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3.22 p.m.

Baroness Knight of Collingtree: My Lords, for 31 years before coming to this House I served in another place. During that time, I took around Parliament countless groups from schools, churches, societies and even the cast of "The Archers". When we reached this Chamber, I told every group that this was the most beautiful legislative Chamber in the world. I believe that it is. I have visited many parliaments and nowhere have I seen such colour, grandeur, dignity and craftsmanship as we have around us. Perhaps, just sometimes, we should acknowledge how truly fortunate we are to work in such a place.

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History surrounds us as well as beauty. The 16 barons and two archbishops who forced King John to sign Magna Carta are always looking down on us from their niches. William Joyce, the most notorious traitor of the last war, faced judgment at that Bar. The Woolsack, which has been part of our constitution since 1350, received a direct hit from a German air-raid in 1941. A bomb crashed through the roof, whistled straight down through the floor and came to rest in the dusty cellars beneath. Thank God it never went off! But as it passed through the Woolsack, its fin sliced through the cover like a hot knife through butter. Horror of horrors, all was revealed! It was not full of wool at all--it was full of good old Victorian horsehair. For years we had a horsehair sack instead of a wool sack. I do not know why.

Augustus Pugin would have known. He was busy directing the rebuilding of the Palace after the 1834 fire and being paid a mere £200 a year for all the drawings and designs of every bit of carved wood around us, from the Throne to the Bar and beyond--a mere £200 a year, although he did say that his train fare from Ramsgate must be paid on top of that.

Today we are also looking back--to 1948 and the foundation of our National Health Service. With all the grumbles and complaints which the press so love to report, its benefits are manifold and miraculous. Tributes are due not only to those who work in the service, but to the way which successive governments have nurtured it, bringing in changes where they were needed.

Quite soon after the service began, it became clear that the original promise--that every single part of it would be free--could not be sustained. It must have taken courage for the Labour Government of the day to bring in charges. Many other necessary changes have been made over the years. For instance, in order to check waste, which was widespread, we had to know what things cost. No one knew what anything in the health service cost--from a bed to a biopsy--until a radical accounting system was brought in a few years ago.

Inevitably, considering the size of the health service and its age, mistakes have been made. Among the worst are schemes which downgrade patients to mere statistics. Mixed wards are dreadful mistakes. They should never be allowed, except in intensive care units. I once visited an old lady in hospital and found her in tears. But it was not her illness that hurt. She said, "The doctors and nurses here are young enough to be my grandchildren, but they all call me Mary". It really upset her. It is wrong for staff automatically to address adult patients by their Christian names because it takes away their dignity. And often in a hospital bed dignity is all they have left. Most problems in the health service concern cost, but that one does not.

Fifty years ago the architects of the health service claimed that the cost would go steadily down as the health of our people improved. They never dreamed what wonderful new operations, treatments or drugs would be invented; nor the insatiable demand for

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them; nor the cost of them. Let us acknowledge that no government of whatever political colour will ever be able to make enough money available to ensure that every patient will instantly receive the treatment he wants at the hospital of his choosing by the doctor he prefers. But all governments will always try. All governments will do their utmost not just to preserve the health service but to keep on improving, with the help of our brilliant doctors and researchers, Britain's care for Britain's sick.

3.29 p.m.

Lord Alderdice: My Lords, I thank the noble Lord, Lord Hunt, for promoting the debate and giving us the opportunity to celebrate and discuss the National Health Service on its 50th anniversary. It is an honour for me, on behalf of your Lordships' House, to congratulate the noble Baroness, Lady Knight, on her maiden speech. She has served her party, she has served Parliament, she has served our country and, more widely, she has served people in a most distinguished way. As I heard her speak of the elegance and beauty of your Lordships' Chamber, I could not help but think what an adornment not only she but her contribution already are to your Lordships' House. We look forward to further enrichment in the coming years.

There is no doubt that we can, as a nation, look back at 50 years of the NHS with a great sense of achievement. We often find ourselves saying--I was going to say with muted pride but perhaps it is not so muted sometimes--what a wonderful service we have in the National Health Service and what a tremendous contribution is made by those who work in it. Indeed, we are right to be proud of it and right to be proud of our country on having sustained it over the past 50 years.

I suppose that when we all come to the time of a 50th birthday--I am probably one of the relatively few who has not quite attained that distinction in this House--it is also a time for review and for thinking about how to deal with the rest of the years that one has. As we look at the NHS, while we can say with great pride what an excellent business it is, we must acknowledge also that there are serious problems.

