--about probably the most important factor in any successful healthcare system; namely, the well-being of the people who themselves look after patients. In the NHS, the quality and dedication of the staff is, rightly, universally recognised. It is because of their work that the health service has always been so widely admired and held in such esteem and affection by us all. I emphasise "by us all" because any attempts by noble Lords to pretend that the estimation of the health service is a partisan issue is completely incorrect.
That is why I echo the noble Baroness, Lady Robson, in saying that it was particularly disturbing to hear a distinguished senior member of the medical profession give the kind of description of his and his colleagues' concerns that my noble friend Lord Winston gave in his opening speech. I am very grateful indeed to my noble friend for tabling this Motion and making such an authoritative contribution. Almost all who took part in the debate spoke from personal experience and knowledge. I hope that, in replying, the Minister will not suggest that those who are critical speak from ignorance. Too often we are told by the Government
I speak from some personal experience, and must declare three relevant interests. First, I am married to a senior consultant physician. His immediate concern is that his department in a London teaching hospital faces an 8 per cent. cut in its budget this year. He and his colleagues have spent a very great deal of time since the cuts were announced, just before Christmas, trying to juggle with figures and adjust plans--time that they might better have spent in clinical work or teaching. They have come, unhappily, to the conclusion that, with rising patient numbers, they cannot possibly absorb an 8 per cent. cut in funding. They will have to close wards and clinics this spring. When the Government speak of ever-increasing funds for the health services, it pays to look at the fine print. Too often extra money does not go to patient services. As the Labour Party discovered this month in parliamentary Questions in another place, an extra £1.5 billion has been spent in the past five years on bureaucracy.
In another part of London I serve on a commissioning health authority. That is my second declared interest. That agency is very well managed. Nevertheless, problems of staff morale, from the most senior to the most junior levels, are a constant concern. Staff there have particular anxieties about the inadequate services they are providing for the mentally ill living in the community--an issue discussed in this House last week and referred to again this afternoon by my noble friends Lord Dubs and Lady Hayman. They also have anxieties about how they can cope with continuing care for the elderly, and anxieties about proper primary care. They are still uncertain that hospital bed closures will be effectively replaced by the much advertised but not very visible improvements in community services that we have all been promised. These are all legitimate anxieties about the quality of care that they can offer and which affect both staff and patients.
My third declared interest is as national chairman of the League of Hospital Friends--a role that takes me into many health service organisations all over the country. My visits are often to celebrate achievements or to mark the opening of new facilities. But I cannot count the number of times that my hosts, who may be local medical staff, nurses, or indeed managers, have taken me aside at a reception or followed me across a car park to start conversations which always begin: "Of course, we are very happy with what has happened today, but extremely worried about what is going on in general". Many of the issues they want to raise are those referred to in the debate this afternoon: the complications of contracting; professional training; local pay bargaining; ITU beds; and above all, staff shortages at every level and in every part of the service.
Two other general worries are also often presented to me. One is the frustration that many professionals in the health service feel about being asked to compete with other health service trusts. These are often neighbouring hospitals which, in the past, were regarded as colleagues and collaborators in patient care and which must now be treated with suspicion as market competitors. On the ground, it is that spurious and artificial boundary that is fuelling fears that the National Health Service is fragmented. As my noble friend Lord Winston demonstrated very clearly, it can give rise to very serious clinical anxieties.
General concern about fragmentation also goes with the feelings of isolation that many staff have as regional health authorities disappear and the Government abrogate more and more responsibility to a very local level. In the past, many enjoyed and took pride in the sense of belonging to the nationwide family of the NHS, which provided networks of professional support and patient referral, as the noble Lord, Lord Walton, explained in his contribution. As well, they maintained universal standards of care. Today, there is very little of that. Horizons are limited to the small business interests of individual trusts. One medical director commented rather sardonically to me recently that the esprit de corps in his particular trust was now expressed through the local marketing brochure and improved hospital signposting, rather than through national recognition as a centre of excellence. I have to say, without any discourtesy, that something of that was conveyed in the contribution of the noble Baroness, Lady Flather.
