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Noble Lords: Hear, hear!

Baroness Miller of Hendon: My Lords, while not agreeing with all its conclusions, Her Majesty's Government consider the Healthcare 2000 report to be a useful contribution to the debate on the future development of health services. It is timely that we are debating this issue on the day that the annual NHS Priorities and Planning Guidance is issued. This provides the overall national framework and the context for the planning and delivery of health services in England for the coming year. Comparable guidance is also issued elsewhere in the United Kingdom.

As my noble friend Lord Hacking told us, the report UK Health and Healthcare Services, Challenges and Policy Options was published by the Healthcare 2000 Forum in September last year. The forum was established and funded by Pharmaceutical Partners for Better Health, an international group of research-based pharmaceutical companies.

The Government do not accept the report's central contention that the need for healthcare will necessarily increase faster than the availability of tax funding. I know that the noble Lord, Lord Rea, agrees with that. Nor, therefore, do we accept that we face a stark choice between increasing user charges and/or patient co-payments and reducing the services provided by the NHS. The Government are firmly committed to the founding principle of the NHS--that it will remain open to all on the basis of clinical need and regardless of ability to pay--and we would not contemplate any system of funding that jeopardised this.

The other main issues raised in the report, which I will address in turn later, are: a proposal for a statutory body to represent the patient's voice at national and local levels; consideration of a common core curriculum for all entrants to the healthcare professions; the development of integrated care management to allow the purchase of packages of care; and consideration of the introduction of competition between health authorities and a mix of public and private franchises in healthcare purchasing.

This Government are justly proud of our record on NHS funding. I note that my noble friend Lord Colwyn felt that all governments do their very best to put whatever is necessary or whatever they are able to into the National Health Service. Since 1978-79 spending by the health service in the United Kingdom as a whole has increased by more than 70 per cent. in real terms. At the same time we have greatly improved value for money in the NHS. In England, for example, efficiency in Hospital and Community health services has increased by over a quarter between 1978-79 and 1994-95.

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The report is probably right in concluding that pressure on health service resources is likely to grow. One key pressure arises from demographic change. However, it is a pity that there is no acknowledgement in the report that demographic pressures are relatively modest for the next decade or so, giving us a window of opportunity before the real challenges of the second and third decades of the next century.

The long-term growth in demand for hospital and community health services from demographic pressures is expected to be lower over the next decade than over the last. Demographic pressures are expected to add only around 0.5 per cent. per year to costs for the next 10 years compared with 1 per cent. a year in the past 10 years. Again, taking figures for England, at a time when demography was adding 1 per cent. a year to demand pressures, real resources for hospital and community health services were rising by 3.4 per cent. and activity was increasing by 2.6 per cent. per year. Recent experience therefore is that extra money used more efficiently has not only enabled the NHS to accommodate the pressures on it but to increase the level and range of treatment that has been provided. In relation to demographic pressures, this task should be easier over the next 10 years than over the last.

The Government welcome the rapid development of medical science, which is contributing enormously to improvements in healthcare. The rate of advance may well accelerate but this will not necessarily mean an acceleration in cost pressures. The impact of medical advance on overall healthcare expenditure is a complex one. Some highly effective innovations increase both treatment costs and overall expenditure. But others can reduce expenditure across the health sector as a whole and also enable us to improve quality in healthcare while simultaneously reducing resource pressures.

To enhance our knowledge of such significant clinical advances, the United Kingdom was the first country in the world to establish research and development as a core function of public healthcare. Since 1993 over 300 studies have been funded by the NHS Executive under this strategy in priority areas, including mental health, heart disease and stroke, cancer and the links between primary and secondary care and health technology assessment. Related activities have also taken place throughout the United Kingdom. The Government will continue to monitor the impact of medical advance on overall healthcare expenditure. There is so far no evidence that the pressures will prove to be unaffordable.

