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Lord Hunt of Kings Heath: Before we move to the Statement on the National Health Service, I should like to take this opportunity to remind the House that the Companion indicates that discussion on a Statement should be confined to brief comments and questions for clarification. Peers who speak at length do so at the expense of other noble Lords.
National Health Service
4.37 p.m.
Baroness Hayman: My Lords, with the permission of the House, I should like to repeat a Statement being made in another place by my right honourable friend the Secretary of State for Health.
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"Madam Speaker, I should like to make a Statement on how the National Health Service is coping with the recent sharp rise in the number of people falling ill.
"First, on behalf of everyone in the country, I want to thank all the people working in the health service and local social services for the huge effort they have put in to try to make sure that everyone is getting the treatment and care that they need. They have done all this because there has been a surge in the numbers of people going to see their doctor and an even bigger surge in the number of people calling ambulances, calling helplines and going to hospital. This sharp increase in the level of illness is confirmed by the increase in the number of people dying, which in some parts of the country has meant that families trying to arrange funerals face long delays.
"From the figures put together by the Public Health Laboratory Service from returns made by the Royal College of General Practitioners, the present outbreak of flu and flu-like illnesses seems likely to be on the same scale as in the winters of 1994 and 1996--although it may go higher. These figures reflect the increased numbers of people with flu-like symptoms who see their local GP. Up till now flu and flu-like illnesses have been worst in the West Midlands and the North, but there have been sharp peaks elsewhere.
"The demand for ambulance and hospital services has shown a much larger increase, with daily ambulance journeys almost doubling in some places.
- Both the Merseyside and the Greater Manchester ambulance services saw the demand for ambulances shoot up to over 1,000 journeys per day compared with an average of 500 to 600. For the London ambulance service, this New Year was the busiest on record with over 4,700 journeys compared with a daily average of 3,000.
"There have also been some tragic fatalities due to meningitis. I extend my sympathy to the families concerned. Of course parents are right to visit their family doctor to seek advice if they have concerns. In November, the Chief Medical Officer advised GPs to refer suspected cases promptly to hospital, and he will be renewing that advice shortly.
"The NHS is better prepared than ever before to cope with these illnesses, and in most places most hospitals have coped well with the pressures they face. In August I asked the NHS to prepare itself to strengthen emergency and ambulance services; make best use of the beds which are available; improve discharge arrangements; and prevent unnecessary admissions to hospital in the first place. And it has done so. Over 2,200 schemes are under way nationally, backed by the £159 million announced by the Chancellor in the pre-Budget Statement. They include £750,000 to improve intensive and high dependency care in London; £200,000 for one-stop clinics in Walsall; £175,000 for better home treatment and care in Leeds; £140,000 for a community-based phlebotomy service in Gloucestershire; and £45,000 to help prevent fractures in the elderly in Kent.
"In August we also announced GPs could this winter, for the first time, offer flu vaccinations to all their patients over 75 rather than confine vaccinations to particularly vulnerable groups. As a result more than a third of a million extra doses have been given this year compared with last and vaccine remains available.
"And we are tackling particular pressure points. Over the last week those parts of the NHS which are suffering particular problems which can be helped by more cash have been told they can draw on the £50 million contingency fund which is there for that purpose. In some places that will mean more high dependency beds are being provided to help relieve pressure on intensive care beds.
"The position today is that 35 adult intensive care beds are free and available for use. The situation seems to be easing but it could well get worse again if icy weather were to lead to a lot of falls, particularly among the elderly. The NHS cannot be complacent. It is not and I am not.
"I will not pretend that the NHS everywhere has coped as well as the public is entitled to expect. Such an increase in illness will always cause difficulties. And those difficulties are worse because of the serious underlying problems we have inherited.
"We inherited a run-down NHS, with serious staff shortages. Many buildings are out of date. Much equipment is old and unreliable. Methods of working are not making the best use of new technology, particularly information technology. There are not
- enough staffed beds. The Government are getting a grip on the short-term consequences of these problems, and also laying longer-term foundations to build a modern and dependable NHS. Much of this work is already underway.