All of this can be dismissed either as shroud-waving or as anecdotal. But many speakers this afternoon rightly quoted from the growing amount of objective, independent evidence from surveys and reports about the attitudes and concerns of health service workers. I make no apology now for again highlighting some of those findings.
First, in relation to nurses, as the noble Baroness, Lady Cox, said in a very powerful speech, they are the largest single group of staff working in healthcare. The noble Baroness quoted the RCN survey which showed that two-thirds of trusts are having difficulty recruiting qualified nurses. Both the noble Baroness, Lady Cox, and the noble Baroness, Lady Robson, referred to the tragically high figure of 40 per cent.--I repeat, 40 per cent., my Lords--of nurses who are considering leaving the profession. Nurses rightly feel that that leaves them in a situation that can often be described as dangerous, and is certainly inadequate for them to feel that they are providing proper patient care. The recent miserly national pay award of 2 per cent. is, as my noble friend Lady Hayman said, bound to undermine morale still further, particularly when it is compared with last year's pay award to chief executives in the health service of 7.6 per cent. UNISON has already polled its nursing and midwife membership about morale. More than three in four--78 per cent.--feel that the morale on their ward or in their unit has worsened in the past year.
The Government constantly tell us that family doctors are completely happy with the changes in the health service; that GP fundholders are the enthusiastic standard-bearers of the reforms. This latest report paints a totally different and very gloomy picture--one that the noble Baroness, Lady Robson, painted in some detail. The only encouraging fact is perhaps the accompanying NOP poll of the voting intentions of GPs, which shows a dramatic swing to Labour. Apparently, the Labour Party now enjoys more GP support than all the other parties combined.
My noble friend Lord Winston, the noble Lord, Lord Walton, and other noble Lords, gave us a vivid idea of the situation in our hospitals. Their experiences of pressures and shortages are reinforced by this month's Health Director Magazine which publishes a survey by the National Association of Health Authorities and Trusts called "Is there a Doctor in the House?" With very dramatic graphics of "wanted" doctors, it shows that most NHS trusts cannot recruit doctors in a whole range of specialties. Seventy per cent. do not have enough psychiatrists; 64 per cent. have shortages of anaesthetists; over a quarter are unable to recruit enough paediatricians; and the same number have shortfalls in accident and emergency specialties. In all of these areas there is real anxiety about the need to rely upon locums or other non-specialist staff, the impact upon waiting times and, above all, the quality and standards of patient care. No wonder that hospital consultants mirror GPs in seeking early retirement! Another survey showed that 70 per cent. would take it if they could.
All of this points to an NHS staff situation which is one of growing shortages and falling morale. That is a very unhealthy combination. We began this debate with an important contribution from a very distinguished physician. I should like to conclude by quoting the president of the Royal College of Physicians who recently sent a letter to fellows of that royal college, all of whom are very senior doctors. In that letter, Professor Sir Leslie Turnberg succinctly summarised the case that we have argued today. He wrote:
This depressing picture must be changed. One million people work in the health service. Without their motivated commitment the NHS will begin to disintegrate. It is the Government's responsibility to act now to prevent that happening.
The Parliamentary Under-Secretary of State, Department of Health (Baroness Cumberlege): My Lords, I am most grateful to the noble Lord, Lord Winston, for initiating this debate and for his generous opening remarks to me personally. As a pioneer in the rarefied field of fertility, he is not only the "father" of thousands, a highly respected academic, and a clinician with a formidable reputation, but also, I understand, a former Thespian. One may think that that combination is perfect preparation for your Lordships' House. However, in the course of the debate I wondered whether the noble Lord was attempting to construct an alternative reality, or a make-believe land, because I did not quite recognise the picture that he painted.
The noble Lord referred, quite rightly, to the Government as the Government of choice. He went on to suggest that we had restricted patient choice. But for the first time ever choice is enshrined in the Patient's Charter. The charter gives patients the right, with the agreement of their GP, to a second opinion. While in no way decrying the international recognition and reputation of the noble Lord's department at Hammersmith Hospital, which I know to be extremely well led and a first-class unit, if health authorities feel that with the agreement of patients they can get better value locally, or wish to break traditional patterns of referral, we do not wish to deny them that right. If I may be a little cheeky, we all know that referral patterns in the past may have had more to do with medical networks than patient choice.
