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Baroness Gould of Potternewton: My Lords, I too offer my thanks to my noble friend Lord Hunt for initiating this important debate on such an historic occasion. I wish to concentrate my few remarks on the health of women. There is no question that over the past 50 years enormous achievements have been made in identifying, preventing and treating women's health needs. It is not possible to present a history of the advances made, as I should have liked to have done, mainly because it has taken time for there to be a recognition of the variations in the health cycles of men and women, except, of course, in relation to maternity care. But these variations are an important factor in the provision of services and the attitude of health providers.

In the short time available I wish to look at four areas and their requirements for the future: breast cancer, cervical cancer, osteoporosis and domestic violence. Enormous changes have taken place over the past 50 years in these areas but there is still a long way to go.

This country has one of the highest incidences of breast cancer in the world. It is the single most common cause of death in women. One in 12 women have a lifetime chance of developing cancer. Every year there are nearly 27,000 new cases, and there are more than 300 deaths a week. The Government's action in releasing £10 million for breast cancer diagnosis for an extra 100,000 patients is welcome; but there are still not enough breast cancer specialist units and breast cancer nurses to provide adequate treatment and aftercare. And of the 90 per cent. of women diagnosed, the cause remains doubtful. Rapid advances have been made in looking at the causes of cancer, but the research will take a long time. Finding better treatments, methods of prevention and certainly a cure will still take many years.

What is without doubt is that the earlier breast cancer is diagnosed, the greater the chance of successful treatment. Early detection is therefore crucial and screening remains the best means of detection--screening which, I firmly believe, should be available to all women irrespective of age. I am now in the category and age group where I no longer receive automatic screening. The cut-off date of 65 for automatic screening raises the false assumption that somehow the risk is diminished. Yet it is maintained that half of all women with breast cancer are over the age of 65. Women need reassurance that they are not at risk. And there is evidence to show that the lack of prompting means that there is a lower take-up among older women. I appreciate that the Minister recently indicated that there is to be no instant change to that policy. But I ask whether there is any prospect of future change.

I do not wish to dwell on recent incidents because, in spite of the appalling mistakes made, cervical cancer screening is essential for early detection. The cervical screening programme offers a good proven test. It has steadily decreased the number of registrations for cancer of the cervix and there has been a 7 per cent. fall in the mortality rate. My noble friend was so correct in her appeal to women to continue to attend screening for

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both breast and cervical cancer. Nevertheless, women throughout the country must now have reservations about the reliability of the system. Their confidence will be restored only when they see the success of the changes being made to improve the service and the elimination of the current unacceptable variations of provision in different parts of the country. Health professionals will need to communicate sensitively and be aware of the intense anxiety screening may sometimes generate.

To look briefly at the problem of osteoporosis, the financial burden is escalating towards £1,000 million each year--a figure that will continue to rise with the ageing of the population. The NHS is faced with having to provide the treatment for one in three women who will be affected by osteoporosis. Around half of all women over 65 will be sufferers and one in four women over 70 will have an osteoporosis-related fracture. Hip fractures make up 90 per cent. of the cost of osteoporosis care.

That does not have to be the case. Osteoporosis is preventable and treatable, but successful treatment depends on successful diagnosis. All too often a fracture is the first indication of the condition. Screening, not generally recommended, should be offered to those women at risk--where there has been early menopause or a family history of the condition. Again, currently fewer than 20 per cent. of health authorities have a strategy for dealing with osteoporosis and, in spite of the degree of suffering and disability, only one in 10 patients are receiving adequate treatment.

Osteoporosis used to be seen as an inescapable factor in the ageing process but now there is a growing public awareness that it is a preventable disease, thus raising expectations of early and better access to prevention. One hopes that a higher degree of co-operation and partnership between primary and secondary care, as outlined in the White Paper, will be a step towards meeting those expectations. That will not only relieve the suffering of many but will save the NHS millions of pounds.

