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Lord McColl of Dulwich: My Lords, I am grateful to the noble Baroness for allowing me to ask one question. What am I supposed to say to the people of Bermondsey who are angry that they cannot have their operations for varicose veins, sebaceous cysts and lipomas done on the NHS when always in the past they could? Please will the Minister tell me what I am supposed to say to them?

Baroness Hayman: My Lords, the noble Lord is supposed to say that the priority given to certain procedures, particularly cosmetic procedures, is a matter for local decision-making. That has always gone on within the NHS. The noble Lord, Lord Clement-Jones, pointed out how important it is to have processes that are clear, explicit and transparent for priority-setting within the National Health Service. We have to recognise that we are all setting priorities, particularly in times of rising expectations--as the noble Baroness points out in her Motion--and when we are looking at a variety of new things that it is possible for us to do. We are improving the service available to patients year on year.

Returning to the spirit in which the noble Baroness introduced her Motion, everyone who spoke paid tribute to the work of the NHS. I think I am the third noble Baroness to admit to having a father who joined the NHS at its inception. My father, too, was a dentist and I, too, had blood on the carpet. That makes three of us; perhaps that is what made us end up in politics!

This evening is an opportunity to recognise, and pay tribute to, the achievements of the NHS over the past 50 years and to say a little about what the Government are doing to address the issues and to ensure that the NHS is fit to meet the exciting challenges of the next 50 years. My noble friend Lady Pitkeathley rightly reminded us that, while for many of us the NHS is a fact of life, for many older people the grief and worry that paying for care meant to so many is still with them and still affects the way in which they make demands upon the service. The NHS lifted the burden of anxiety about ill health which so affected previous generations. It was one of the best civilising endeavours ever undertaken by a Labour government on behalf of the people. It has been applauded abroad and cherished at home as part of our nation's fabric.

It is cherished for the reasons highlighted by the right reverend Prelate. It symbolises the right of an individual to the dignity of healthcare based on need and not on wealth. It is a tangible experience of what we mean by "community"--working together and paying taxes together to create and sustain a service in the interests of every individual within that community. I agree with him that the NHS has at its heart a moral imperative, even if perhaps not a religious one.

Over 50 years the NHS has transformed the delivery of healthcare and helped to bring about a dramatic improvement in the length and quality of life enjoyed by millions of people. National immunisation programmes

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ensured that killer diseases such as polio, smallpox, TB, and diphtheria were conquered. There has been an 80 per cent. reduction in the number of children dying before their 14th year. Life expectancy is up for men from 66 years to 75 years and for women from 71 years to 80 years. People are attached to the NHS not just for sentimental reasons but also because they know it works--although I have to say to your Lordships, after two weeks of spreading coughs and sneezes across the Floor of the House, that there are still those dark corners that scientific research has not yet penetrated!

However, our pride in the achievements of the past 50 years does not mean that we should stay in a system in which we recognise no need for change. There are enormous challenges. We have set ourselves targets and ambitions for the next 50 years which are challenging in the extreme. We aim to improve health, to tackle inequalities and to modernise services. If we are to do that and to keep up with the advances in technology and the scientific challenges to which so many noble Lords have referred today, it is essential that we not only look at technological advance but also tackle the root causes of ill health and the inequalities in health status that were highlighted by the right reverend Prelate and my noble friend Lord Rea.

I listened carefully to the debate. There were many references to the demands that would be made on the service and the need for extra resources to meet those demands; but I did not hear as much as we could have heard about issues of prevention and improving health, thus reducing demand. In particular, the programme that the Government will shortly set out for reducing smoking and tobacco consumption is a prime area in which we can reduce the need to spend money as well as the terrible toll on individuals and families caused by the effects of smoking.

It was right that the debate inevitably dealt with some fairly challenging scientific concepts. The noble Baroness, Lady McFarlane, rightly reminded us not only of the need to ensure that the professionals who work within the health service have the skills, training and education to meet the much more demanding tasks that we ask of them but also that in the emphasis on a more highly trained nursing workforce it is important that we do not lose our recognition that care and human contact are a vital part of training. The same is true with regard to the point made by the noble Lord, Lord Jenkin of Roding, about the need to ensure that the training of medical students recognises the enormous challenges and changes that there will be in the science base on which they are working. That is an important area for medical education to address. In addition, we need to ensure that the ability to communicate with patients is included in the medical education curriculum to deal with the rising expectations of a better informed patient base, a point referred to by my noble friend Lady Pitkeathley.

There has been much talk about the clinical futures laid out in the book produced partly by the British Medical Journal. I was involved with that and attended the conference for the launch of the book. This gives us immense possibilities. If we put on our "retrospectoscopes", we could all predict that there will

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be enormous change, but not what that enormous change will be. How the human genome project translates into service demands and possibilities is something that we do not know, but we know that we need to know. The work being done by the MRC and the NHS R&D programme are important ways of addressing some of the implications.

