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Baroness Robson of Kiddington: My Lords, I too thank the noble Lord, Lord Hunt, for introducing this debate today. We have listened to 24 speeches, all of which have had important points to make. As a result it is almost impossible to find something that has not already been said. Therefore, I am likely to be slightly repetitious here and there. The number of speakers who have taken part today and the speeches which have been made, cannot leave anyone in any doubt as to the importance all sides of the House believe the National Health Service to have for the future of this country.

It is true that the NHS is probably the best loved and most highly regarded of all public services in the country. It is seen by all the British people as something of which we as a nation can be justly proud. I do not know of any other country that has as comprehensive a health service as we have. I was born in Sweden, which for years had the glory of being pointed out as having the best health and social service, and everything else, in the world. Sweden's service has always been and still is very good, though it is going through the same problems as the health service of this country. But it never had something which is the most important and fundamental part of the health service here--that is, a complete general practitioner service in which every individual can be registered with a doctor. That never existed in Sweden and it was always a lack. However, having watched what has happened in this country, Sweden has, after years, finally begun to establish such a system.

When the National Health Service was established in 1948 Aneurin Bevan achieved personal immortality. It has been referred to particularly by the noble Lord, Lord Bruce of Donington. I enjoyed listening to his ideas on how Aneurin Bevan would have reacted to this debate today. But it must not be forgotten that it was due to that great Liberal, Lord Beveridge, and his report that the basis for establishing the social service was there already. The leading principle of the Beveridge report was that social insurance should be treated as only one part of social progress. Its aim to fully develop and provide income security was an attack on want. But there was more to it than that. There were other evils that had to be attacked. They were disease, ignorance, squalor and idleness.

The development of the NHS was perhaps the most beneficial reform ever enacted in Britain because it relieved people of the terrible worry of not being able to afford to look after their children or their relatives. The White Paper that was published in 1944 stated that everybody, irrespective of means, age, sex or occupation should have equal access to up-to-date medical and allied services. It stated something else which I find very important. It said that the service should be comprehensive, free of charge and that the service should promote good health rather than simply preventing ill health. It was therefore with great interest that I listened to my noble friend Lord Alderdice talking about the responsibilities that we ourselves must accept for part of the health service. We have responsibilities, too. I equally enjoyed listening to the noble Baroness Lady Young of Old Scone, who made very much the

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same point. Those were the founding principles. Like those everywhere else in the House, we on these Benches accept them as the basis for what we want to achieve.

Some of the matters with which I want to deal have already been covered to a certain extent, but at the moment I am particularly worried by the staff shortages in the NHS and by the lowering of morale. That is partly due to the public sector pay awards that have recently been announced. Although the Government accepted the recommendations of the review, to stagger the pay award, particularly to nurses, by paying only 2 per cent. in the first phase with the rest in December, means that the pay increase will not be the 3.9 per cent. which was promised for the year. I believe that that is wrong in principle. The nurses, who are the backbone of the NHS, deserve better treatment.

It is frightening to read the report from the Royal College of Nursing which states that there is a shortage of 8,000 nurses in the country and that that shortage is growing. What worried me most about the report was that it showed that this year, for the first time ever, there has been a shortfall in the number of applications for nurse education places in England. In 1993-94 there were 18,100 applications for 12,000 places. In 1996-97 there were only 15,400 applications for over 16,100 places. In other words, we are not filling nurse education places although we have increased the capacity of our nursing schools.

There is another problem relating to the recruitment crisis. I refer to the fact that up to about 25 per cent. of NHS nurses will be eligible for retirement by the year 2001. We are not only short in terms of recruitment, but we are losing nurses through retirement. There is also a high drop-out rate.

Why are there such difficulties in recruiting nurses? I believe that it is because the Government have made statements about the importance of the nursing profession to the NHS yet, as a result of the pay award, nurses feel let down by the Government.

Another matter which greatly concerns me is that there is a shortage not only of nurses but also of about 1,600 hospital doctors and about 900 GPs. I said at the beginning of my speech that the GP service in this country is the backbone of the NHS. As we already have a shortage of GPs and we are looking forward to a much more community-based service, in which GPs will be even more important than in the past, we are in trouble. I should like the Government to tell us how they hope to deal with those problems.