Lastly, I come to the subject of domestic violence--not usually talked about in a health debate, but it is a public health issue; it is a women's issue and a crime issue. The vast majority of domestic violence sufferers are women. It accounts for 25 per cent. of all reported crime. But it is also clearly a health issue. The first port of call for many of those women is either their GP or an A&E department. As well as their physical injuries, domestic violence victims are more likely to have poor general health, depressions, addictions and difficult pregnancies and to attempt suicide. That raises considerable implications for the health service, not least that of cost.

Apart from raising public awareness of the extent of the problem, we must ensure that health and social care professionals are trained to recognise and deal with the problems such violence creates. But alongside that there is the need for a co-ordinated national strategy, extending across medical and social agencies, professionals and voluntary groups. It would be helpful if my noble friend in her reply could update the House on government action being taken.

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If time had permitted I would have examined many other key areas of health that affect women, including HIV/AIDS in pregnant women, heart disease, contraceptive provision, the problems of black and Asian women and also the problems of mixed wards--a question so eloquently dealt with by the noble Baroness, Lady Knight.

The NHS must ensure that gender sensitive health services are provided for all. It must identify and meet the specific needs of women from minority cultures. It must continue to ensure that provision and uptake are maintained and, importantly, that there is adequate training for healthcare professionals so that they can respond to women's physical and mental needs.

As the Government recognise, health is not only about health services, but also about lifestyle--as referred to by my noble friend Lady Young of Old Scone--poverty, environment, unemployment, bad housing and social isolation. Improving health is a matter for interdepartmental co-operation by government and liaison at local level between local authorities, community groups and industry. Only if we understand that can we truly hope to have a society which promotes services which are equitable and gender sensitive and which promote the health and physical, mental and social well-being of all, as was envisaged by those health pioneers 50 years ago.

4.37 p.m.

Baroness Gardner of Parkes: My Lords, I open with the traditional thanks to the noble Lord, Lord Hunt, for introducing this debate.

The 1948 introduction of the National Health Service was a brave step and there was a great need to improve the health of the nation. Much has been achieved and treatments routine today were not even dreamt of 50 years ago. I was one of many Australian dentists who came to Britain to meet the need for enough dentists to provide national health treatment for patients. My arrival in London was in 1955 and by that time charges for national health treatment already applied. A full set of false teeth cost the patient 30 shillings.

In the 1950s and 1960s we extracted hundreds of teeth every week in our surgery. Patients used to say, "I might as well have them out now as they've got to come out sooner or later". The condition of many teeth then made that a fairly realistic statement. In the north of England a full set of dentures was a common 21st birthday or wedding gift. Those were the days when the surveys showed that most people bought one new toothbrush every year--when they were going on holiday. At that time they would buy a new toothbrush and a new pair of knickers. They were not concerned about dental treatment, but did not want the toothbrush to look bad in the bathroom when they were away.

Today's London dentist rarely takes out a tooth. Teeth are now for life. Dentistry has been one of the major success stories of the National Health Service. The new Swedish gel treatment for caries--tooth decay--claims to remove the need for any drilling at all and fissure sealants have been in use here for years. But in spite of all those remarkable advances, I have a real concern

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about the future of dentistry. Why is it that so many patients are unable to find a national health dentist? Why are this Government, the members of whom, in opposition, supported my amendment, passed in this House and reversed in the other, to retain free dental examinations, doing nothing now?

Above all, it is the children's teeth that we must care for. Today's children represent the future and we must not allow dental health to regress. There are many children in areas of deprivation who receive no dental care at all and who would not dream of going to see a dentist. These are the children we must reach with our treatment now. Their only real hope of general dental improvement is the introduction of fluoride to the drinking water.