"One of the causes of the shortage of nurses is the cuts which the previous government deliberately made in the numbers of nurses going into training--down from 15,000 a year at the time of the 1992 general election to fewer than 13,000 when they left office; and having fallen at one point to just 11,700. If they had not made these cuts there could have been an extra 11,000 nurses available today. It takes three years to train a nurse and so the country is now paying a heavy price for these years of neglect.
"This year, 15,500 nurse training places will be available and 2,500 more people are already in training now compared with when we took over.
"As I have said before, we must also reform the system of nurse education and training which was introduced in the 1980s. It has achieved some of its objectives but its emphasis on the academic element has put off some potential recruits. Many nurses when they do qualify feel they lack the practical skills necessary on a ward. The transfer of responsibility to the education sector from the health service has broken the old links between individual hospitals and nurses in training to the disadvantage of both. Many nurses and nurse managers recognise the need for change and so I hope to carry the profession with us--but reform there must be.
"The previous government refused, right up to the end, to recognise that there was a shortage of nurses. This Government recognise that reality and training extra nurses is a major objective. We spelt that out in our evidence to the Pay Review Body. This year we also made clear that the review body should give special attention to the pay of nurses in the lower grades. Like the nurses themselves, we want to see a reform of the present rigid grading structure and better career development prospects so that these vital staff have a modern, fair and flexible system for both pay and promotion.
"I repeat my hope that the independent review body will propose a settlement which is fair to nurses and midwives and which the Government will be able to implement in full.
"We are also addressing the concerns of qualified nurses who have left the NHS. We want to attract them back, not just with better pay but with family-friendly shift patterns and a better and safer working environment. If we are to retain existing staff, recruit new staff and persuade former staff to return, we must provide them all with the modern buildings, plant and equipment that they need. We have already started on the biggest hospital building programme in the history of the NHS and there is more to come. A high priority for more small-scale investment will include replacing out-dated and unreliable equipment.
"Last September the Prime Minister announced that the National Lottery New Opportunities Fund will help provide new and better quality equipment for the detection and treatment of cancer. He also announced that from April we will be investing £30 million to renew a quarter of all accident and emergency departments to make them better and safer for both patients and staff. Ambulance services will be getting new control systems, new vehicles and new equipment. All these will help the NHS cope better with winter pressures in future.
"New methods of working will also help. We started three pilot schemes in Newcastle, Preston and Milton Keynes to test out NHS Direct--a nurse-led 24 hour helpline. These have been a great success. Providing advice and reassurance round the clock, they have been very popular with patients and have had a positive impact in helping patients look after themselves and reducing unnecessary calls on other services. Over the Christmas and New Year period, the NHS Direct pilots took almost double their usual number of calls--itself an indication of the upsurge in illness. After receiving advice from the nurse they spoke to, about half the patients with flu-like symptoms were able to look after themselves. This shows how the NHS is delivering new and better services. It is being extended to the rest of the country.
"From the special investment of £44 million which we have provided, NHS Direct has already been extended to the West Midlands where it took over 1,150 calls in its first week of operation. By April this year it will cover more than 20 million people in the West Country, Manchester, South London, West London, Essex and Nottinghamshire--over 40 per cent. of the population. This will both provide a new and better service for patients and, at the same time, help people avoid resorting unnecessarily to the GP or the 999 service or their local hospital.
"Finally there is the question of beds. Under the previous government, the number of acute beds was reduced by 40,000, and the number of general beds by a further 23,000. In September I announced a review of beds in the health service, how many beds, what sort of beds and where they should be. Preliminary work for the review is showing that the health service needs more beds. Our extra investment in the NHS over the next three years will see to it that we can respond rapidly when we have the final report.