Although we recognise that priority setting is a fact of life, we reject the centrally determined approach to priority setting that appears to be proposed by Healthcare 2000. Instead, the Government favour priority setting at three levels: Ministers set out a framework of national priorities and targets for improvement; health authorities (or health boards in Scotland and health and social service boards in Northern Ireland), and GP fund-holders assess the needs of their population and the services required to meet them; individual clinicians decide the most clinically appropriate treatment and clinical priority for each

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patient. This overall approach was endorsed last year by the Health Select Committee in its inquiry on priority setting in the NHS.

Improving the effectiveness of NHS clinical services has been a central objective for a number of years now. An example of this is the NHS Executive's approach for England which is set out in Promoting Clinical Effectiveness and was launched in January this year. Similar initiatives are also under way in Wales and Scotland. The Healthcare 2000 Report also rightly refers to Health of the Nation, with its aim of reducing avoidable ill health and premature death and promoting longer and healthier lives. Similar strategies are being taken forward in all four home nations.

Health Ministers and officials regularly meet patient groups in a wide variety of different contexts. We do not see a need to create a statutory body to represent the patient's voice at national and local levels as Healthcare 2000 proposes. This would compromise the independence of patient groups and could present a false and bureaucratic picture which underplayed the great diversity and richness of their views.

However, the Government welcome the report's emphasis on improving patient information and representation. I know that the noble Lord, Lord Butterfield, is concerned about this. In England, for example, it is one of the six medium-term priorities for the NHS to:

    "Give greater voice and influence to users of NHS services and their carers in their own care, the development and definition of standards set for NHS services locally and the development of NHS policy both locally and nationally".
We are also developing a programme of action throughout the United Kingdom at both national and local level, building on the Patient's Charter programme. We are seeking to foster a variety of local good practice and avoid inflexible national blueprints.

Under an information systems strategy for NHS research and development, arrangements are in place to make information from research findings accessible to patients, carers and self-help groups. This is being addressed in different ways. The NHS Centre for Reviews and Dissemination is tasked with reproducing research findings in a user-friendly way to the public by, for example, publishing information leaflets on maternity services. I have other examples, but in view of the time, I must move on.

Like the noble Lord, Lord Rea, we welcome the report's suggestions about the developing role of healthcare professionals as a valuable contribution to an ongoing debate, and I know that that is of interest also to the noble Lord, Lord Butterfield. We are encouraging and promoting inter-professional learning opportunities. We have commissioned a survey of inter-professional learning initiatives in England, the results of which will be shared when available. The NHS Executive has also commissioned a major programme of research into human resource effectiveness and one key strand is the issue of role boundaries of healthcare professionals and the educational implications. Comparable work is under way elsewhere in the United Kingdom. But it is a matter for individual university medical schools to determine

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their own undergraduate medical curriculums. The noble Lord, Lord Butterfield, is right to say that we must attract the best people into the medical profession.

Among the competencies required of the next generation of doctors are: flexibility and appreciation of the benefits of multi-professional working, which both noble Lords opposite mentioned; better communication skills; an ability to empathise with patients and colleagues; a greater appreciation of the opportunities and challenges of primary and community care; and a greater understanding of ethics. The noble Lord, Lord Butterfield, was so right to mention that. These are major developments in undergraduate medical education which will not fully work through until well into the next century.

I turn now to the report's proposals for integrated care management. These are precisely what we are aiming to achieve through a primary care led NHS, the aim of which is to empower patients and primary health care teams to oversee the entire programme of care for particular patients or groups of patients. However, unlike Healthcare 2000, the Government wish to see the primary healthcare team, with their better understanding of an individual patient's needs and requirements and the ability to make appropriate links to social services where necessary, playing the leading role in purchasing and managing integrated care.

The noble Lord, Lord Hacking, referred to a gentleman who had a problem with mental health services. Yesterday I had the great pleasure to stand in for my right honourable friend the Secretary of State at the opening of a GP fund-holding practice. It was extremely good to see counsellors present in the practice.

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