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The Lord Bishop of Birmingham: My Lords, I must begin by, first, thanking the noble Lord, Lord Hunt of Kings Heath, for introducing this very timely debate. I am sure that we can think of no one better qualified than he to have done so. Secondly, together with the noble Lord, Lord Alderdice, I must congratulate the noble Baroness, Lady Knight of Collingtree, on her maiden speech in this House. It is a particular pleasure for me to find myself doing so, not simply as the third speaker from Birmingham, as it happens, but because I in fact live in the constituency which she represented with such distinction for so many years. It has been marvellous to have her as a friend. Thirdly, I must

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declare something of an interest not only as a patient but also my late wife worked for the National Health Service for 30 years and both my daughters now work for the NHS, one on the managing side and one as a doctor.

The National Health Service is a standing refutation of the notion that governments can do no positive good. It is a product of ideals translated into policy and practice. It also shows that there are some things which, for the sake of the common good, can be done only by governments. They cannot be left to private or voluntary initiative alone. As we have already heard, the NHS is indeed an amazing institution--an institution so secure in the affections of the people of this country that no politician, even when he or she has apparently been chipping away at the foundations, has ever dared to suggest that he or she was doing anything other than strengthening it.

It is striking that people's deep affection in general for the NHS remains apparently untouched by their particular experiences of things going wrong. In the present culture of blame and complaint, it is worth remembering that, while some bad experiences are a direct consequence of individuals not doing their job properly, far more often they are symptoms of a system which is under great strain.

Of course, the possibility of clinical or managerial bad practice can never be entirely eliminated. It is one of those issues which has to be addressed again and again. Indeed, as we have already heard from the noble Lord, Lord Hunt, it is the same with one of the basic issues which prompted the establishment of the NHS: how are we to provide for equality of access to the best possible provision of healthcare for all? Fifty years ago the inequalities were shameful, and 50 years later the problem is still with us. It has to be addressed again and again.

If one looks back over the past 20, if not the past 50, years of the NHS, one is struck by the phenomenon of almost continuous change and reorganisation. That has partly been caused by changes in political and managerial fashion; partly by advances in medical practice; and partly by pressing questions about the availability of resources. There have been ups and downs but undoubtedly there have been improvements. I shall mention only one--the developing culture of accountability. It is right that practitioners should not only be professionally accountable but that they should also be accountable for the consequences of their decisions in terms of their use and material resources.

There is no point in looking back without also looking forward. So what about current proposals? The recent White Paper is, I believe, to be welcomed, not least because it represents development rather than revolution. In thinking about its proposals, I hope that the Government will be able to reassure us on three particular points.

First, there can be no doubt about the rightness of the emphasis on primary care. But can we be assured that that will be adequately resourced? I have in mind not only financial resource, but also medical, nursing and

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other personnel. In my own city of Birmingham we are faced not with a rise but with a cataclysmic decline in the number of general practitioners in the next few years. How is that trend to be reversed? Further, if there is to be no substantial overall increase in funding, how will developments in primary care be adequately resourced without taking resources away from other parts of the system? We need some openness on that point.

Secondly, can the private finance initiative really deliver what is asked of it? Birmingham certainly needs the rebuilding of one, if not two, of its major hospitals. Can this really be done through the PFI without putting intolerable burdens on the delivery of the services which those hospitals would be expected to provide?

Thirdly, there is the question of how to handle change. I hope that lessons will be learned from the experience of recent years. I know, both from personal contacts and still more from what chaplains have told me, about the terrible pressures which are being placed on managerial and nursing staff who have had to continue to deliver care to vulnerable people while themselves being made to feel personally insecure. That was not good for patients, nor was it good for professional morale or recruitment. I hope, therefore, that questions of staff morale in a time of change will not be forgotten. In saying that, I deliberately mention managers as well as clinical staff, because I believe that managers are too easily underrated or even denigrated. If the system is to run well, we need the best possible managers and they, like everyone else, deserve appreciation when it is due.

It is worth asking why change is so hard to manage in the NHS. Why does the prospect of change provoke such high levels of anxiety? Why is rational discussion so quickly overlaid with disproportionate feeling? I believe that health is an area in which all of us feel naturally insecure; an area in which we crave assurance and certainty. We need to know that the doctor will be there when we need him or her. We need to be assured that the hospital is there when we need it. Those who are responsible for change need to reflect, among other things, on the symbolic function of a hospital in a community. People need to know that it is there, rather like a cathedral or a parish church. If a hospital is felt to be threatened, it feels as if a whole community is under threat.

All of that means that proposals for change must be handled with very great care. Reasoned argument is not enough. In this area of life, people are not simply reasonable. They need assurance as much as they need argument. Those who are responsible for proposed reform must take the people with them--which is not the same as succumbing to the meretricious rhetoric of, "Let the people decide". What is at issue today is whether our successors in 50 years' time will be as grateful to this generation as we are to those who established the NHS 50 years ago.

3.47 p.m.

Lord Winston: My Lords, the whole House will be in debt to my noble friend Lord Hunt for introducing

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today's important debate. It is a great pleasure and, indeed, a privilege for me to join in this tribute to the remarkable work of the health service over the past 50 years. Although I believe that the little red book tells us that it is not customary for mention to be made of a maiden speech in every following speech, I should like to be the first from these Benches to pay tribute to my noble friend Lady Knight. She and I have had some differences of opinion about certain areas of healthcare in the past. However, it has been a great pleasure to listen to my noble friend's maiden speech today. I am sure that there will be other times when I shall have the pleasure of arguing with her, but not on this occasion.

