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Baroness Young of Old Scone: My Lords, I add my thanks to my noble friend Lord Hunt of Kings Heath for his excellent introduction to this important debate. I have a particular thrill in wishing the National Health Service a happy 50th birthday as this year I am also 50 years old. I am three days younger than the National Health Service. Unfortunately my mother miscalculated and booked into a private hospital for my birth. Therefore I was cheated of my NHS birth, but I have been a proud customer ever since and have worked for 20 years in National Health Service management.

Therefore the National Health Service and I are both middle aged, but what a middle age! She is a decidedly active 50 year-old and still has tremendous "oomph", but she has that touch of wisdom gained from her years and she is much loved by those for whom she has worked hard and tirelessly for 50 years. On the odd occasion she has a bad day. Middle-aged women sometimes have bad hair days, whereas the NHS has bad bed days!

I shall discuss some of the old chestnuts that have beset the health service over the years and discuss what hope we have for the future. First, is the health service a service for health, or is it only a sickness service? When I used to manage health districts I became rather confused as to how I judged whether I was performing a good job. Was it a good thing to treat more people, or did that show that the population I was trying to serve

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was becoming sicker? We should of course be trying to achieve a healthier population and an improved health status. However, after 50 years we are still dependent not necessarily on what the NHS can achieve by way of healthcare, but on completely different issues.

The reforms of the NHS signalled in the White Paper cannot just continue to improve the effectiveness and efficiency of healthcare, but they must tackle, or at least work in tandem with, three other issues. The first issue is that of lifestyle. I worked in St Thomas's health district and drew up its first strategy for healthcare. Yesterday's announcement on the pattern of health services in London appeared to endorse that study that had been drawn up 15 years earlier. Everything has its day. But the professor of general practice in those days was asked to write a "forward look" for the people of Lambeth. He began with the epic statement that the health status of the people of Lambeth will never improve until they cease to abuse themselves with sex, nicotine and alcohol. So we have some way to go towards improving lifestyles through a variety of processes, not least education. However, we have also to tackle issues of poverty, unemployment, homelessness and social exclusion because those are the major determinants of the health of the population.

A third set of parallel issues is now beginning to impact more clearly on healthcare. They are environmental issues, air pollution and childhood asthmas, air pollution and cancer, water pollution, the need for environmentally safe food, and the need for sustainable ecosystems. We have to seek environmental improvement if we wish to see good health status as well. I welcome the forthcoming Green Paper on public health. I hope that it will tackle all three of those strands.

The second chestnut is that the NHS is always short of money. It is always short of money. I feel rather like the chap who fell asleep on a hillside and woke up 110 years later. Every time I dip my toe into the health service again, having been away from it for eight years, I still hear about beds, cash, nursing crises, and A&E departments full of patients on trolleys. Since the early 1980s we have heard that that was the ultimate crisis which would propel the National Health Service into cataclysm.

The real question is this. The health service is short of money, but how short? Over the past 50 years, by chance in this country we have stumbled across a unique system of managing healthcare that is cost containing. It is, and has been for many years, the envy of other countries which fail to stumble upon the system, in particular the United States of America where the health system costs twice as much yet still leaves 30 million people uncovered by healthcare.

We have benefited from that happy stumbling upon a system that controlled costs. But as a result of successive financial squeezes we are now running a system which has small financial tolerances. There is little room for error in the system. Even small mistakes in the way that patients are dealt with, or services provided, can provoke disasters. I do not talk of major disasters but the disasters that noble Lords or their relatives experience as individuals. Those experiences are truly disastrous for the individual. I cite, for

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example, patients spending 24 hours on a trolley in an A&E department; an operation that one has dreaded for months and has wound oneself up to go through being cancelled three times; long waits for cancer checks when one does not know whether one is positive or negative; and no place of asylum for an acute psychiatric patient in extreme breakdown. Those are personal disasters for the people involved.