"Then there is the question of intensive care and high dependency beds. Soon after coming into office, on the advice of the specialists in children's intensive care, I authorised a shift of extra funds from the paperwork of GP fundholding into children's intensive care and for the service to be concentrated in regional and sub-regional centres, with special arrangements for retrieval of very sick children by specially trained and specially equipped staff. As a result of the additional investment, the service can now provide up to 300 children's intensive care, very specialist new-born and high dependency beds. The new system has been working well, but recently there was an unacceptable delay in despatching an
- ambulance from Nottingham to Rotherham. In the light of that experience I have insisted that each children's intensive care unit, with its local ambulance service, reviews its arrangements to ensure that it is possible to stabilise and transfer very sick children safely and promptly.
"Intensive and high dependency care beds are vital to the treatment of many people who have had operations as well as accident and emergency cases. They demand a huge amount of resources. Intensive care is not just a matter of a bed and some specialist equipment. To care properly for one patient for one day in intensive care can require the services of around six specialist nurses as well as specialist intensive care doctors, anaesthetists and others. Previously the overall level and availability of intensive and high dependency care has not had the attention it deserves. That is why the Audit Commission is now co-operating with the NHS and the Intensive Care Society to carry out a detailed study of the operation of intensive and high dependency care in the NHS. I hope this will provide a sound basis on which to plan for better services in future. I am also reviewing the role of the Emergency Beds Service and the National Intensive Care Beds Register. None of this is a criticism of the people working in these services; they, more than anyone else, want the system to be modernised.
"It has always been a source of pride in our country that when difficulties crop up people rally round to help out. They have certainly done so on this occasion. I should like to thank them all. In particular I should like to thank Dr. Ian Bogle, Chairman of the BMA, for his advice to the public that normally healthy adults should use services in a considerate and responsible way.
"Madam Speaker, from next April for the first time in 20 years the NHS will operate on a budget entirely set by a Labour government. It will benefit from the first stage of our £21 billion extra investment.
"I know that the people of this country realise that when so many people suddenly fall sick, as they have in some places recently, it is inevitable that treatment and care cannot be as prompt as at other times. I want to make sure that we provide the people who work in the NHS with sufficient tools and resources to ensure that its impact is much less in future.
"Over the past few weeks, nurses, doctors, midwives, health visitors, cleaners, kitchen staff, managers, porters, ambulance staff, laboratory scientists, therapists, pharmacists, telephonists, clerical, administrative and maintenance staff and social services staff have all performed wonders at a time when their own ranks have been severely depleted by the same illnesses as are affecting the rest of us. Many of them have kept on working while 'under the weather' themselves; many have returned early from leave to help their colleagues; others have cancelled leave which they planned to take. I thank them all. They have done us proud".
4.51 p.m.
Earl Howe: My Lords, I am grateful to the Minister for repeating the Statement which, as I am sure she will acknowledge, addresses the deep concerns felt throughout the country about the pressures currently being experienced within the NHS. The Statement is right to highlight the immense efforts of doctors, nurses and ambulance staff everywhere to cope with the surge in numbers of flu victims, particularly in the North and the Midlands.
It is perhaps indicative of the intensity of this winter crisis that the Government are already drawing on the contingency fund for high dependency beds. Can the Minister say whether that fund looks set to be fully utilised and whether £50 million will be sufficient? Will she also confirm that the other expenditure plans set out in the Statement are in fact a reannouncement of money already set aside?
The Minister mentioned that there are 35 adult intensive care beds currently available for use. Can she say where those beds are? It is no use telling someone on a trolley in the north of England that there is a free bed somewhere in Cornwall. It matters that the beds are available for use by real patients.
There is one aspect of this serious situation about which the Statement made no mention at all; that is, the effect on the availability of beds of the Government's drive--one could almost call it an obsession--to reduce the numbers of those on waiting lists for elective surgery. The fact is that in many parts of the country the hospital system is being run at far too high a level of utilisation of bed capacity solely because hospitals have been pushed, badgered and even threatened to force through a reduction in waiting list numbers. That is happening in order to enable the Government to meet their election pledge to reduce the numbers on hospital waiting lists by a certain date.