The noble Lord, Lord Dubs, implied that noble Lords on these Benches thought that the NHS was perfect in every way. That is not so. Your Lordships have heard many of my noble friends say this evening that we are never complacent or satisfied with the NHS. I believe that some noble Lords on the opposite Benches under-estimate recent achievements, which have been Herculean. Great credit for that goes not only to the Government but, more importantly, to the commitment of NHS staff.
There are three very powerful forces that influence the service. These were referred to by my noble friend Lord Clanwilliam and went unchallenged by any of the speakers on the opposite Benches this evening. They are the increasing number of elderly people, mounting consumer pressure, and technical change. The noble Lord, Lord Winston, is at the leading edge of developments in medical science and must also be well aware of consumer pressure. He will know that these forces are hard to influence. Indeed, some argue that they are unstoppable. He will also know that not only is change a challenge to manage but that the provision of buildings, technology, staff training and the redevelopment of a service take time.
The noble Lord, Lord Winston, mentioned another factor: politics. In commercial firms which, like the NHS, also have to change, restructuring can be done without the glare of publicity. In the NHS, which we all recognise as one of the great institutions of this country, policy and management are always topics for debate, including debate in the political arena. The noble Lord,
The Government are engaged UK-wide in spending over £41 billion of taxpayers' money. We are accountable for doing that prudently and for the benefit of the whole population. It is a responsibility that any government accepts. However, there is a fundamental dilemma. The media and well-organised opposition can together make people believe that the NHS is not doing a marvellous job. They neglect the fact that 83 per cent. of people who have used NHS services say that their treatment has been average, satisfactory or very satisfactory. That is a higher satisfaction rate than almost any service industry can show.
The Government have privatised many industries, such as British Steel, British Airways and Britoil. In so doing, they have removed their management from the political arena and so concentrated the areas of opposition on fewer services. But the NHS is still a mutual society and is there solely for the benefit of taxpayers and users. One may say that it is "nationwide". Sadly, the NHS has become, not a treasure to be guarded, but a quarry to be thrown to the pack. That is not a good principle of management. Everybody wants to work for a winner. The NHS is a winner, not only among most staff but among most patients, but some parliamentarians egg on the media and are motivated to portray the NHS as a loser. I accept it but resent it, because it is not like that. The NHS combines two great principles: "love thy neighbour" and "each according to his needs". When one has great principles they are an inspiration but are incredibly difficult to fulfil. Doom and gloom can trickle down from Parliament into the NHS and on to patients.
As the noble Baroness said, the NHS has a staff of nearly 1 million, but its great ethos draws millions more actively to support it. Hundreds of thousands are volunteers, and millions give money. They manifest the great achievement that the NHS belongs to the people. Few organisations have so many and so sure defenders.
I agree with the noble Baroness, Lady Hayman, that it is extremely difficult to define and gauge morale. I spend much time visiting throughout the service and find both high and low morale. Recently, I went into a ward in a hospital and was met with a barrage of complaints from the ward sister. She complained of under-resourcing, under-staffing, absenteeism, the junior staff wanted to leave--nothing was right. A few minutes later on another ward in the same specialty, and in the same hospital with the same catchment area, it was all smiles and only a slight embarrassment at the size of the waiting list. I refer to the waiting list of staff who wanted to join the team.
Now, of course, there are jobs that are hard to fill in some of the best hospitals and GP practices, but behind many local disasters lies indifferent leadership. Rather unexpectedly, and delightedly, I agree with the noble Lord, Lord Haskel. The importance of leadership is crucial. I am sure he will agree that managers must also lead and that we have a huge workforce that needs to be led, the vast majority of whom are excellent. But, as my noble friend Lady Brigstocke implied, it would be beyond belief if we did not have a few bad doctors, a few bad nurses, a few bad managers and a few bad technicians among a million people. But they are remarkably few because, on the whole, the NHS is full of committed staff and it is very well run.