I do not wish to focus on those to the exclusion of everything else because 95 per cent. of people who go through the health system have a good experience. They are well treated technically and personally. But we cannot ignore the 5 per cent. who are not so well treated. At present the root of the problem is the fact that we still spend 30 per cent. below the OECD average on healthcare. We spend a lower sum partly because the system has been naturally cost containing in the past; and that is good. But comparatively small sums of additional funding could make a disproportionately huge difference to that 5 per cent. to whom the health service does not provide a good service.

The White Paper flags up £1 billion which can be redirected from the transaction costs of the internal market to improved healthcare. I welcome that. We need to take great care in managing that money across the system into healthcare; and it will take some time. The White Paper also indicates the possibility of improvements in clinical effectiveness and better direction of funds on clinical grounds. Again I applaud the measures in the White Paper for that. However, at the end of the day we come down to this question: will £1 billion extra into care, and efficiency and effectiveness savings be enough? Having made those changes, if that small number of patients still have a very poor service, we must seriously examine our consciences to see whether as a nation we wish to continue to be the poor relatives of the OECD countries in terms of investment in healthcare.

I have one last point to deal with as an ex-NHS manager otherwise I shall no longer be invited to dinner parties! I refer to the question of NHS bureaucracy and the fleets of administrators that it has always been claimed are wandering around the health system. When I began managing health systems in 1971, I ran a 500 acute bed teaching hospital in Glasgow. Two and a half administrators ran it. We did not run it; it ran us. We managed the odd support service. We did a few things to keep the doctors happy. But, generally speaking, the system managed itself. I did not think that that was good. We were only able to get away with that at that stage because we were seeing increases in funding on a year-on-year basis. We were buying ourselves out of trouble most of the time. I worry that the NHS White Paper will fall into the ready trap of management bashing. There are costs to be saved, in particular from the high cost of running the internal market. But the health system is large, important and complex. It is close to the real needs of individual human beings. It needs to be managed effectively if it is to make the changes flagged up in the White Paper, and continue to develop increased quality and effectiveness.

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I conclude by saying that I think that the NHS is pretty frisky at 50. She is a precious national friend, and with a bit of that NHS commodity, tender loving care, both she and I will look forward to another 50 glorious years provided that as a nation we can resolve the issue of how much we want to spend.

4.6 p.m.

Lord Jenkin of Roding: My Lords, as I listened to the noble Baroness, Lady Young, speaking, I realised that the National Health Service is quite young. I enjoyed very much what she said. I, too, thank the noble Lord, Lord Hunt of Kings Heath, for the opportunity to have the debate.

I have a somewhat unique perspective. Almost 25 years ago I began to shadow the Department of Health, helped by my noble friend Lady Knight of Collingtree, who was a splendid member of my team. I much enjoyed the noble Baroness's maiden speech and congratulate her on it.

I subsequently became Secretary of State. For two and a half years I was responsible for the National Health Service. More recently I have chaired an NHS trust, from which job I retired at the end of November, so I think that technically I do not need to declare an interest. However, having had that double perspective over nearly half the lifetime of the health service, it is worth sharing a few thoughts on the subject with noble Lords.

In the early days it used to be said, "For goodness sake, can't we take the NHS out of politics?" We do not hear that said today. Today's generation of managers and doctors is a great deal more realistic and less starry eyed. That came home to me yesterday when I chaired a seminar run by the University of Manchester health unit for chief executives of trusts. It had asked me to describe how the political and professional interface works. How does it work? How does one have on the one side Ministers and Parliament, and on the other departmental officials and the managerial, professional and clinical staff? To prepare myself, and to remind myself how the system worked, I went back to the department and asked to see some of the old files which were brought into being in 1979 when I became Secretary of State. I found them fascinating. I remembered some of the contents, but most had gone from my memory. Perhaps it is not wholly irrelevant in the context of this debate to share my findings with the House.