Another matter which concerns me particularly on this 50th anniversary of the NHS--other noble Lords have mentioned this--is the inequitable access to treatment across the nation. Access to treatment has always been inequitable. There have been attempts to put that right, but they have not achieved what we had hoped. Now that there is a funding shortage in the NHS, we are having to resort to rationing. There has always been rationing to a certain extent, but it is the fact that the rationing is inequitable across the nation that threatens and undermines the founding principles of the NHS. We believe that only an increase in funding to a

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GDP level that is more in line with those of other European countries will bring rationing to an end. Many noble Lords have mentioned this point.

Reference has already been made to the BBC's survey into public attitudes to the NHS, which showed that 63 per cent. of people said that they would pay an extra 2p in the pound in income tax if they could be certain that it would go to the NHS. I believe the noble Lord, Lord Bruce of Donington, and others who have said that we can afford to increase the funding to the NHS, but, even if we could not afford that, the nation--the people--want the funding to be increased and they have said that they are prepared to pay for it. We must look forward to greater funding for the NHS.

However, it is not only a question of funding. Not only does the NHS have to be funded, but that funding has to be evenly distributed across the country and across the various services. I am not sure which noble Lord referred to the private finance initiative--

Noble Lords: Time!

Baroness Robson of Kiddington: My Lords, I am sorry. I shall not be able to refer to the PFI. I am too late. I do not have enough time, but I should like to put forward a proposition before sitting down. To avoid this kicking backwards and forwards between the political parties about the future of the NHS and what should be done, I think that we should set up a standing conference on the future of the NHS. That forum could comprise patients, professionals, practitioners and politicians. It should conduct an ongoing debate on the NHS so that there will be no more drastic changes. The NHS would then develop slowly because it would always be under consideration. We would not hear so many frightening stories about underfunding or about the neglect of NHS staff. It would be an honest attempt to put the NHS beyond a state of permanent crisis. My colleagues in another place have already spoken to patients and professionals and have secured their involvement. What is needed now is the commitment of those in this place. On its 50th anniversary, we could give no better present to the NHS.

7.18 p.m.

Earl Howe: My Lords, from these Benches I should like to express my gratitude to the noble Lord, Lord Hunt of Kings Heath, for initiating this debate. I am delighted that he has done so and I hope that he will feel, as I certainly do, that the quality of the contributions today from all sides of the House has done justice to the terms and the spirit of his Motion. I add my congratulations to my noble friend Lady Knight of Collingtree on an excellent and sparkling maiden speech.

As is appropriate on an anniversary, today we have had a mixture of celebration, reflection, and looking forward. I should like to follow suit by indulging in a little more of each. I am also pleased that, with only a few exceptions, the debate has been free from the intrusion of party political carping upon a theme which for most noble Lords rises above such considerations.

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The heartening aspect of those in this House and Members of another place who are close to the National Health Service and care passionately about it is that they are a living rebuttal to the rather cynical observation in one of John Galsworthy's novels that idealism increases in direct proportion to one's distance from the problem.

Looking back over the 50 years of the NHS, we can point to some of the more obvious markers of its success in terms of the nation's health and well-being: the vast improvement in perinatal mortality; the mass immunisation programme introduced after the war, which has continued ever since; the huge improvement in dental health, as my noble friend Lady Gardner has reminded the House; the female cancer screening programmes of more recent years and, perhaps above all, the dedication and professionalism of the men and women of the NHS, who over the years have delivered a standard of care that I believe is second to none in the world.

As my noble friend Lord Colwyn has said, those 50 years have also witnessed in parallel a vast improvement in the nation's standard of living. As we are only too well aware from observation of countries in the third world, better housing and sanitation, better food and nutrition and better air and water quality all make an important contribution to the standard of public health. But none of that diminishes the achievement of the NHS. The achievement is more than simply medical, clinical or political. A while ago the noble Baroness, Lady Hayman, said in a debate that the NHS was the nearest we came to institutionalising altruism in this country. I agree with her. It is that cultural achievement, and the NHS ethic that underpins it, of which we can be particularly proud. Its influence is felt throughout the world wherever there are doctors who have come to the United Kingdom to train or study.

Noble Lords have also referred to the seemingly perpetual tension in the NHS between demand and resources. The NHS has never had more resources than it has today, yet the tension is no less apparent than it was in 1948. The reasons for that have been well rehearsed in this debate, not least by the noble Lord, Lord Hunt. Unless a certain amount of such tension existed there would be little if any incentive to perpetuate that other signal virtue for which the NHS can take credit: its cost effectiveness. That is a quality which no government can afford to downplay.