That election pledge made no sense when it was made and still does not. It hangs like an albatross around the Government's neck. Even without this winter crisis, it was serving to distort and undermine clinical priorities. I put it to the Minister that the crisis in the health service is far worse than it need have been as a direct result of the Government's political priorities. Can the Minister say how many hospitals continue to admit routine waiting list cases while emergency patients are being kept on trolleys or turned away altogether? Is it not time for the Government to admit that their manifesto pledge is detrimental to patient care and that they should drop it in favour of more sensible targets focused on waiting times for individual conditions?
On the subject of trolleys, does the Minister recall her right honourable friend Miss Harriet Harman--and indeed the Prime Minister--promising the public before the last election that, when elected to office, they would immediately set up a task force on "trolleys" under a Labour government? Can the Minister clarify what happened to that task force? I wonder whether it too is stuck on a waiting list?
The Statement mentioned nurse numbers and I should like to cover that point. Will the Minister confirm that the Government have actually cut back nurse training
by 3 per cent. from the levels that the Conservative government planned for 1997-98? The NHS is crying out for more nurses. How will the Government's wish-list for nurse recruitment be met? When and where do they expect to find the extra nurses we need when morale in the health service is as low as it is? If the Government are now acknowledging the shortage of nurses, why is it that in the national priorities guidance issued last year nurse recruitment did not feature at all?I must put the record straight on nurse numbers. The Government claim that the last government cut the number of nurse training places. The fact is that nurse training places funded by the Conservative government actually increased by 8 per cent. in 1995-96 and by 14 per cent. in 1996-97. Another 14 per cent. increase had been planned for 1997-98 and, as I mentioned, by Labour's own figures the Government have cut back that target by 3 per cent. Once again they are trying to take the credit for an increase that was planned by the last Conservative government and which now has been cut back.
The claim that there were only 11,000 new trainee nurses in 1996-97 is not right. That figure only counts the Project 2000 scheme--33,000 or so graduate nurses over three years. As the Minister well knows, Project 2000 is only one scheme designed to replace the Nurse Learner Programme which accounts for the paper falls--they are only paper falls--in the early 1990s; they do not count all the other nurses who were set to come on stream such as midwives, practice nurses working in the community and the extra 1,000 intensive care nurses that we created over the last five years of our time in government.
I welcome the words of comfort relating to nurses' pay. We shall see what that expression of hope amounts to at the end of this month or shortly thereafter when the pay awards are announced. I quite understand that the Minister cannot say more about the actual awards or on the question of staging. However, can she say what the Government's policy is should the review body recommend an award that is higher than inflation and the Government agree that recommendation? Will she undertake to fund the hard-pressed health authorities in order to avoid money being siphoned off from patient care to other areas?
The Statement makes a strident boast in relation to hospital building. The fact is that the Government's hospital building programme was largely planned for by the last government, as the Minister will know, and the only reason that the present Government are trying to take credit is that they enacted legislation which we framed in order to clarify the powers of trusts to enter into PFI contracts. Of course we welcome the new hospitals being built, but let us give credit where credit is due.
Can the Minister assure the House that the Government are prepared to learn the lessons from the past week of crisis? In particular, will she take on board the fact that there is spare capacity in the private sector? Will she confirm that during the crisis our health service has now started to make use of the resources of the private sector, as we on this side of the House have
been urging for a long time? If that is so, will she now acknowledge that the ideological barrier that this Government have erected, really a dogmatic refusal even to talk to the private sector, is not in the best interests of patients or hospitals and should be reconsidered in the face of the past week's evidence that our health service is simply unable to do it all?5 p.m.
Lord Clement-Jones: My Lords, on behalf of these Benches I too thank the Minister for repeating the comprehensive and important Statement made by the Secretary of State in another place. I only hope that the noble Baroness is not suffering from her own winter pressures as regards her health.
