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The Minister of State, Department of Health (Baroness Jay of Paddington): My Lords, I am pleased to be able to echo the noble Earl's final sentiments. This has been a powerful and wise debate. As always in your Lordships' House, discussion of the NHS has been illuminated by deep personal knowledge and experience which have been reflected in speakers' contributions. No one is more knowledgeable or experienced than my noble friend Lord Hunt of Kings Heath. I am especially grateful to him for his fascinating overview and clear analysis of the past, present and future.

As I said, this has been a wise, intellectually rigorous, and wide-ranging debate, but it has also been, in the best sense, an historically emotional one. We heard personal testimony of how the health service has affected everyone's lives in the past half century. I pay particular tribute to the speeches of my noble friends Lord Bruce of Donington, Lord Prys-Davies and Lady Jeger in that respect. Their memories and observations told us much about the hopes and principles upon which the NHS was built by the post-War Labour government. I confirm that those are the principles upon which those of us who are in government today are determined to build again.

Perhaps I may also congratulate the noble Baroness, Lady Knight of Collingtree, on her maiden speech. Although she was a maiden speaker in this House, she has a long and distinguished record in another place to which I am sure she will add here. I was especially

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pleased to hear her comments on the dignity of patients. That is a subject to which my colleagues and I give priority. There were many other speeches of equal value. I hope that noble Lords will understand if I cannot, in this time-limited debate, respond to every point. If any noble Lord feels that I have missed an important point, I shall of course be delighted to write to him or to her, or to discuss any matter outside the Chamber.

Although mine is a concluding contribution, I still believe that it is worth while going back to the beginning and the words of Aneurin Bevan when introducing the 1948 Act. The then Minister for Health said:

    "I believe it will lift the shadow from millions of homes. It will keep many people alive who might otherwise be dead. It will produce higher standards for the medical profession. It will be a great contribution towards the wellbeing of the common people of Great Britain".--[Official Report, Commons, 30/4/46; col. 43.]

To what extent has that faith of Aneurin Bevan been justified? Life expectancy has improved since 1948 by about eight years for both men and women. The perinatal mortality rate, which has already been mentioned, in 1995 was less than a quarter of that between 1946 and 1950. For the same period, the infant mortality rate dropped by nearly 82 per cent. The death rate for children aged one to four years is now less than 17 per cent. of what it was in 1948.

Although the main cause of death remains what it was in 1948--that is, heart and other circulatory disease--we are much less likely to die of respiratory diseases--for example, tuberculosis. As my noble friend Lord Winston rightly emphasised, many of those changes have been due to the close collaboration of science, academic medicine and the NHS. It is a collaboration which, like my noble friend, I hope will be as vigorous and productive in the next 50 years as it has in the last.

Of course neither the NHS nor the scientific community can take all the credit for the health improvements in the past 50 years. Other social factors, such as improved housing, social security and education, have played a significant part. I am pleased that my noble friend Lord Bruce of Donington laid great stress on the cross-government responsibility for health in that context.

Today we must re-emphasise the social factors involved in health: poverty, unemployment, bad housing, social isolation, pollution, ethnic minority status and gender have, for too long, been regarded as somewhat peripheral to health policy. I am delighted to tell the noble Lord, Lord Colwyn, and other noble Lords who spoke about it, that that is about to change because tomorrow we shall be launching a Green Paper on common health strategy, Our Healthier Nation. The themes of that strategy will be broader, social and economic determinants of health. The strategy will focus upon the stark health inequalities which still divide our citizens, three generations after the introduction of the health service.

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We need to expand community responsibility for a broad approach to the choices and priorities involved in reducing health inequalities. I am grateful to the right reverend Prelate, the noble Lord, Lord Alderdice, and my noble friend Lady Young for emphasising that point.

It is obvious that, wherever a broad approach may take us, the NHS will always have a key role, not just in treating ill health but in preventing it. Many speakers today have rightly concentrated upon the White Paper, The New NHS, which represents a milestone for the health service. For too long many people have told us that the NHS is in an inevitable state of decline, unable to cope with the pressures facing it, and that rationing and charging are inevitable. It was interesting that that charge today came most loudly from the Liberal Democrat Benches. The Government reject that view, and so, as I understand it from the noble Earl, do the official Opposition.