I am pleased that the noble Lord, Lord Rea, welcomed the move to a primary care led NHS. I share the admiration of the noble Baroness, Lady Robson for GPs. Perhaps this is the time for me to declare an interest. I am the daughter of one and I grew up in such a family household. We all agree that family doctors are central to the NHS. Together with community nurses they are nearest to patients. They understand the family dynamics, the nature of an individual's employment and the community in which they live. A primary care led NHS puts the GP at the heart of healthcare--no longer a doctor, as the noble Lord, Lord Moran, declared, who had "fallen off the ladder". I strongly agree with my noble friend Lady Gardner that GPs have never been better. Today, the vast majority are highly trained and supported by a skilled primary healthcare team with better premises and increased staff. They are pivotal to the future development of the NHS, a recognition warmly welcomed by the Royal College of General Practitioners in its statement on A Primary Care Led NHS, published earlier this month. GP fundholding is an extension of that. But, as my noble friend Lord Clark of Kempston said, in a very powerful speech, the party opposite wish to abolish GP fundholding; unlike Brian Abel-Smith, the former chief adviser on health to the Labour Party and presently vice-chairman of the Fabian Society, who recently said that all GPs should be fundholders.
Who would have imagined five years ago, when GPs and the BMA were implacably opposed to it, that today we should witness over half of all GPs having chosen to become fundholders. As the noble Lord, Lord Walton, said, pioneering fundholders have shown what can be achieved. They have negotiated same day test results, arranged consultant clinics at their surgeries and provided extra physiotherapy, chiropody and complementary therapies on site. The benefits are many and other GPs wanting to do the best for their patients have followed the lead. Fundholding gives them opportunities which they never dreamt were possible only five years ago.
The noble Baronesses, Lady Masham of Ilton and Lady Hayman, suggested that GP morale was in crisis. But that is scarcely borne out by their recruitment, which is an issue that concerned the noble Lord, Lord Rea, and the noble Baroness, Lady Robson. Despite recent pessimistic reports, I am pleased to be able to tell your Lordships that the number of GPs increased by more than 11 per cent. between 1984 and 1994. It
That is not a picture of a service in decline; but the Government are anxious to ensure that the pivotal role of general practitioners remains attractive to doctors in training. To help understand where government action might be able to enhance further the delivery of primary care, my right honourable friend the Minister for Health recently embarked on a listening tour to hear at first hand the aspirations and concerns of family doctors. I am sure that he will pick up many of the points mentioned by the noble Lord, Lord Rea.
Like my noble friends Lady Gardner and Lady Flather, the Government have been resolute in their appreciation of good management. It is quite bizarre to think that highly complex hospitals or GP practices can be run without the highest quality management. I am sure that the noble Baroness, Lady Hayman, will agree, as no doubt will the noble Lord, Lord Haskel, that getting the numbers right is a process of adjustment. We share the noble Lord's view that training doctors, nurses and technical staff to manage is an imperative. Personally, I am very encouraged that over 30 nurses are now chief executives of trusts.
We agree with the noble Lord, Lord Desai, that bureaucracy must not take over and gobble up resources that could be better used. By abolishing regional health authorities--a move opposed by the noble Lord's party--and also by merging FHSAs and DHAs, and streamlining the department, we have cut bureaucracy and saved £300 million a year for reinvestment in patient care.
The noble Lord, Lord Winston, was critical of the internal market, which he described as a mask for under-funding. The separation of responsibilities between hospitals and health authorities has, as the noble Lord acknowledged at one point, brought immense benefits to patients. He is right that health authorities, through their pressure on quality standards and trusts, have ensured that hospitals have delivered shorter out-patient waits, shorter waiting times for operations and shorter waiting times in A&E departments. They have also put appropriate pressures on community services. That is not a mask for underfunding. Under this Government, funding for the NHS has increased every year and now, as I said, stands at £41.2 billion in the UK.