We inherited a totally "top-down" service, structured in such a way that not only did the money flow down but so did an enormous amount of instruction. It was a command and control system. However much people wanted to see decisions made locally, the managerial and professional hierarchies that existed then had the inexorable effect of sucking decisions away from the place where patients were looked after up into the higher levels of the service--from the units, through 200 district health authorities, 90 area health authorities, 12 regional health authorities, and so on, up to the DHSS. That "suction-pump" effect was brought home to me clearly as we studied the service when in opposition. We pledged ourselves to try to return more

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decision-making to the levels where patients are looked after. We saw it as an essential part of the improvement of the service.

The files showed that a day or two after the election I handed to my department a substantial folder of documents with a clear statement of our policies and priorities, a list of public pledges and a big bundle of policy reports on which my honourable friends and others had worked in opposition. In turn, I was handed the usual position statements by the department. They were not quite so thick as my bundle, but probably a great deal better written. The problem over the next two or three months was to marry those two inputs into policy. I found particularly interesting the summary of the policy that I asked the department to introduce. In the light of subsequent history, it bears repetition.

Accountability to Parliament was to remain at the heart of the system. We rejected the recommendation in the Royal Commission report that the service should be a corporation, rather like a nationalised industry. We intended to abolish the area health authorities; the districts were to become,

    "largely autonomous bodies, carrying so far as possible total responsibility for using all the resources at their disposal to provide the most appropriate service required by their local communities".
I wanted to see the region as "a co-ordinating tier" carrying out strategic planning, collecting information, allocating finance and being responsible for regional specialties. I saw no reason for regional health authorities. But, I have to say, it took me and my successors a good many years to get rid of them.

In management, I wanted to maintain consensus at district level, but with much stronger management at local level, the local manager with the chairman of the medical committee and the senior nurse occupying the key managerial roles at local level. Functional management should be accountable to general management. That was not the case when we took over; there were functional hierarchies. I was once told by a member of the Association of Hospital Porters that there should be a "regional hospital portering officer." That is true. I told him that that was not an election pledge we were prepared to give. I wanted to see the highest salaries paid to those who were doing the most responsible jobs at local level. I get very cross when the newspapers and the Labour research group castigate senior health service managers who are doing an enormously difficult job because they are paid a sum which they believe is too great but which is still very small compared with payment for comparable jobs in the private sector. I wanted consultant contracts held at district level. Again, that took some time, but we achieved it. I wanted to save money on management. That is the sort of refrain that runs all through the documents.

But all of that had to be accompanied by a much more effective system of monitoring for quality--the noble Lord, Lord Hunt, referred to "quality assurance"--to ensure proper standards of care. And of course I insisted that the Secretary of State would still set national standards and priorities--because, as a number of speakers have said, this was a national service. The rest

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is history. Virtually all of that has happened. It took some time. I did not achieve it all during my two and a half years. But all of it has come about.

So when I became a trust chairman in 1991 I had a worm's eye view. There we were, running a very devolved service with a high degree of local autonomy, able to take major decisions off our own bat using the resources that we had at our disposal and able in many ways to run a much more effective service.

But, as the right reverend Prelate remarked the change was very difficult for professionals in the health service. Huge cultural changes were needed, and it took time. But we did see clinicians become responsible for major management decisions. In my trust almost all the service directors were clinicians by the time I left and were taking responsibility for their contracts.

Much has been said about the internal market, to my mind a great deal of it exaggerated. It was never more than a managed market. In our part of north-east London we were sharing all the information with our health authorities and GP fundholders. We were withholding nothing. We were collaborating, and long before Mr. Dobson's White Paper. Part of the problem is that too much is claimed in that White Paper.

I wish to draw attention to two developments of enormous importance. The first, which is comparatively recent, is the emphasis on outcomes. I welcome that. The noble Lord, Lord Hunt, talked about clinical audit and clinical effectiveness. All that is hugely important. It is again now being accepted by clinicians as a matter to which they have to pay attention. I refer to the Cochrane collaboration and so on. The other is public expectation. The public in our part of London have just raised half a million pounds for an upgraded special care baby unit. Public attention and criticism there may be; but public support for the NHS is certainly evident.

4.17 p.m.

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