The orderly management of decline is not part of our agenda for the NHS or for Britain. Our White Paper is a vote of confidence in the ability of the NHS not just to survive as a universal comprehensive service, funded from general taxation, providing care on the basis of need, but to prosper as well. It is true that if the NHS is to survive in that form in the future it has to change. We do not want change for change's sake. We want to change the NHS for the better. So in the White Paper we have set out an ambitious and far-reaching programme of modernisation.

In his introduction to the White Paper, the Prime Minister said that creating the NHS was the greatest act of modernisation undertaken by the post-War Labour government. It is now our task to modernise it for the 21st century. The task is to build a health service which is modern and dependable. We shall need to get right the funding. We have already put large extra sums into the NHS. We are committed to raising spending in real terms every year.

I am grateful to my noble friend Lord Rea for his imaginative idea of NHS bonds. I understand that the authors of that idea have already met the Secretary of State, and have been invited to have discussions on that subject with officials. I cannot of course foresee the outcome of those discussions, but I can assure my noble friend that there will be more public investment.

With that money will come a responsibility within the service to change: to produce better treatment when patients need it, and to guarantee them excellence. The White Paper gives patients a guarantee of excellence. To achieve that we need to raise standards throughout the health service. Let there be no misunderstanding about that. This Government are as committed to raising standards in the health service as they are in education. To achieve high standards however we need to get the best out of the resources available to us. We want to set and raise standards for efficiency as well as for quality. We believe that the two go together.

There is no denying, as many noble Lords have said, the achievements of the NHS over the past 50 years. It has helped banish the general fear of becoming ill. But today the service needs to become better attuned to the needs of the individual patient.

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Only recently the Audit Commission reported that almost half of women were not completely happy with the care they received during and after pregnancy. The survey also found significant variations in standards around the country. In other areas, emergency readmissions to hospital are 70 per cent. higher in one area than in another. Unit costs in one hospital may be four times higher than in another.

There is that kind of variation which is both wasteful and unfair. Of course, equally high standards cannot be achieved overnight. No one would believe us if we said that they could. However we believe that patients have the right to see demonstrable improvements every year. That is what the White Paper promises--a 10-year programme of modernisation making the NHS better every year.

I am grateful to the several noble Lords who commended the evolutionary methods that the White Paper proposes. We have to change from the old models because they fail to deliver the goods. The previous government told us that the internal market--competition--would drive up performance. But competition is not the answer for the National Health Service. Nor is the return to the old centralised command and control system of the 1970s. There are one million staff, a large range of professions and a large variety of organisations. I am delighted to agree with the noble Lord, Lord Jenkin of Roding, that we cannot possibly manage the NHS on a day-to-day basis from Whitehall. Experience tells us that improving the NHS means finding the right incentives as well as issuing the right instructions.

There must be local ownership of the process of change. That is why we will keep what has worked in the current system, and we believe that one of those is devolution of responsibility. I respectfully say to the noble Viscount, Lord Bridgeman, that it is local responsibility rather than local competition which we believe will improve the sense of local ownership.

It is already well understood that by giving the NHS trusts control over key decisions they can improve their local services for their patients. However, for too long their sole statutory responsibility has been to balance their books. That financial duty will remain--I wish to reassure noble Lords who believe that the financial strictures will disappear--but, for the first time, in addition NHS trusts will also have a statutory responsibility for quality. Every trust will have to introduce clinical governance arrangements to ensure that quality is at the heart of the organisation and at the heart of each and every one of its clinical teams. We want to see greater devolution of financial responsibility to clinical teams within NHS trusts. We want to see hospital doctors helping to shape change rather than feeling that they are the victims of it. That is why they will have a key role to play in agreeing long-term service level agreements which will focus on quality as well as cost and we hope that they will be working together with family doctors and community nurses.

The GP and the community nurse will be in the driving seat of the new primary care system. After all, they are usually the first port of call for the patients and

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probably best understand their needs. It is right, then, that the new primary care groups will combine clinical responsibility with financial responsibility. They will be expected to reach agreement for high quality, efficient services. These may, for example, be organised around a particular care group, such as children, or a special disease area, such as heart disease. They will be linked to new national service frameworks. We believe that this is what the clinicians want, what the nurses want, what those people working on the front line want and we are sure that it is what the patients want; that is, a more integrated form of care where the individual patient is no longer passed from pillar to post but where the health and social care system is shaped around the needs of the individual.