The noble Lord, Lord Desai, was critical of the way in which the internal market is working. But one has to bear in mind that this is still very new and very young. It needs time to mature. I can assure the noble Lord, Lord Haskel, that co-operation is breaking out. I could give a list of examples, but time is running on.
When the internal market was introduced, the Labour Party predicted total collapse. That did not happen. It was a relatively smooth transition and we are beginning to see the benefits coming through in a very
My noble friend Lord Bridgeman also referred to nurses training. He is right. We have invested hugely in the Project 2000 courses. From April they will be countrywide. The benefits are visible. One has only to walk the wards or go into the community and one finds confident, competent, thinking nurses doing a very good job indeed.
The noble Lord, Lord Dubs, mentioned the percentage of GDP spent on healthcare. But he acknowledged that the percentage of GDP is no measure of the healthcare that is provided. My noble friend Lady Flather was right when she pointed out that the real measure is what that money can buy. We believe that £41.2 billion in the NHS represents outstanding value for money.
I am very grateful to the noble Lord, Lord Walton, who described accident and emergency care in this country as the best in the world. But I understand the concerns of the noble Baronesses, Lady Masham and Lady Robson. A&E services are demand-led and it is not easy to find the right balance, so that peaks can be accommodated while avoiding the inefficiency of empty beds and wasted resources. But in the majority of cases, that balance has been found. However, this winter we have seen undue pressure on accident and emergency services in many parts of the country. There are many reasons for that. The 'flu epidemic early in the year both increased the demand for beds and reduced the number of fit staff; more people are coming forward as emergency admissions; discharge procedures in some areas are preventing beds becoming available. I also have to say that not all social services departments have got their act together in regard to discharge procedures.
The NHS has tackled peak demand in its customary professional way. The Government have also responded flexibly. Earlier this year my right honourable friend the Minister for Health announced that trusts can appoint extra staff-grade doctors to ensure full cover for A&E departments. In addition to the 39 extra consultant posts funded through the new deal, we have also approved a further 38 specialist registrar posts. Consultant expansion in A&E is the fastest within the medical specialties.
The noble Baroness, Lady Masham, raised the issue of intensive care beds. Those have increased by nearly 90 in the past four years and now stand at 2,600. The number of qualified intensive care nurses has also increased by over 1,000 to 7,650. However, there will be times when intensive care units, despite having a full complement of staffed beds, will be full. In those circumstances, suitable specialist beds will be found in an alternative hospital as close as possible. Perhaps I can reassure the noble Baroness that to ensure that transfers can be arranged where necessary we are reviewing the options for a central intensive care bed bureau to build on the pioneering work which has been so successful in London and which we believe could be used in other areas.
My noble friend Lady Gardner asked about junior doctors. I thank her and other noble Lords who are actively involved in the NHS. My noble friend spelt out clearly the achievements of the Royal Free Hospital. She also made clear that running a trust to deliver a high quality, modern healthcare service is a demanding task. She referred to the new deal, which we put in place to improve the living and working conditions of junior doctors. It has meant that they are better able to deliver care to the benefit of patients and to benefit from their own training.
The noble Baroness, Lady Hayman, expressed concern about the future of research. This country used to have a brain drain; today we have a brain gain. Scientists beat a path to our door to visit the Cochrane Centre--a world beater--to talk to our director of research and development; an appointment due purely to your Lordships who moved for that when a Bill passed through this House. They come to see how we guarantee central funding for research and development and they come to work here. My noble friend Lord Bridgeman also asked about the investment in nurses and the services that they carry out today. That is an issue close to my heart and I concur with all that he said concerning the increasing role of nurses and the pivotal role that they play.
Many noble Lords raised the question of nurses' pay. It was an issue clearly addressed by my noble friends Lord Clark and Lady O'Cathain. My noble friend Lord Clark, as a master of finance, put the case clearly in terms of figures and I do not want to go over that ground. But he is right to contrast this Government's good record on nurses' pay with that of the Labour Government, whose record I have to say was miserable. In their time in office nurses' pay did not even keep pace with inflation year on year.
