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Baroness Ludford: My Lords, I, too, warmly welcome the opportunity to discuss the NHS and thank the noble Lord, Lord Hunt, for initiating today's debate. I should also like to congratulate the noble Baroness, Lady Knight of Collingtree, on her interesting maiden speech. Like my noble friend Lord Alderdice, I am one of those who do not match the NHS in reaching its 50th birthday. I am an NHS-reared infant; indeed, I believe that I imbibed my fair share of NHS powdered milk and orange juice.

As has been noted on all sides of the House, the NHS is a unique and highly valued national institution. Perhaps I may say that I am impressed by the proportion of women speakers in today's debate. In fact, I think it is the highest proportion in any debate in my short time in this House. I am also grateful to the noble Lord, Lord Butterfield, for mentioning the role of William Beveridge. The fact that the NHS is one of our finest institutions is something that Liberal Democrats are proud--and, indeed entitled--to share, given the Liberal origins in the person of William Beveridge, who was of course later a Liberal MP.

The value of the NHS rests on it being supported by all parties and by a wide social consensus. However, I understand from a new MORI poll for the BBC released today that nearly one quarter--23 per cent.--of people think that the NHS will not exist in 10 years' time. It is worrying to think that people now hold that view. Perhaps that is linked to the fear of 70 per cent. of that sample of nearly 5,000 people that the NHS is underfunded. As other speakers have observed, the NHS is under strain from funding constraints, staff shortages, low morale, a staggered pay award for nurses, and so on.

The situation as regards dental services has also been commented on today. The problem with that service is that it is gradually being eaten away. Like long-term care--and I am glad that there is now a Royal Commission in that respect--that service has been partially privatised over the past few years, without public debate and without the long lead time allowing people to take out private insurance if it is available, or to make other provision. Indeed, in many places no NHS dentist is available. We also no longer have free eye tests, which I happen to believe is economically counter-productive.

The same poll as I just mentioned also shows that almost two-thirds of people--that is 63 per cent.--said that they would be willing to pay another 2 pence in the pound on income tax for the NHS. Before anyone becomes cynical about such statements compared with what people do at the ballot box, I should also point out

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that another finding showed that about the same proportion of people believe that there must be budgets and that they should be respected even if rationing has to be observed. Therefore, people are not advocating unlimited spending; indeed, they are perfectly aware that there are constraints and they are saying that they are willing to pay more. It is vital that quality and standards are maintained, not least to enable the middle classes to continue to use and help fund the NHS so that it does not deteriorate into a safety net service for the poor.

I should like to concentrate on the need for NHS decision-making to be open, honest and accountable. We need democracy, not bureaucracy, in the health service. It is unhelpful to deny that rationing takes place. Everyone knows that it does, not least rationing by waiting-list. I am sure that no one begrudged Her Majesty the Queen Mother her immediate hip replacement operation, but many will have been envious. I know of cases, including my own family, where people have despaired of receiving treatment on the NHS because of an 18-month or even a two-year waiting-list. They have had to pay for private treatment when they have not been insured, because they never intended to seek private provision. Indeed, the survey from which I am afraid I shall continue to quote, indicates that nearly one in five people--that is, 18 per cent.--have had to do precisely that; in other words, they have had to pay for private treatment while not being insured. That suggests that they had not anticipated such a thing happening. So there is an NHS lottery at present, which needs to be addressed by open debate through democratic channels. I strongly agree with what the noble Lord, Lord Desai, said in that respect.

Health authorities are not democratically elected at present; they are appointed quangos. But there is at least some public access to their deliberations through consultation and public meetings. Despite what the other advantages might be of local commissioning groups of GPs which the Government now propose, I worry that purchasing decisions will be even less transparent than they are at present. I was interested to hear what the noble Baroness, Lady Pitkeathley, quoted in that respect. Her quote suggested that GPs really cannot be bothered to talk to patients. I found that rather ominous. If GPs are going to make purchasing decisions, how will they debate those requirements with their patients?

We heard yesterday the Government's conclusions on the London health services review, and I made my own feelings rather clear. The experience of the past five years in London is an example of how not to make decisions. Ever since the Tomlinson Report five years ago, it has been a top-down exercise--a mix of medical, Whitehall and party politics. Local people's views have been arrogantly ignored. When 99.5 per cent. of the people in the area said that they wanted to keep Bart's accident and emergency department open, it was closed. There has been no real participation or open debate. Therefore, the public have never owned the result; they have never felt that it belonged to them.

I believe that the noble Lord, Lord Jenkin of Roding, spoke about taking the NHS out of politics. I am sorry, I see that the noble Lord is shaking his head so perhaps I misunderstood him. We need to get it back to community politics and take it away from administrative

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politics. I think that the public are prepared to consider hard choices if they are truly involved and have the facts; and, indeed, if they feel that they are enjoying respect for their own views as citizens. There has been administrative devolution in the NHS, but we now need political devolution.

When the public are consulted they are much more likely to take account of factors such as public transport and accessibility to hospitals. That is something which is not always considered by managers. They also put some value on the psychological benefits of an attachment to their local hospital. The word "emotional" was mentioned in yesterday's debate, but I believe that there is now an appreciation of the link between mind and body in getting well. If people go into hospital with a positive attitude, they are more likely to get better. We have often actually externalised the costs of longer travelling times to hospitals and pushed those costs on to private individuals, instead of the health service.

The survey from which I have already quoted found that 75 per cent. of people believe that community hospitals should not be closed to pay for larger regional hospitals, mainly because of the travel difficulties. Again, one could be slightly cynical of that figure were it not for the rest of the survey's findings which show that people are ready to pay for their choices. There may be a trade-off between accessibility and cost. I believe that that trade-off should be put to the public to enable the choices to be made openly, transparently and democratically. We also need to look at the artificiality of health authority boundaries of which, I am afraid, Bart's has been a prime casualty. At present, local people are not able strongly to influence the purchasing decisions of health authorities. As was mentioned yesterday in our debate on London, we on these Benches feel strongly that a Greater London authority--a democratic authority--should have responsibility for the strategic planning of health. I suggest that that should also apply to other regions in the future.

I conclude by agreeing with other remarks that have been made about the need, as Beveridge proposed, for a "comprehensive policy of social insurance" to attack the five giants of want, disease, ignorance, squalor and idleness. At present we do not have an integrated approach to public spending to reflect the cross linkages between different budgets, especially between social housing and healthcare, between education and healthcare, and even between social services and healthcare. To get an effective seamless web of provision, we need to merge the providers and the budgets.

Overall, my main point is that I believe the public are perceptive and responsible, not irresponsible. Government need to treat people as responsible citizens on a partnership level and not impose top-down solutions upon them as if they were incapable of understanding the issues.

Lord McColl of Dulwich: My Lords, before the noble Baroness sits down, I should point out that the Queen Mother broke her hip and the treatment of a hip that has been broken is an emergency treatment. You can either fix it with a pin or you can replace the hip. It

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was appropriate in her case to have a hip replacement. She was not jumping any queue and there is no question of putting people on a waiting list if they are an emergency.

Baroness Ludford: My Lords, I hope I made it clear that there was no suggestion of my implying that she jumped a queue. I was making an observation that has been made to me. No one begrudged the Queen Mother her treatment but other people who may be in pain, although they may not have broken hips, are unable to get treatment. I hope that I did not in any way make a disrespectful remark.

6.1 p.m.

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