The White Paper sets out a system which devolves responsibility for improving the standards clinically and financially to those who are working on the front line. Devolution of responsibility will be matched with accountability for performance. This is obviously crucial because the NHS is a public service--taxpayers have the right to see their cash spent wisely--and it is a national service where patients have the right to expect clear national standards and the consistency of care which so many noble Lords emphasised tonight.

The new NHS will have clear lines of accountability. It will also have a clear framework for judging the performance of every part of the service. The new performance framework, which has been mentioned today, was published for consultation on 21st January. It signals to the public and to all those working in the NHS where and how we want to raise standards. The old efficiency index failed to reflect what is important in the NHS, but we want the new performance framework to deal with what we believe really matters.

We are suggesting six areas which together could give a rounded assessment of performance and the kind of indicators which might deliver that information. The first is in general health improvement. That would cover the overall health status of the population. The second is in fair access. The third is in the effective delivery of care. We might want, for example, to look at whether the right surgery has been provided or how we are managing chronic conditions such as asthma or diabetes. The fourth is efficiency. We need to make absolutely sure that we maximise the use of all our resources. The fifth, which is important and has been mentioned by several speakers, is that we need to judge performance by the experience of patients and carers of the NHS. We want to find out whether patients and carers feel that they are receiving an effective service. The sixth will be health outcomes of NHS care. We are already piloting some clinical indicators to try to judge success. This is the consultation document and we look forward to hearing the views of those who are working in the service. I look forward in particular to a quiet discussion with my noble friend Lord Rea, who has indicated his concerns in this area but does not want to talk about them today.

We believe that those goals are in line with the fundamental principles on which the NHS was created. The methods we are using may properly owe a great deal to modern business management and the

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advantages we can gain from the use of information technology. However, the values they represent are immutable. As regards information technology, I thank my noble friend Lord Winston for his imaginative vision of the way in which the expansion of information technology within the general area of healthcare could provide such a wonderful contribution to improving services. I hope that we can explore and develop that as we go forward with the modernisation programme.

There is another factor in the new NHS which is essential to raising standards. It involves patients in providing planning services. Their views--after all, our views--should become a key to measuring performance. I am grateful to my noble friend Lady Pitkeathley, for emphasising that and, in particular, for drawing your Lordships' attention to the new national patients' survey which the Government will conduct for the first time later this year.

It is interesting that currently there is no systematic means of assessing patient experience. The new national survey will operate at both health authority and national level and it is likely to involve a substantial number of patients in order to gain an accurate picture. The results will be published locally and nationally in order to allow comparisons between areas and to measure performance over time. Where, in the views of patients, there is conspicuous or continual under-achievement of local health services we expect that to prompt NHS trusts, health authorities and primary care groups to sort out the problem. Failure is not going to be tolerated. For example, the new commission for health improvement will be able to intervene on the direction of the Secretary of State or by invitation from primary care groups, health authorities and National Health Service trusts. In these instances, the commission will be empowered both to investigate and identify the source of the problem.

However, trouble-shooting will be only one aspect of the commission's role and it should intervene only as a last resort. But, potentially, the new body will be a useful tool to help services deal with the extreme cases where both managers and professionals have in the past felt some important levers and support mechanisms were missing. We can all probably think of cases where an independent source such as the commission could have played an important part in helping services to get quickly to the root of the serious clinical problem and to identify ways of resolving it. Most recently, perhaps, were the well publicised problems with cancer screening in breast services and cervical cancer screening which have occurred in different parts of the country this year. I am grateful to my noble friend Lady Gould of Potternewton for emphasising the fact that, in spite of such concerns, the use of such screening services is essential to improving women's health.

I wish to make it clear, however, partly because of the way in which the commission for health improvement has been portrayed in the media, that raising standards through this method is not about sending in heavy hit squads. It is certainly not about a witch-hunt against NHS staff. I am extremely pleased that several speakers today have emphasised the central importance and the need for the staff themselves to be

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involved in delivering the plans and for their concerns to be taken fully into account, as they will be the people who will deliver the new quality care for patients. After all, for 50 years it has been the staff who do the work. The staff know what can go wrong and how things can be done better. If we want to raise standards we must make sure that there is also a high quality of care and concern for the one million staff who deliver care for patients.