The noble Baroness, Lady Hayman, and my noble friend Lady Cox referred to impending shortages in nurse recruitment. But the review body was in no doubt that the Government's move towards local pay is right. It is right that the solutions will increasingly be in the hands of trusts, the local employers. No organisation can afford not to have control over 70 per cent. of its costs. My noble friend Lady Cox asked why only nurses are subject to local pay negotiations. But every group in the NHS is subject to local pay, except the doctors; they are the one exception. But even this year the doctors and dentists' review body will start to introduce local pay by abolishing C awards and introducing a local points system. My noble friend Lady O'Cathain put the case on local pay so well, and I want to endorse all that she said. It makes a nonsense today to have centralised pay countrywide; no other organisation does it.
My noble friend Lady Cox was right to draw our attention to staffing issues. I hope that she will take comfort from the fact that next year the commissions for training will be increased by 14 per cent. That has already been debated this week in your Lordships' House and I am sure that my noble friend knows the issues as well as I do. But I just want to say on shortages that it was only three or four years ago that the RCN's concern was that nurses were without jobs; that we were training nurses for the dole.
The noble Baroness, Lady Nicol, was worried about two-tierism. The Government stand by the 1991 guidance agreed with the medical profession which states that common waiting lists should apply for all urgent cases and no hospital should offer contracts to one purchaser which would disadvantage the patients of another. That refers particularly to GP fundholding. We are determined that there should not be two-tierism, but we want to ensure that we bring the rest up to the level of the best.
I thank my noble friend Lady Brigstock. She is absolutely right that we have to ensure that staff are consulted and have an influence on the nature of the work that they are doing, their organisations and their trusts. Indeed, we believe that with our new arrangements that is easier.
The noble Lord, Lord Ashley, mentioned cochlear implants. I am grateful to the noble Lord for his courageous advocacy on this issue. I can assure him that all health authorities have been sent copies of the famous report to which he referred and it is something that we are watching closely. If there are individual cases, I shall be grateful if he will bring them to my attention. I thank my noble friend Lord Clanwilliam for his contribution and we will study it carefully.
In summing up, I believe that the NHS is a pioneering organisation. Every year we see an increase in new developments. Ten years ago we carried out three lung transplants; last year 115. Cataract removals are now carried out on a day-case basis; where they were once considered leading edge, they are now the norm.
The NHS is full of innovation, full of change. I do not believe that we would see nurses raring to prescribe--which is one of the projects in which I have been interested--nor that we would be seeing GPs more than meeting their targets if this was a service on its knees. It is not a service in decline; rather, it is an NHS that strives year after year to do better and better. It is part of our heritage, a force for unity and inspiration; but it is inextricably dependent upon the fortunes of this country. A thriving economy cherishes a thriving NHS. A thriving NHS requires acceptance of change by staff, resolution by government and understanding from the people. The lesson we are all learning is that only the best will survive. In global terms, I believe that the NHS is the very best; it deserves to survive and we should rejoice in its supremacy.
Lord Winston: My Lords, I thank all those who spoke this afternoon and also the Minister for replying to our anxieties. However, I feel that we are faced with a serious problem. The problem lies in being courageous enough to stand up and talk about what is happening in one's own area of practice. That is not easy for a medical practitioner to do; it is not easy for a trust manager and it is not easy for a nurse.
I do not want to denigrate managers; I never said that. I am concerned about the bureaucracy, which is quite different. I would just say to the noble Lord, Lord Clark, that it seems to me he is perhaps just a touch complacent, if not a touch out of touch.
The health service is a major constituency. It has a million employees. A manager said to me about two weeks ago, when I was trying to negotiate treatment for a leukaemic patient, "I have had to make eight telephone calls on my inflated salary to different managers". The manager said to me, "Don't blame me, I did not start this ridiculous system". Many eminent consultants and friends of mine who are certainly Conservatives, say that they will not vote for this Government again. I fear that as regards the National Health Service the moving finger has come out; the writing may be on the wall. I fear that the Government have been weighed in the balance and found wanting. I beg leave to withdraw the Motion.