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Lord Colwyn: My Lords, this is another in our series of debates on this subject. I too should like to thank the noble Lord, Lord Hunt of Kings Heath, for initiating the debate this afternoon. In our debate on 6th November 1996 again to call attention to the 50th anniversary of the NHS--which I believe coincided with the 50th anniversary of Royal Assent--the noble Baroness, Lady Jay, promised the House that a new Labour government would restore the NHS to its public service vigour. She said:

She said that there would be substantial increases in funding under a Labour administration.

The Times last Monday also announced massive increases in funding. Under the headline "NHS to get £2 billion extra each year" it reported:

    "Tony Blair is planning a permanent increase of between £1.5 billion and £2 billion next summer to coincide with the fiftieth anniversary of its creation".

The implication of statements by successive governments has always been that they will ensure that the NHS has sufficient funding. Reference to funding of the NHS is probably mentioned one way or another every single day on radio, on television or in the newspapers. But are we really talking about health or

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something else? I make no apology for repeating something that I have said in this Chamber on many occasions. Public debates on the NHS rarely concentrate on health but on the nature of funding, the provision of services, the appropriateness of cuts and the conflicting claims of private and socialised medicine. They have consistently ignored discussion of the more fundamental issues, above all the question of whether changes in the financial structure in the medical services will result in improvements in the health of the population as a whole.

The assumption that greater availability of medical services, more doctors and health-related personnel, the construction of more hospitals and clinics and the development of a wider range of drugs and surgical techniques, will lead to improvements in health, increased longevity or the eradication of disease is ill-founded yet widespread. In its 50 years the NHS has been a wonderful example of an emergency service--a sickness service--but has had very little to do with health. In our debate on poverty and ill health, introduced again by the noble Baroness almost exactly one year ago, I said I thought that the greatest advances in the promotion of health during the 20th century had been due mostly to the installation of efficient plumbing and drainage systems. I am delighted that the noble Baroness, Lady Jeger, in her marvellous contribution this afternoon agreed with that. Sadly, the incidence of chronic illness is still rising. Instead of focusing on health, the NHS has concentrated resources on illness and encouraged a general increase in the use of synthetic pharmaceutical drugs.

When introducing a debate on poverty and the NHS I believe that the noble Baroness agreed with me when she said:

    "But good health is about more than the NHS. It is about how we live. It is about the kind of country we are. It is about what priorities we give to things like proper childcare, to worthwhile employment for school-leavers--and, indeed, for everyone of working age--to decent housing, to the environment and to building cohesive communities".--[Official Report, 12/2/97; col. 246.]

With present attitudes to health it is inconceivable to think that illness should be viewed as a helpful though often severe reminder that perhaps there is something at fault with one's lifestyle or attitude. It is precisely because this possibility has been ignored that so little attention is paid to the whole concept of health promotion. Health promotion is about the maintenance of good physical and mental health. It has very little to do with medicine and disease management and everything to do with the way people live and the social and psychological environments in which they do it. Millions of people in this country suffer unnecessarily simply because they are not being directed towards health promotion, early diagnosis and prevention, and--the noble Baroness will expect me to say this--natural complementary therapies which are safer, more therapeutic and usually less expensive.

I should now like to follow my noble friend Lady Gardner of Parkes and turn to my own profession of dentistry. Here it is a different story, with a dedicated profession spending much more time on preventive advice and, over the past 50 years, being responsible for dramatic improvements in the dental health of the

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nation. I am sorry that the noble Lord, Lord Hunt, was unable in his introduction to give a preview of his speech on 23rd April of this year when he is due to address the annual conference of the BDA on what will drive public spending on dental services into the future. The entire profession is waiting to hear the answer to this.

Since the fee cuts in 1992 morale has been low and there has been limited investment in new equipment and premises. The previous government tried to address these problems through reform of the general dental services, which was agreed with the profession and announced by the Minister of Health on 12th June 1996. At the same time he announced that he would be proposing amendments to the Dentists Act to allow pilot studies into different roles for dental ancillary workers and a statutory complaints scheme for private patients.

The previous administration also introduced measures to increase the number of NHS practices in Wales as well as in England. In the last days of the previous Parliament the primary care Bill became law, allowing the piloting of schemes to target resources where they are most needed. Over 100 dentists have expressed interest in this scheme and I understand that 25 will be funded to work up firm proposals which should start in October of this year.

The British Dental Association is active in bringing the problems of NHS dentistry to the attention of all political parties. Before the election the present Government promised to work closely with the BDA to identify ways of tackling the problems within the resource constraints that will inevitably exist. I quote from a response to the BDA:

    "Labour will want to discuss with the dental profession how existing resources can best be used to address the problems of NHS dentistry".
Can the noble Baroness confirm that her department is working with representatives of the dental profession to honour these pledges? Can she give any hint of parliamentary time being made available to allow amendment of the Dentists Act?

The BDA's General Dental Services Committee has estimated that by the end of this financial year £51.8 million less may be spent on patients than had been forecast when the reforms were introduced. My profession will be grateful if the noble Baroness can confirm that this amount and the savings which will become available as patients' registration with dentists is reduced from 24 to 15 months will be returned to the general dental services of the NHS.

The dental profession was delighted when the Labour Party recognised that oral health was an extremely important part of general health and promised to,

    "bring dentistry back into the mainstream of the NHS".
Yet in the White Paper The New NHS: Modern and Dependable there is virtually no mention of dentistry and only two references in the recent consultation document to a national framework for assessing performance in the NHS. Dentistry is once again being

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marginalised and the contribution of over 22,000 dentists who provide dental care for the NHS is not being fully recognised in this 50th anniversary year.