I heard what the noble Baroness, Lady Robson, said in relation to her concerns about the lack of nursing staff and their problems with the nature of the pay award which has been agreed recently. I simply remind her that that was the highest pay award for the past six years and that in that survey, which I agree was disturbing, about the number of nurses leaving the nursing service, pay was not mentioned among the top number of nurses' concerns.

I should like to mention too that we are extremely alarmed by the potential problems which may be caused by a lack of medical staff in particular specialties. That is why this year we have invested £766 million on nursing and PAMs education. That training includes provision for more nurse training places and £10.4 million to support recruitment and retention initiatives. A further £30 million to support those programmes has been announced for 1998-99.

I was grateful to the noble Baroness, Lady Emerton, for placing emphasis on the need for further and specific education for nurses to include them properly in their new role at management level within the primary care groups. I agree with her that that is something which needs to be observed and followed through very carefully.

In general, trusts need to treat staff as valued colleagues who work best if they are respected, listened to and have their real needs addressed. Too often, perhaps, in the past, staff have been seen as a problem, perhaps even as a threat. That is why we feel that that must change and why we recently launched a consultation on developing the first ever human resource strategy on the history of the NHS. The White Paper also underlines the importance of that agenda. I am delighted to assure my noble friends Lord Desai and Lady Amos that racism, to which they both drew attention, is high on that agenda in dealing with particular staff concerns.

I stress also to my noble friend Lady Young that the problems and interests of managers will not be ignored in the new human resources strategy.

The White Paper brings NHS trusts with their staff--their medical, nursing and management staff--into the heart of the local health economy alongside the primary care sector and the health authority. In future, NHS trusts, their clinicians and nursing staff will play an essential role in setting the new health improvement programme which will identify local health needs, healthcare requirements and investment decisions.

Of course, in return for that influence, NHS trusts would incur, as I tried to explain, considerable obligations as regards national accountability. Having helped to set the health improvement programme, they

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will be bound by it, like everyone else. I am sure that NHS managers would not want it to be otherwise. The importance of those managers in spearheading and concluding a lot of that work is something which we fully understand.

All of that will be spelt out in the new statutory duty of partnership when we legislate for our changes. It will go wider than the new NHS. We want it to include local authorities as well and we shall continue discussions with their representatives about how best to achieve that.

The existing duty in the 1977 Act is too widely drawn to be of much impact. We want to underline the requirement for real operational partnership, to break down those Berlin Walls to which several speakers referred. This spring, we shall be piloting 10 health action zones and they will provide an excellent test bed for better local co-operation of that kind. I should emphasise that we expect that local co-operation to develop, not simply across the statutory agencies but also in collaboration with local voluntary organisations and local private sector business.

Both locally and nationally, we want the NHS to meet the challenges of the 21st century. The White Paper sets out in detail how we shall do that. The new arrangements go with the grain of what is wanted by NHS organisations and their staff. Expectations laid on the service are challenging, requiring good leadership, good management and a positive approach to partnership. The commitment of all concerned will be needed to develop that new role and for everyone to be full participants in local health services. As I said, formal changes in duties will be introduced through legislation. But the new approach to partnership is broader than law-making. We believe that it is already developing and will continue to grow. I am grateful to the noble Baroness, Lady Masham of Ilton, for underlining the sense of local co-operation as the basic tenet of improved care.

It is a matter of great personal pride to me to be a Minister for Health today and to be part of those partnerships for improvement. I was touched when the noble Lord, Lord Bruce of Donington, said that he felt that Aneurin Bevan might have some faith in my performance. I believe that all of us in the new ministerial team charged, as we have been since last May, with improving the country's health recognise the awesome duty we have but also the awesome legacy of the past 50 years.

We believe firmly that by concentrating on what really matters--improving standards for patients and staff alike--we can create a new National Health Service which is both modern and reliable. There is no better time to start than by celebrating the 50th birthday of the health service and at the same time planning positively to take it into the new century.

7.56 p.m.

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