I have been checking the situation in some of the regions. The West Midlands has the best d.m.f.t.--decayed, missing, filled, teeth--in the UK for the under fives. The north west has the worst! Birmingham introduced fluoride to the water system in 1964. I note that we have had two outstanding speakers from Birmingham today--the noble Baroness, Lady Knight, and the right reverend Prelate--and I am not sure whether the noble Lord, Lord Hunt, has a Birmingham connection. I know that if the noble Baroness, Lady Fisher, were here she would strongly support what I have to say. Birmingham supports water fluoridation and has seen the great benefit to the community.

As I fought a parliamentary election in Blackburn in 1970, and saw the reference in the Observer last Sunday to the fluoride debate there, I had inquiries made in that area. The manager of the community dental services estimates that as many as 100 children a week have teeth extracted under gas anaesthesia, something which I thought was a thing of the past. Many of these children have all their deciduous teeth removed. It is outrageous that children's teeth are allowed to deteriorate to this extent when fluoridation of the water supply could do so much to avoid the pain of tooth loss, the damage to the spacing of the permanent teeth and, very importantly, the psychological damage for those children going to school for the first time in a toothless, gummy condition.

Those who oppose fluoridation do so on an emotional basis. Fluoridated water has long been in use in Australia. It commenced in Tasmania in 1953 and in Canberra in 1964. Canberra is the seat of government for the Federal Parliament and the early introduction of fluoride to the water supply shows that the Australian politicians had great faith in it. It has been justified dentally and no adverse health effects have occurred over what is now a long period. I ask the Government to introduce fluoridation of water supplies throughout Britain at the earliest possible date.

There is time to comment briefly from my much wider experience in the NHS. I have served at most levels on local committees and hospital boards. I was chairman of the Royal Free NHS Trust for over three years, until November last year. That was a most satisfying experience, at the sharp end of the NHS, and I was very privileged to have that position. This very afternoon the newly rebuilt out-patients department is

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being opened by His Royal Highness the Duke of York at the Royal National Throat, Nose and Ear Hospital in Gray's Inn Road, which has now become integrated into the Royal Free.

Morale in the health service is very important. As a dentist, and again now in the nurses' case, I have seen the pay review body's recommendations either ignored or phased in by successive governments. I deplore that. It is very hard for dedicated National Health Service staff to see private sector pay rushing ahead of their own.

As joint chairman of the All-Party Osteoporosis Group, I must mention the importance of the growing awareness of osteoporosis. Indeed, I do not need to say anything more because I was so impressed by what the noble Baroness, Lady Gould, said on this subject. Last week, at a meeting we had here in the House, researchers came to speak about it. They made the point that the noble Lord, Lord Winston, made. One speaker from University College made the point that it is difficult for researchers on one site to know what is being done, although they know work is being done, at Bart's. It would be desirable to have information technology or databases to let people know exactly what was happening at the other site.

We spend an unbelievable amount of time on compiling statistics. We should try to find out how many of them are really useful and try to assess which ones are valuable and which are not.

The Corporation of London has asked me to say that it welcomes the news that some services will continue on the Bart's site. I am pleased to be able to say that my dental practice was in that area for 35 years. In that time there were dramatic health improvements for local residents. The City Corporation's view is that:

    "Adequate provision for emergency treatment is manifestly important ... the upgrading of the current minor injuries clinic provided at the Smithfield site must be considered as part of the implementation process".
In its letter the corporation points out that the City has a very small resident population and a large day-time population, a situation which is quite different from other parts of London. I know that from my own practice there.

There is so much to say about the NHS and little time to say it. I should like to comment on two linked major problems at the present time. The first is the ever-rising costs of the new and exciting drugs and treatments being developed and introduced. The second is expectations. Other noble Lords have made this point too. Treatments almost magic in the results they achieve are available today. Everyone hears about them and wants them and expects to have them. No government can provide unlimited resources. Current and future expectations will be almost impossible to satisfy. The present Government will need to assess health priorities carefully and ensure that whatever budget is available is spent wisely and fairly and without waste.

4.47 p.m.

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