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Lord Graham of Edmonton: Time!

Lord Hacking: My Lords, as I end my remarks--well within the time-frame--I am asking your Lordships for a constructive discussion--

Lord Graham of Edmonton: Twelve minutes!

Lord Hacking: My Lords, according to my note I have 15 minutes, but I am now ending my remarks, so let us not have a debate about whether I have 12 or 15 minutes, which was the time that I understood was available to me for opening the debate.

Let us have a constructive discussion. Above all, let us look at the valuable contribution which this report has made to the debate on healthcare in the future. I shall not read it out because there is not the time, but I draw your Lordships' attention particularly to the moving patient scenario which is identified on page 47. I commend the report to the House.

7.32 p.m.

Lord Butterfield: My Lords, as the lone Cross-Bencher, I am pleased to enter the debate which the noble Lord, Lord Hacking, has so wisely and kindly initiated. The Healthcare 2000 Report comes from a very prestigious committee led by Professor Sir Duncan Nichol, who has produced a penetrating and comprehensive report, which is not surprising because for a long time he was at the centre of the NHS. His committee is a powerful one and its report reflects the

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growing interest in such matters as the new roles of, and responsibilities for, the well-informed patient and how we are to make patients well informed. It raises interest in the movement of the centre of gravity of healthcare towards community services and it probes the questions of trials in the organisation of medical care and the flexibility of payment.

There is no doubt that it is very important for all of us who are concerned with the health service that we do not allow the fact that the examination is arduous to mean that people do not even try to take it. I urge noble Lords to read the report because they will find that a wide network of healthcare ideas is incorporated into the committee's deliberations. There will have to be a good deal of debate about the points raised in it well on into the millennium.

We are always concerned about training in the health service and I have been intrigued by the Chinese philosopher who urged that when facing complicated questions, leaders of organisations should always try to find the key link of the net of complexities, because if you find that key link, you can cast your net onto the river where it will settle evenly and enrich the chance of a good catch of fish.

For me, the key link is buried on page 8 of the report. Your Lordships will not be surprised when I say that it reads:

    "It will be important for the caring professions to continue to attract the most able young men and women into their ranks. The growing diversity of need for the different types of professional ability requires people of varying characteristics and abilities".
To that, I should like to add that we must ensure that we attract the most ethical and sensitive young people. I believe that that is likely to happen only if the right philosophy lies behind healthcare. Students, whether they are nurses, doctors, physiotherapists or social workers, must be selected from the cohorts of young people who can be expected to put the patient first and not see patients simply in economic or profit terms.

I spoke earlier today to the President of the Royal College of Physicians, Sir Leslie Turnberg, who was involved for a time with the healthcare committee, and he is particularly anxious that we do not allow the funding of the NHS, and particularly the education of workers in the NHS, to fall behind in the eyes of either the public or the Treasury. I agree, but I think that that interest will be maintained only if the demographic problem in particular is constantly put before Parliament and the public.

It is equally important that the students selected for the health service have a philosophy of helping people to stay fit and that they see health promotion not as a bore but as a vital part of their co-operative work with their patients. David Green recognised the increasing burdens of self-inflicted disease on the health system and wrote an interesting note of dissent. As an economist, he was intrigued by the idea that health planners appreciated the power of individuals over the maintenance of their individual health programmes. That brings one face to face with the concept of patients

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planning their own care. It is expensive and, in my experience, even the rich are not able to work out particularly good health programmes for themselves.

The whole idea of an individual organising his healthcare programme is fairly common in America where the public are genuinely concerned about their personal responsibility for healthcare costs and where people are used to looking over and paying health bills. The idea of choosing the best buy becomes a feasible family procedure in America, but it is a strange sort of occupation for the great majority of the British people. To me, it seems best to leave the responsibility for determining the best health buys over the next 20 years or so to those general practitioners who are fund-holders and therefore have some authority in this area. I think that that is the sort of solution which the British would find most acceptable after 50 years of the NHS. However, I must add that it is important that such matters are debated.

When David Green considers the cost distribution of health between people of different ages, he recognises that the elderly are more expensive, but I do not think that he allows a high enough variation in their direction. I believe that the elderly can cost between three and five times as much as the middle-aged for the very expensive care and therapies that they need.