So how can the noble Baroness and her right honourable friend celebrate the past and look forward to the next 50 years? I have asked that Ministers should start to work with those who can deliver improvements in dental care. In general health care the Government must redirect some of their new funding away from the sickness element of the NHS and into some of the new initiatives that can now aid early diagnosis and provide treatment before people become ill. The Government must look forward 20 years or longer and use the skills and innovations of British biotechnology and bio-pharmaceutical companies. There is so much science and new knowledge available that can detect health problems before they appear as symptoms. I declare an interest as a director of a bio-pharmaceutical company which specialises in diagnostics and drug delivery. There are now available diagnostic devices and treatments that could make dramatic, effective cuts in the healthcare budget. The noble Baroness, Lady Gould of Potternewton, referred to osteoporosis, which is a perfect example of this.

The previous Government listened but sadly did not have the foresight or courage to understand that relatively small amounts of money spent on the integration of these techniques into the NHS now can save millions of pounds--and hundreds of millions--in the future. I am a passionate supporter of the NHS. The Government told us during the past 18 years what they would do. Let us see them keep their promises, but also listen to those of us who are trying to help them.

5.19 p.m.

Lord Desai: My Lords, first, I thank my noble friend Lord Hunt for introducing the debate. I add my congratulations to the noble Baroness, Lady Knight, with whom I worked as chair of the IPU for many years. It is a great pleasure to see her here, and I thank her for an excellent maiden speech.

The noble Lord, Lord Colwyn, said much with which I agree. I shall speak mainly about the future. We are celebrating 50 years of the NHS, but, as he put it, some of the attitudes towards the NHS are still mired in the past. Although there are differences across political parties about the internal market, they should all agree that the British people want to keep the NHS, and that no political party, when in power, will take it away. If we agree that, we can stop a great deal of day-to-day skirmishing, because it wastes a great deal of energy and diverts attention from the important problems affecting the NHS.

There have been three major changes over the past 50 years to which I wish to draw attention for future analysis. First, our society is much more multiracial than it used to be. Our society is much more open and democratic, in the sense that people want to participate in the decisions that affect their lives. Of course we are a much richer society, and we must not forget that.

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My noble friend Lady Jeger said that she saw patients from around the world. We have NHS staff from around the world. We must acknowledge the contribution made by doctors and nurses who come from Commonwealth countries. Their proud contribution to the NHS has been important. I was disturbed to read recent reports about racism in the NHS. When my noble friend replies, will she make it clear that the Government and British society will not tolerate racism in the NHS, especially towards its staff?

Multiracism does more than make a contribution, as it were, on the supply side. I argue, again in support of the noble Lord, Lord Colwyn, that notions of health are also culturally dependent. Our Commonwealth citizens bring to us notions of health and medicine which are much richer than those we are used to discussing. By its excellent service the NHS has prevented people from thinking clearly about health. We say to ourselves that we do not have to think about health, because the NHS exists. That is partly why we are more neglectful of our health than we were before.

We should have a debate, not on the NHS, not on cuts, not on queues, but on health. Let us find out what the various communities think about health. Health is not just a simple, mechanical notion of the way the body functions. It is much more holistic than that. There are alternative medical systems available, although not on the NHS--I hope that they will be available on the NHS--and so we should be able to discuss health in a much wider way, and evaluate how, using different cultural practices, we can promote the health of our citizens.

When we are talking about whether the NHS is expensive, we fall back too readily on crude measures: such a percentage of GDP is spent, and so forth. We should realise that the number of years our citizens live is a great achievement. More people are living longer, and that has never been factored into the measurement of the needs or achievements of the NHS.

I once suggested to the UN, which was looking for a measure of wellbeing, that the remaining lifetime of each and all of us would be a good measure of our wellbeing. We should ask ourselves what we really value. We value the years that we have left to live. A good health service gives us all a longer life. That is what the NHS has done. The longer people live, the wealthier the country is. It is not surprising that with a longer lifetime, we spend more money. However I am sure that if a calculation were made carefully, we would discover that we are spending less money on health now per year of extra life than we did before. That is an achievement of which to be proud.

Society is more democratic, and we should have an open discussion about health rationing. There is no need to be embarrassed about it. Rationing used to occur through doctors' decisions. Doctors used to decide how to ration healthcare. Society is now different. Patients want to know more about diagnoses and alternative treatments. They want to have some say in the way things are rationed. Other countries have experimented with open public discussions on rationing. The Oregon experiment is well known in that respect.

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If we can take the NHS out of party politics, we can have an open discussion about the strategy of rationing: who should be rationed; and how we should ration. There should be a participative mode of rationing, because people would like to know what is being done to them. If they know, they will accept it; they will not accept arbitrary decisions, Treasury-driven cuts, administrative decisions, and such things.

We should not just have a debate about notions of health, it is important that we all sit down together and agree the health needs of the people of whom we are taking care. We must also ration healthcare sensibly, and we must have a way of deciding that.

We do not yet have--I may not be fully aware of the research on this matter--information on how our patterns of demand for health services change over a lifetime. The statistics I have read refer more to the US than the UK. They show that the greatest demand for hospital beds happens in the last years of our lives. I do not want to go into all the numbers, because numbers are boring. Our needs for acute care are concentrated on certain phases of our lives. Between childhood and old age our demands for healthcare are random and accidental. They are not systematic. If we knew how the demands changed, we might be able to plan hospitals in relation to them. We now plan hospitals as if all of us might want them all the time. That may not be true. The bed crisis occurs because many people go to hospital and cannot be discharged. There is input but no output. People have to stay there. We should be able to provide specialist hospital care. People between five and 85 need a different kind of healthcare from those of 85 and 90, for example. We should have such data, so that we can combine new data and new concepts with an open discussion. We should then be able to plan a better health service for the next 50 years.

5.29 p.m.

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