It has not been a good start to the new year for many patients, with overflowing hospital beds and overloaded emergency services and intensive care units. Staff in the NHS have performed heroically in the face of current circumstances. I join the Minister in paying tribute to them.
We welcome the eventual acknowledgement by the Secretary of State, after some days of stalling, that there is a crisis in the National Health Service. We welcome many of the steps being taken to cope with it. This is not, however, an exceptional winter and there is not an exceptional flu epidemic, as has been acknowledged. However, without wishing to be unduly combative at this stage in the Session, the air is thick with the sound of chickens coming home to roost.
With their eyes open to the possible consequences, in their first two years of office, with some broad exceptions, the Government stuck to the former government's spending plans for the NHS. They phased nurses pay last year which effectively meant that their award then was worth less than the full award. They failed quickly enough to grapple the issues underlying the problems of nurse recruitment.
By concentrating so heavily on cutting waiting lists for elective surgery--indeed, spending 10 ten times more money than originally envisaged--they skewed priorities within the health trusts.
Some of the reasons for the current problems were created by the previous government. The number of acute beds has fallen inexorably since the 1980s. There are now only some 100,000 acute beds. The occupancy rate, as has been referred to, is as high in many hospitals as 95 per cent. The new private finance initiative developments will, it appears, reduce the number of beds even further. What assessment is being made of the specific consequences of PFI in that respect? Will the department think again if the review shows that the current level of development under the PFI will reduce those beds to an unacceptable level? No doubt the Minister will have seen speculation in the press that in some cases PFI development cut beds by as much as one-third or one-half.
As regards recruitment of nurses, we welcome the Statement made by the Secretary of State concerning training. We look forward to the recommendations of the nurses pay review body. The figure of 5 per cent. has been widely trailed, but if parity with newly-qualified
teachers is to be achieved the pay rise needs to be substantially more. Will the Minister confirm that the department recognises the fact that not just a fair settlement should be reached but that a generous pay rise is needed for nurses and that that will not be phased? Without that, we will carry on with the ever-rising cost of agency nurses, which has doubled in the past seven years, overtime totalling £600 million at the last count, and an inability to staff beds, even if they are available.We have a massive shortage of doctors coming down the track as a result of the Calman training reforms and the New Deal. That will be further exacerbated by the working time directive. What plans do the Government have in that regard? At the end of the day, however, as the Minister knows, the issue is not purely about resources and recruitment; there is the key issue of public expectations. We cannot have a situation where the Secretary of State continues to reassure us that there are enough resources for virtually every treatment when every health professional will tell you that there is some form of rationing at every level within the National Health Service.
Without government realism on the subject, is it any surprise that members of the public imagine they have a right to ring an ambulance when they are suffering from a bout of flu? The Secretary of State has commended the BMA on its advice. Can we expect similar realism from the Government?
5.4 p.m.
Baroness Hayman: My Lords, I am grateful to the noble Earl and the noble Lord for the support they gave to the efforts made by NHS staff over the past difficult couple of weeks. I shall try to answer the points that have been raised.
In terms of the 35 intensive care beds that were available today, as the noble Lord will understand, the situation changes hour by hour and day by day. At lunch time today there was availability throughout England in each of the regions except for the West Midlands, which started the day with three potential beds expected to become available during the day, and the eastern region where two beds were expected to become available. The bids that have come in under winter pressure funding schemes for expanding high dependency beds in order to ease pressure on ICU beds are also spread throughout the country. I do not think we can ever totally eliminate transfers in intensive care when we are under that sort of pressure. On the other hand, we want to minimise such transfers to acceptable levels. The general picture is not of an uneven spread across the country. I believe that is the issue that the noble Lord raised.
I turn to the number of beds available overall, which was raised by the noble Lord, Lord Clement-Jones, in terms of the possible consequences of PFI schemes. It is important to stress that the review being undertaken will be broad and strategic. It will look at overall needs and ensure that we have the resources available to meet such needs. After that, we shall need to look at individual areas as regards availability.