Of course, when people pass the ages of 60 or 65, they move into difficulties with the healthcare insurance folk. If they want to start a health insurance programme, they find that they can be covered into the future only for conditions which will be new to them. If they are discerning, they will notice that the financial premiums rise at the rate of 3 per cent. or more per annum. In effect, it seems that the diseases with which the elderly have been wrestling as their own weaknesses, such as osteoarthritis, emphysema, chronic lung disease, dementia or incontinence, are the very conditions that will bring them into difficulties with the health insurers who say, "We will be delighted to cover you for new conditions, but not for those which you already have". As chronic diseases last a long time and doctors strive to recognise diseases as early as possible, they are likely to lead to conditions which will put elderly people into difficulties in obtaining private health insurance. There is a great deal of scope for discussion about this matter in future. I suspect that one of the issues to be faced is the reopening of the question of euthanasia. I apologise for introducing that thought. However, the more one hears of the age spread, the more we shall hear about that subject in future.

I conclude by speaking about the role of exercise in staving off immobility, which so often mars old age and adds to the cost of caring for the elderly. In a speech I made in the House last year I believe that I amused one noble Lord by stressing the importance that I attached to the need for all of us elderly people to keep our thigh muscles, the quadriceps, strong and firm to keep us mobile and enable us to get up from chairs and so on.

On this occasion I feel compelled to bring to the attention of your Lordships, and your Ladyship, a small illustrated booklet--which I hold up and will place in

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the Library--entitled Exercise for Healthy Ageing. That booklet is published by Research into Ageing, a charity that I had the privilege to help launch in the 1970s. This booklet was first published in December 1994, and by March of this year it had reached its 11th impression. It makes the important point that it is never too late to start exercising. A commitment to stay active and exercised is an investment to help one remain independent.

My gesture in this short debate, which can touch only the tip of the huge iceberg covered by the report of Healthcare 2000, is to place a copy of the booklet in the Library in the hope that it will be a practical contribution to people's health and so to the NHS and the cost of the caring programme. I am not naive enough to believe that this approach--the provision of guidance--solves the problems. The publication of a booklet only starts the process of health promotion. We are still only at the beginning of what can be done to promote the nation's health and the health of the elderly and, most particularly, to stave off the difficulties and disabilities experienced by an increasing number of people in future.

7.43 p.m.

Lord Colwyn: My Lords, I am grateful to my noble friend Lord Hacking for introducing this short debate this evening. I welcome him to the ranks of the medical speakers of this House. I also welcome my noble friend Lady Miller who is deputising this evening. I hope that my noble friend Lady Cumberlege will be back with us soon and regains her good health.

I read the report and found it interesting, provocative and challenging. Surprisingly, I found myself in agreement with the two previous speakers and much of the note of dissent written by Dr. David Green. In particular, I agree with his regrets that party politics and partisan affiliation are intricately involved in the NHS debate. In one way or another I have been involved in debates on the NHS in your Lordships' House for nearly 30 years. I sincerely believe that successive Governments have provided and always will provide funding and instigate changes that they believe are beneficial to the service.

It was not until I arrived this evening and realised there were so few speakers in the debate that I regretted having prepared only a four or five-minute contribution. I should like to say a few words on integrated care management which features in chapter seven of the report under the title "The Purchasing and Provision of Healthcare". The report states:

    "The integration of purchasing for primary and secondary care will allow the purchasing of a co-ordinated package of care within which a clinical pathway becomes the basis for disease management".

I declare an interest as a dental practitioner and the director of a biotechnological company. Disease management is not a concept; it is reality. It is not a marketing tool for the pharmaceutical companies; it is a fundamental change in the nature of managing chronic disease that is happening now and will affect every participant in the health care industry from scientist to manufacturer to consumer. Disease management is the marker and the means for the shift from a component

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based to an overall integrated approach to diagnosis and treatment. Healthcare is a system, and there will be great financial savings for the health budget if the UK Government are able to use the system's new tools for making much needed improvements. The report states this as a challenge. It states that information technology will increase the quality, quantity and accessibility of information.

Disease management encapsulates the economic and social cost of disease, methods for detection, treatment and prevention. In assessing the cost and benefit of any one product, these issues must be considered by government, industry and patients. I believe that my noble friend the Minister will agree that an understanding of the economic and social costs of disease and a reduction of those costs are paramount in effective disease management. Having identified an illness and a section of the population for disease management, there are many decisions that need to be made. In some instances those decisions require funding to be made available now in order to realise significant long term savings.