I was struck by the comments made by the author of the Turnberg Report which looked at the health service in London:

    "We found a health service under pressure. Services across the whole spectrum of care, from those in the community and primary care to those in the hospitals, were sorely stretched. Although the impact of these pressures were most keenly felt in the care of elderly people and those with mental illness, others were not immune from failures to meet an acceptable standard of service. Furthermore, there is evidence to suggest that the pressures are increasing. Despite all this, health care workers are doing the best they can and we found examples of good practice, even in circumstances of severe pressure".
We all know those words to be a true reflection of the situation. But is it not because resources have not been put into the service? Of course, those of us involved with healthcare could want and could use more resources. It is not because we do not have quality staff who are committed. It is not because we do not have a community which is concerned for it. Therefore, it is appropriate to try to ask ourselves why it may be that at

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this juncture, when we have a health service which is the envy of many and which is admired by our own community, it is in such difficulties and why many people begin to wonder whether it is sustainable in its present form. We must address those questions.

It seems to me that there are a whole range of difficulties but perhaps I may outline a couple of very broad principles. For much of its time the health service was conducted under an old socialist principle. I do not say that in a political way but in terms of principle and understanding. It was a caring way which said, "We are disturbed that there are those who are vulnerable, unwell, handicapped, or very young, and who cannot care for themselves and who have difficulties and we want to ensure that they are all cared for. Therefore, we shall reassure our people that whatever happens they need not worry about money or whether care will be available. We shall make sure that whatever is necessary is provided. It may take us a year or two, a decade or two, or even longer, but we shall make sure that whatever is necessary is provided by the community as a whole."

That was very commendable. But the difficulties were two-fold. First, there was no end to the demand. As time went on, as medicine progressed, and as people's expectations rose, more and more requests came forward. The demand was not satisfied but rather expanded by increased provision. Curiously, within that, no one ever felt particularly that what was needed was being provided. People acknowledged that the staff were doing their best but felt that more was needed. People were not saying, "I have a part to play in my care. I am responsible for my health."

A pathologist spoke to me recently of his despair. A cervical smear came through on a patient who had developed cervical cancer. The pathologist looked back through the records and discovered that the patient had had a cervical smear carried out on two occasions. On both occasions, two or three years apart, it had been demonstrated that there were changes of a dangerous sort occurring. "But", the note went on, "the patient is not keen to come for a review appointment." If the pathologist had made a mistake and had not noticed that situation and the patient had subsequently died of cancer, there would have been national outrage. A committee of inquiry would have been instituted immediately. Sadly, the problem was that the patient did not feel responsible for her own care. That is a problem which exists and we must pay attention to it.

On the other hand, there are those who say that the service is not sustainable; that it costs too much; and that the financial question must be introduced. The problem is not that finance is not a significant consideration because of course it is. That is the reality. The problem is that finance was introduced as the motivation and not a consideration. The market was introduced as the mechanism for making decisions about the distribution of healthcare. The money was not an issue for the person receiving the care. Patients still do not know how much their care costs. They still do not look at that as an issue for them; it is a matter for doctors and nurses. Even more it is a matter for managers, accountants and, perish the thought and worst of all, the

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inevitable management consultants who are brought in who can always find something to do, something on which to advise. Frequently, it is another review carried out by another set of management consultants.

The problem is that the community as a whole does not see what is happening in terms of responsibility. I have often felt that rather than producing accurate bills which could then be used for contracts we would have achieved much more in our health service if we had produced less precise bills but handed them to all patients as they left hospital with a big stamp saying, "Your bill has been paid by the community as a whole." In that way we would all know that we were sharing in the responsibility of dealing with our care.

Money is a consideration. It should never have been introduced as a motivation. People do not go into healthcare to make money. They need to make money to live and they deserve a reasonable lifestyle. But the health service did not come from businessmen setting up healthcare. It came from people with a vocation--from the Churches, charitable bodies and others. It came from people committed to the care of others.

What does that mean in terms of how we might further develop that care? We must consider the ethical dilemmas which face us in a major way because we can now do things which are disturbing for us to think about. We must make decisions in relation to where we should put our resources, which areas of care should receive more resources and which areas of care must be left to be dealt with in another way. We must consider the general question of how much money we should put into healthcare. We should not pretend to the community that there is a bottomless pit of resource; that every problem can be resolved; and that if anyone falls ill or dies, it is someone's fault.

Nor, on the other hand, should we suggest that if you happen to fall ill and you are vulnerable or poor it is your problem and you should earn more or find someone else to contribute. Rather, as a community we should work together on those decisions; struggling with the ethical tensions, deciding how much money to put in. That is why my right honourable friend in another place talked about that dreadful phrase "hypothecation of taxes." We must take responsibility for our future and our healthcare, our health service, the welfare of the community and all the rather precious individuals within it.

3.39 p.m.

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