I should like to emphasise the point made by my noble friend Lord Rea that we too often tend to see new technology as simply an extra cost pressure. We should see it first and foremost as an opportunity to benefit patients and to provide better services for them, and we should welcome it on that basis. However, we have to recognise, too, that all kinds of advances have given us the potential to spend more money on drug interventions. For example, we discussed yesterday the new and improved treatments for schizophrenia, which seem at first sight to be more expensive but which, when looked at in the light of reduced costs in terms of hospital admissions, can produce cost savings. The same is true of some of the ulcer treatments which have replaced surgery. There are many opportunities, too, in diagnostic advances, such as the possibilities that MRI has brought in replacing the need for arthroscopies. There are many opportunities for the new technology to allow us to manage conditions better and more cheaply in the community. It is not all doom and gloom. There are enormous possibilities.

A number of references were made to the recent report on the possibilities of the therapeutic applications of cloning. That report by the Human Genetics Advisory Commission and the HFEA has only just been published. Ministers will want to look very closely at its conclusions and recommendations, and their implications, and will publish their response next year. I restate that Ministers have made clear that they regard the deliberate cloning of humans as ethically unacceptable. The report recognises that the current legal safeguards are wholly adequate to forbid human reproductive cloning in the UK.

There are still major challenges about possible therapeutic applications. I accept that there are wider social and ethical implications, as well as scientific ones, that need to be addressed. That point was also made by the noble Lord, Lord Jenkin of Roding. The Human Genetics Advisory Commission chaired by Professor Sir Colin Campbell has given a high priority to consideration of these issues and has been in discussion with major funders in this field, including the MRC, the Wellcome Trust and the Department of Health.

Substantial reference was made by implication, and directly by the noble Baroness, Lady Hooper, to the need for evidence-based research to help to translate some of the new developments into applications within the health service. I should like to reassure the noble Baroness that the focus of the NHS R&D programme is very much on the applications end, that is the "D" rather than the "R" side of this work. We shall play our part in promoting appropriate research and try to ensure that there is the correct balance between blue sky research,

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albeit thematically based, that organisations like the MRC can undertake and the more applied research in which the NHS R&D programme can take part.

Noble Lords referred to the increasing expectations of society and among users of the health service. We should welcome the legitimate desire for more information. It demands a different model of decision-making as to the pattern of care and greater emphasis on partnership with local communities--I believe that that will be reflected in health improvement programmes--but also a different model of care from some members of the medical profession whose education was very different and related to a patient base that was much more deferential and not as well informed. I believe that better information can help patients make fewer demands on the health service. Perhaps a prime example of that is the prescribing of antibiotics. Better information can allow people to understand why general practitioners may not give a prescription for antibiotics both in their interests and in the wider interests of public health.

Our responsibility--it is one that the NHS information strategy will take on--is to ensure that patients have access to well referenced and reliable sources of information to allow them to take informed decisions in partnership with their clinicians. Another example of that is NHS Direct to which the noble Baroness, Lady McFarlane, referred. It demonstrates in its initial stages how the provision of the correct advice, with the technological back-up that is available to nurses who give it, can direct patients to the most appropriate services. Sometimes it may be a matter of confirming that people's conditions can be managed at home. But there is also evidence that sometimes it may be a matter of persuading people that it is better to seek emergency help because that is what is required. A service like NHS Direct can have an enormous effect upon the mismatch between understanding the symptoms and the appropriate response.

The trends in expectations and scientific developments exert extra pressure on resources. We have faced up both to the need for extra resources and the need to get better value from what has been invested. We have announced plans to spend an extra £18 billion on the NHS in England over the next three years on top of the £2.25 billion that has already been invested since we came into office. This represents the biggest cash injection in the history of the NHS and gives a stable base for longer-term planning. But this massive cash injection is targeted on change; it is an investment in reform to ensure that patients everywhere get the high quality care that they deserve. There are three elements to ensure that that happens. The crucial element has been referred to in tonight's debate: to make sure that the NHS provides cost and clinically-effective interventions. That is why the National Institute for Clinical Excellence will be very important in assessing and providing information on the cost-effectiveness of existing technologies as well as new ones. It is very important that we take on the task of seeing what is new and needs to be introduced and assessing what has not been effective in the past and stopping it to free up resources to do what is better. National service

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frameworks will be of enormous importance both in terms of producing better evidence and giving guidance on best service configurations and clinical standards.

Time is marching on and I must end. I recognise that I have not answered some of the specific questions that have been asked. Perhaps I may write to noble Lords about those. I end by saying that high expectations are important for our public services as they are important for our children. We should not shy away from them, and we as a government are willing to meet those challenges.

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