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Baroness Jay of Paddington: My Lords, I am grateful to the noble Earl for pointing out the excellence of the services in his locale. I wish that it were true throughout the country. Some extremely good services are offered by the NHS. One of the particular frustrations of the way in which the service was fragmented by the previous internal market system was that precisely the excellent service (which I am glad that the noble Earl enjoys in his part of the country) was not spread throughout the country. Excellent services were not available to everyone. They were available only in certain areas. We are not downgrading what happened previously. As I said in my first sentence in response to the noble Earl and the noble Baroness who spoke earlier, all of us are agreed on the enormous skills, dedication and commitment of NHS staff. What we want to do is to improve the service. We do not want to preside over something that people think may last only another 10 years. We intend the service to improve and

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modernise so that it is there in 50 years' time, serving all of the people of this country in the way in which the noble Earl is being served now.

Lord Winston: My Lords, I am grateful to my noble friend the Minister for repeating the Statement. Those of us who work on a day-to-day basis in the health service know how far short the protestations that we have just heard about the health service are from the actual practice. It is true that the previous government made some improvements--I have grave doubts about the internal market--but despite what the noble Earl, Lord Howe, said, the previous government at least made some investment in research and development. However, one consistent problem has been that that research and development has not been able to be put into practice. I am sure that the House would be grateful if the Minister could refer to the new national institute of clinical excellence and say how it will help us to improve the application of research in the health service and how that body will interface with our existing centres of excellence. We welcome the opportunity of this body; it seems like a very far-seeing idea.

Baroness Jay of Paddington: My Lords, I am grateful to my noble friend. He is right that it is the excellence of research and development and the clinical care by individuals like himself in the health service that maintain the quality of standards. He is also right that we want those standards to be broadly disseminated and most effectively introduced. We hope that the National Institute for Clinical Excellence will do precisely that.

There are a number of such organisations funded within the health service, some of which have been set up in the past few years. For example, the health technology assessment organisation at the University of Southampton is already doing good work in this area. However, these bodies are rather disparate and do not pull together in providing a national basis for assessing and disseminating the best quality evidence on which clinically-led medicine can proceed. The intention is that the national institute should bring together those organisations that already provide some of the evidence and lean on some of the others to ensure that throughout the country the understanding of research and development is put into practice.

Baroness Gardner of Parkes: My Lords, I am concerned that the Statement recites that the health service has set doctor against doctor. I do not accept that for a moment. My experience of the health service is that all of those within it work well together. It is most unfortunate that the Statement says that.

However, my main interest lies in the costs to which the noble Baroness has referred. The Statement says that management costs will be capped. The noble Baroness went on to explain that that would mean £3 per person. Can the Minister elaborate on exactly what that £3 covers? I believe that it refers to the management of the new structure.

The Statement goes on to refer to the fact that there will be clear incentives and sanctions to help drive improvements in performance at every level. It is clear

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that the budget will be tightly operated. The Minister said that the health service and the social services would be working together. Can she elaborate on the budget? Does this mean that we shall have to pay something for health services or that all of the social services will be free? One of the problems has always been the division of costs as between care, particularly long-term care, in hospitals in the NHS and care in residential homes.

I note that on page 2 of the White Paper the document of 48 years ago is reproduced. I have seen the original document. Until I saw it recently I had not appreciated that at the opening of the National Health Service the then Labour Government said that they were unable to introduce a proper dental service. When the Minister says that we are going back to the position 50 years ago, I believe that that is exactly so. There is still an inadequate NHS dental service. It is only on page 85 of the document that one sees any reference to dentistry. It states:

    "Primary Care

    Family health services provided by family doctors, dentists, pharmacists, optometrists and ophthalmic medical practitioners".
That is the definition of primary care. Except for doctors and nurses, there is no mention anywhere of how the primary care services are to be run. As a dentist I believe it is very important that people should be given access to national health dentistry again. I ask the Minister to comment on the points that I have just made.

Baroness Jay of Paddington: My Lords, the noble Baroness has made several points. I hope that I can remember all of them. I start with the last point. Of course, the Government intend to include dental care in the organisation of primary care. The precise proposals in that regard will be provided in the consultation document on the framework for developing the management organisation, which I suspect will not be published until after Christmas. It had been intended that it should be published alongside the White Paper but it was regarded as rather indigestible. As regards dentistry, I do not believe that I have said anything to suggest that we want to go back 50 years. In many ways we do not even wish to go back to the 1970s. I was merely responding, perhaps in a light hearted way, to the noble Earl's point about presentation and the adoption of this particular title.

The costs will be much more clearly spelt out in the management framework document. However, we are all aware of the Berlin Wall, as we call it, between social services and healthcare organisations. When we looked at the very specific problem of how to spend the relatively small sum of extra money on the winter pressures, we made a deliberate effort to try to devote some of it to social services, for example to ensure that community care in particular areas was in place over the Christmas period and people were not held in hospital who could otherwise be discharged to their homes. There has been a very effective and co-operative development at practical level, often in mundane areas such as the provision of local patient transport to deal with a short-term situation. But I believe that it bodes quite well for the future development of partnership in this area.

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As I said in repeating the Statement, there will be a statutory requirement for partnership. It is hoped that some of the more detailed mechanisms or arrangements between the two will evolve. For example, a chief executive of a local authority will not be a member of the local health authority but will be able to take part in that authority's deliberations. The opportunities for partnership are there. As I said in my original answer to the noble Baroness, there are questions about funding which it is hoped we will have a chance to explore through health action zones and other pilots.

Lord Bruce of Donington: My Lords, I rise to congratulate my noble friend on repeating the Statement this afternoon. Over the past 19 years I have watched the tremendous efforts of all those who have participated actively in the health service, in particular in a direct capacity--doctors, nurses and so on. Nevertheless, as one who was marginally responsible for the introduction of the health service in 1948, when I stood behind my noble friend on the other side of the House I witnessed the depressingly steady erosion of the values that we sought in those days in founding the National Health Service. It was very depressing indeed. It has not been pleasant to observe the degeneration in the administration of the health service to a point where it is rapidly becoming a two-tier service, as everyone who has participated in it as a patient or otherwise knows perfectly well.

I am confident that a beginning is now being made--and that I can be cheerful once again--to restore progressively the old values of the health service. I dislike the terms "new" and "modern". I believe that there are two factors which my noble friends in government should bear in mind. First, it is not true that we are at the limit of our financial resources in financing the National Health Service. This country's expenditure on health is marginally less than 6 per cent. of GDP; in France it is 7 per cent. and in other countries it is more than that. Therefore, literally speaking, it is not true that we are at the limits of our prudent financing of the health service. What is true is that we can have a profound effect upon its cost by ensuring that poverty and bad housing are progressively abolished, unemployment ceases to be a chronic problem and the fear and insecurity that lie behind many of the claims of patients in the health service are progressively eliminated. I am confident that my noble friend and her colleagues will do that, and I hope that they will take account of the observations that I have ventured to make.

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