If we look back as little as seven years to the time when the previous government's reforms were introduced, it is significant for all the present Government's criticisms of those measures that the number of NHS treatments carried out each year has gone up during that period by more than one third. Compared with 20 years ago the figure is 80 per cent. higher. Over the past 10 years the number of patients waiting for over a year for hospital treatment has been cut by over 90 per cent. Eighteen-month waits had almost disappeared by the time of the last election. There are now 55,000 more qualified nurses and midwives than in 1979. The pay of NHS staff is higher than ever. Capital spending has increased by two-thirds in real terms since 1979.

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How has all that been achieved? Contrary to what was said by the noble Lord, Lord Davies, the proportion of GDP spent on the NHS during the time when my noble friend Lady Thatcher was Prime Minister rose from 4.7 per cent. in 1978-79 to 6 per cent. in 1992-93. It is now 75 per cent. higher in real terms than it was 20 years ago. However, the improvements I have listed do not reflect simply a much higher health budget but much greater efficiency as well. That process needs to continue if the budgetary cake is to satisfy those who slice it. When I see, as I did yesterday, the Department of Health disguising itself briefly as the Department for Culture, Media and Sport in its decision to keep open Bart's Hospital I am slightly fearful that Ministers are not focusing on the taxpayer and the patient quite as closely as they should.

This brings me to the future. Before Christmas the Government unveiled a major White Paper setting out their plans for the NHS over the longer term. I said at the time of the announcement that the proposals were well intentioned and bold. I stand by those words. There is much in the White Paper to be applauded, not least the recognition that the health service should be primary care-led and the purchaser/provider split should be retained so that purchasers have the freedom to make choices for patients. All that is good. But the package as a whole looks very prescriptive. We must be careful that, in creating large primary care groups--effectively, a compulsory broadening of fund-holding--we also create the necessary drivers for efficiency to ensure maximum value for money. I very much echo the sentiments of my noble friend Lord Bridgeman in this context. I believe there is a danger that the flexibility of the present structures may be lost in these changes, that the process of decision-making may become unwieldy and that accountability will be less clear than it should ideally be.

These matters bear directly upon the quality and quantity of care delivered to the patient, on which the Government have rightly laid strong emphasis. The NHS needs to be well managed. I very much agree with the noble Baroness, Lady Young of Old Scone, that while we are all in favour of ditching unnecessary bureaucracy we must recognise that for many years the NHS was if anything under-managed. There is a balance to be struck, and I wish the Government well in their search for that balance.

As we celebrate at this anniversary and look ahead, the challenges facing the NHS are not hard to discern: waiting lists, long-term care, care of the elderly, more expensive treatments, the need to recruit and retain doctors and nurses and, as the noble Lord, Lord Winston, reminded us, the need to sustain academic medicine. All of these are bound to intensify the pressure on resources. Noble Lords have mentioned a number of others. Much as we may feel like congratulating ourselves on the welcome reduction in mortality from the most serious diseases over the past few years--coronary heart disease, breast cancer, lung cancer and strokes--the prevalence of those conditions does not always bear happy comparison with

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corresponding figures in other European and OECD countries. The incidence of certain chronic conditions such as diabetes is rising. Clearly, there is work to be done in both treatment and disease prevention if the targets set out in the previous government's White Paper Health of the Nation are to be achieved. I hope that the present Government subscribe broadly to those targets.

In common with the noble Lord, Lord Hunt, I believe that the NHS has a sound future. It will survive as it always has through its ability to adapt to change and to do so within the budget that Parliament gives it. There is no need to talk in terms of rationing care so long as efficiency is maintained and we are realistic about what the size of the NHS budget should be and how much of it the taxpayer, the patient and private finance should each contribute.

If there is one thread that has run consistently through this debate it is the shared vision of the kind of service that the NHS should provide. I believe that that should give us all encouragement, because no matter what problems face the NHS it indicates that there will always be a will to overcome them. It also shows that the principles underlying the service are not the property of any one political party.

The Government may expect questioning and criticism from this side of the House as their stewardship of the health service continues, but it is also right that the Official Opposition should support Ministers when such support is justified. That selective approach will, I hope, conduce to the greater good of an institution which, perhaps more than any other, is part of the fundamental fabric of our lives.

7.30 p.m.

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