Osteoporosis is one disease state which illustrates the point well. In the UK there are approximately 3 million osteoporosis sufferers but, as Healthcare 2000 points out, there are signs that not all patients who would benefit from some new treatments are obtaining them. Only 250,000 are treated at a cost of £640 million annually. The majority of costs occur as a result of fractures. One in three orthopaedic beds is occupied by an osteoporosis victim. It is only after suffering a fracture that an individual can be identified as having osteoporosis. Prevention is too late, and hence the £640 million associated costs follow. If the remaining 2.75 million patients are undiagnosed and untreated, it is only a matter of time before there will be an explosion of costs associated with osteoporosis.

Looking ahead, new innovations which can enable the diagnosis of disease in the doctors surgery must be promoted by the Department of Health. The improvement in diagnostics, developments in medical imaging and access to centres of specialist expertise can take treatment of diseases such as osteoporosis out of the hands of healthcare institutions and back to the general physician. Going the other way, it is my belief that oncology disease management should be taken away from the general physician and placed in the hands of specialised out-patient centres. The majority of general physicians are not comfortable with or completely knowledgeable about competing therapies and their costs. We have recently seen examples where breast cancer patients are treated differently in different parts of the country and have different chances of survival. If oncology patients are treated in specialised centres, I envisage improved outcomes and convenience together with a reduction in costs.

Disease management is no longer a concept. The Government must accept its arrival and take advantage of the new opportunities it will offer. Diagnostic and therapeutic tools exist today which have the ability to put disease management into practice and new

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developments in the same must be carefully assessed for their ability to contribute to the reduction of healthcare costs.

I hope that my noble friend will have time to comment on some of Dr. Green's remarks. The report believes that patients should be given statutory recognition along with clinicians and management. I agree with Dr. Green that giving patients statutory recognition is irrelevant to the exercise of personal responsibility and assumes that we are not capable of any personal responsibility and must have all aspects of healthcare managed for us. He refers to the Government's Health of the Nation report, where some of the national targets set by the Department of Health give officials responsibility for matters which should be strictly personal.

Declaring another interest as President of the All-Party group for Complementary and Alternative Medicine and the Natural Medicines Society, I agree that to a large extent our health status depends on our lifestyle: on what we eat, how much we exercise, and whether we smoke and drink. I agree with the noble Lord, Lord Butterfield, that this has to be a personal responsibility. I was sorry not to have seen anything in the report about the increasing national interest in complementary medicine and nutrition and the role that they will play in the future. I suppose that that is not unusual for a report funded by the pharmaceutical companies.

In conclusion, the report is a useful document to encourage discussion. I congratulate the members on their comprehensive analysis. Disease management and managed health-care are factors about which we will hear much more in the future. I feel sure that many of the recommendations are likely to be considered by the Government, and I look forward to hearing what my noble friend has to say.

7.52 p.m.

Lord Rea: My Lords, I am grateful to the noble Lord, Lord Hacking, for giving us the opportunity to discuss the report, although I am sorry that he chose today, because today is my birthday and I was perhaps hoping to do something else this evening. There is still time!

When the report was published, it received, as the noble Lord said, a great deal of publicity, but much of it was critical, from the Left to the moderate Right, including, as he said, the Secretary of State. As the noble Lord said, the matter has not been raised in Parliament except as an Unstarred Question in your Lordships' House on 17th October last when it occupied precisely three minutes. Clearly it had not exactly excited the House. An explanation for that may be that it was the first day back after the Summer Recess.

The noble Baroness, Lady Cumberlege, said on that occasion that while not agreeing with all the conclusions, it was a useful contribution to the health debate. I would put it the other way and say, "While agreeing with some of the conclusions, it is not a particularly useful contribution to the health debate,

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despite the time, trouble and expense obviously given to it". The report was financed wholly by the pharmaceutical industry. The authors however claim:

    "It is entirely independent of both its sponsors and of any other sectional interest either within or without the National Health Service".
Therefore a great deal depended upon the outlook of the steering group and its chairman, Professor Sir Duncan Nichol, wearing his academic hat for the publication--which did not, incidentally, mention that he is also a director of BUPA.