Instead of dealing in macro, as previous speakers have done, I should like to concentrate on two issues which are slightly more in micro and which were raised by the White Paper. In fact, the whole issue of the health service is such a large one and the White Paper is such an excellent document that it is difficult to know where one should focus. I hope that my noble friend the Minister will forgive me if I seem to raise some spectres in my short contribution to the debate.

There are two issues which will be of great concern. They were raised partly by the White Paper and partly--inevitably--by the conduct of the health service as a whole. First, the remarkable management of the health service proposed in the White Paper is not, I believe, possible without a radical change in our thinking as regards information technology. It seems to me that the key to implementing much in the White Paper will depend on taking a fresh look at the way we handle information in the health service. There are essentially three different kinds of information which come to mind. The first is information to the average doctor. The White Paper makes mention of the NHS Net, which is an excellent idea. The Government have made a commitment to invest in that which I welcome. However, I am quite certain that that on its own will not be sufficient.

Secondly, information to patients is a different area entirely. One of the good aspects of the health service which has endured under successive governments has been the remarkable way it has become much more in tune and focused to patients' need for information. That is still happening. I should have declared an interest at the beginning of my speech as I am an academic medic working in the health service and in the university sector. We, as doctors, have become much more attuned to explaining matters to patients, but there is still much more work to be done. Information technology is one way of achieving that. I do not believe for a moment that a computer print-out or a printed document will ever replace--God forbid!--face-to-face contact between doctor and nurse and doctor and patient, but the documents help to implement the exchange of information.

The third issue is one which is dear to my heart. It is a completely different and more expensive aspect of information technology; namely, the communication of digitised information. We have a remarkable opportunity here. It is now possible to communicate vast amounts of information down a telephone line. Over the next few years we shall see not ISDM, which will be

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completely out of date, but the ability to transfer eight, perhaps 10 megabytes of information rapidly down a telephone line. Provided that one is within a few miles of an optical cable, it will be possible to show operations in real time; to show endoscopic photographs; to show X-rays, and to report on X-rays in Wales when one is in London; to look at an ECG monitor in real time and to look at ultrasound photographs. I believe that will revolutionise the way that we communicate and exchange information in the health service. However, the provision at present is woefully inadequate.

I perform laparoscopies regularly. Those operations depend purely on a visual inspection down a telescope. At the moment in 90 per cent. of cases doctors do not even have a still camera which will record a simple photograph. We must rethink how we record this kind of information. It is possible and the method of doing it is not particularly expensive, but the whole system clearly needs to be reviewed and a proper systems analysis carried out. It is clear that data collection in hospitals is woefully inadequate. I work in a hospital which was one of the first to have a computer terminal in a clinic from which we could obtain results, but that is still an incredibly slow and inadequate system. There needs to be a re-evaluation of how best to do this.

Another example of inadequate provision was highlighted this morning during discussion in a Select Committee. I hope it is not inappropriate to discuss the results of our investigation into microbial resistance. There is a potentially serious problem here with bacteria that are becoming increasingly resistant to antibiotics. We do not know the scale of the problem because we do not have the information technology in place to work it out. Organisations such as the Public Health Laboratory Service are underfinanced and cannot install the kind of information technology that we need at the present time. The Government will need to consider how we can achieve this investment in the health service. It seems to me that this is a golden opportunity for PFI in that we could sell our ability to read digitised information to other countries. There are remarkable opportunities here for the development of the health service.

I wish to discuss briefly academic medicine in the time that remains to me. There has been a magnificent relationship between the NHS and the universities. Indeed the university sector has provided a major part of healthcare in this country and it has been responsible for some remarkable developments, not all of which, unfortunately, have been capitalised in this country. I refer to CAT scanning and ultrasound. Is it not sad that all those machines are made in America, Japan and Germany? I refer also to renal dialysis and heart lung machines. I refer to my own field of in vitro fertilisation which the health service initiated. The list is endless.

However, there are serious threats to academic medicine. Threats are posed by the fabric of our buildings and the underfunding of universities. The research assessment exercise has meant that often certain departments which must provide a service cannot undertake competitive research and maintain a four or five rating in terms of the exercise. Therefore universities are finding it difficult to support those departments. We need to look at that issue.

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The NHS has depended on centres of excellence. The White Paper has omitted to focus on how those centres of excellence will interface with the national centres for clinical excellence. We have a series of national centres for clinical excellence which carry out remarkable work. The internal market resulted in a loss of autonomy of patients to visit the best centre. Some years after the introduction of the internal market I still receive letters from 50 patients a week who write from all over the UK explaining that they cannot receive the relevant treatment locally in Bradford or Aberdeen and asking me whether I can treat them at Hammersmith under the National Health Service. They do not understand that I cannot do that. The internal market has resulted in a loss of best practice for patients and a loss of critical mass of practice so that we cannot carry out the best research trials because we no longer carry out large competitive trials which used to enable us to compete with any country in the world. At one time when I visited the United States I could show people large studies which the Americans could not undertake because they were so private practice oriented. There has also been a loss of adequate training to pass on these developments to other major centres.

This White Paper focuses on primary care, as it should do, but we must not forget that many of the basic elements in the development of healthcare have concerned such issues as endocrinology, immunology and now molecular biology, cellular biology, neurosciences and other such issues. These studies will make important contributions to the way we continue to improve the health of the nation.

3.58 p.m.

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