My broad brush criticism of the report is that it barely touches on how the health of the nation could best be improved but concentrates almost entirely on how the health service can best respond to a demand for care which is painted as virtually spiralling out of control. One sentence refers to the fact that:

    "Alleviation of poverty, improvements in housing and environment rather than the NHS, may be the best way of improving the health of individuals".
It went on only to dismiss that as impractical since:

    "all political parties are committed to sustaining and increasing the funding of the NHS".
That suggests that these major, highly desirable and necessary improvements in the fabric of the nation can be achieved only by cutting the percentage of GDP going to health.

One of the deficiencies of the report leading to such a mistake may be that of the 68 experts who were consulted only two were public health specialists or epidemiologists, and one of those told me that his evidence was not used in the report, although his name is given as one of the advisers.

In 12 minutes, it is impossible to do justice to a 70-page report. The best way to tackle the task may be to address one or two of the areas which the briefing for the report kindly sent to us by the publishers suggests the Government and opposition parties should be asked to clarify. First, do we agree about the pressures on the NHS? The answer of course is yes, in so far as those are due to an increase in the number of elderly people, increasing technology, and increasing public expectation, but those will not continue to escalate for ever. They will eventually tail off.

Only one elderly person in four is in need of care. Although more people are surviving to 85 plus, they are now much fitter. Technological improvements can lead to reduced costs as well as increased costs. However, I agree that the balance is likely to be upward. Some of those extra costs are excessive. The Government need to continue to be firm in their pricing negotiations with the pharmaceutical industry and in their efforts to reduce prescribing costs.

Yes, public expectations are bound to rise. What is interesting however is that better off and better educated people are fitter and use the NHS less than poor or less educated people. That applies even to those who do not use any private care. They live longer, but they are more self-reliant. As society has increased its standard of living, a higher and higher proportion of the population moves into the professional and skilled sector. It is those who are left behind who have the worst health and the greatest burden of illness which falls on the NHS.

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Dr. Richard Wilkinson of Sussex University and UCL has shown in a series of papers that the health of a country improves in proportion to the equity of distribution of income between the better and less well off.

The second question the briefing asks is: do we agree with the conclusions of the report? In brief, those relate to patients' views, healthcare professionals and funding. We feel that current avenues can be developed rather than that a new system be brought in to discover the views of patients. The community health councils need to be strengthened. The CHC members must have a right to be present and speak at all meetings of health authorities and trusts.

The membership of trusts and health authorities needs to be more representative than it is now. We spent many hours in this House talking about the membership of health authorities as the National Health Service and Community Care Bill went through the House. I thoroughly agree--this is the best part of the report--that healthcare professionals should explore the merits of a common core curriculum and greater flexibility between the professions.

It is the funding proposals with which we have the greatest problem. The report suggests that more private resources should be brought into the NHS; that those who wish should be able to buy certain extras within the NHS. The reason given for that is that it is unreasonable to expect the public sector to go on increasing its share of taxation revenue when other countries have a higher proportion raised privately.

In the table on page 34 of the report, four other countries which are wealthier than the UK are shown to have a higher proportion of healthcare spending in the public sector than we do. In fact, it is not given in the report; but they also have a higher proportion of their total GDP spent on health as a whole. The countries are Norway, Luxembourg, Sweden and Iceland. All of them have health statistics equal to or a little better than the United Kingdom. There is no great move that I know of in any of those four countries to change its system. I dare say that governments are in difficulty all the time about keeping up with the costs of those health services, but their health service systems are effective and popular.

To conclude, this expensively produced report is, to my mind, flawed because although some of its suggestions are excellent, it is inconsistent and cannot claim to be representative. It has not consulted widely enough, nor does it properly represent the views of the professions who work in the National Health Service. That is a great pity because the report took a great deal of time and expense to produce.

8 p.m.

Baroness Miller of Hendon: My Lords, my noble friend Lady Cumberlege is very disappointed that she is unable to be here tonight for this debate, as it was she who originally replied to a Question by the noble Lord, Lord Dean of Beswick on 17th October last year. However, it has given me the opportunity of listening to this interesting debate, and I would like to thank my

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noble friend Lord Hacking for making that possible. He started his speech by saying that he hoped I would give a thoughtful reply and I very much hope that he will consider that my reply is a thoughtful one.

Also, while I am making these pious wishes, perhaps I may say that I hope that the noble Lord, Lord Rea, enjoys the rest of the day, and we all wish him a very happy birthday.

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