As concerns PFI schemes and the hospital building programme, which is not exclusively PFI, it may well be that the previous government had grandiose plans. Unfortunately, they did not deliver on them through the PFI schemes. That is why the success of this Government in signing up and getting the building on track is important and has to be acknowledged.
I believe there is a general acceptance that we have a real and pressing need to recruit more nurses. The issue is more complicated than just getting more nurses into training, important though that is. It is important that we look at the other measures taken by the Government. I have given the figures. For example, I refer to the encouragement through bursaries for enrolled nurses to convert to trained nurses and to the encouragement for healthcare assistants and others already working within the health service to be able to train as nurses without losing income by guaranteeing their income during that time.
The noble Earl, Lord Howe, asked what we have been doing. The recent advertising campaign on nurse recruitment had some 14,000 responses. Throughout the country, individual units are working hard to encourage nurses. There is a vast workforce of people who were trained as nurses who are not working in nursing or not working at all at present.
Although pay is obviously an issue overall for the profession, for many nurses flexibility is as important as pay. We must ensure that we provide opportunities within the NHS for people to work flexibly. On a visit to Addenbrooke's Hospital over Christmas I was very impressed with its work to replace the use of agency nurses by running its own internal agency through a bank system. Often people work through agencies because they provide flexibility. That system is useful, not only in saving fees to agencies but in providing the opportunity for people who were thinking of returning to work to try it over a period of time without making a full-time commitment.
Both the noble Earl and the noble Lord asked me to comment further on the pay review body's possible recommendation on nurses' pay. I am sure that both will understand that it is not possible for me to hypothesise about what we may do if certain things happen; nor is it possible for me to give commitments about what we shall do. We made it clear in evidence to the pay review body that we are looking for a settlement that will be fair to the nurses as well as affordable for the NHS. We said that we were anxious to consider issues relating to nurses' starting pay.
If we are serious about increasing the morale and status of nursing, we must recognise that there is more than one problem. I have referred to family-flexible employment policies and to money, but there is also the question of the career structure in nursing. We must allow people to develop and progress within their profession without having to leave hands-on nursing. The more examples we can give of that and the more rewards we can give to such people, the more we shall encourage people to stay in nursing.
Perhaps I may deal finally with the ideology or political commitment to particular ideas, if I may put it that way. In the past, ideological barriers to co-operation
created difficulties for units which may have felt that, first and foremost, they had to continue to fulfil their contracts. The recent willingness of units to co-operate has been encouraging. The flu outbreak has been patchy and some units have recognised that if they have spare capacity it is important to make it available for acute medical admissions rather than to continue with their routine elective surgery. I am glad that the noble Lord raised that point. It is a complete canard that the waiting list initiative has in some way been fuelling the current difficulties.Noble Lords who know the NHS well will be aware that in the two weeks immediately preceding Christmas very little routine elective work takes place anyway. Units under pressure have been cancelling elective surgery so that they can meet the emergency pressure. That causes problems for potential elective patients. Some conditions requiring elective surgery are not minor, but are major conditions. Cancelling such treatment causes problems and difficulties.
I make absolutely no apology for being committed to fulfilling our manifesto commitment on waiting lists. From the letters that I receive every day of the week, I know that it is important to patients that we continue to fulfil that commitment. In doing so, we are reducing waiting times, as well as numbers. However, with the current difficulties, the priority must be to meet the needs of the severely ill patients who are coming into accident and emergency units. This weekend I saw for myself how that operated, when I visited a community unit which, under waiting list initiative money, had opened beds to deal with elective orthopaedic discharges from hospital. Last week that unit had stopped dealing with surgical cases and had handed over those beds for medical cases. So the flexibility is there; we recognise the priorities and, as I said earlier, NHS staff are working extremely hard to meet the stresses on the system.
5.13 p.m.
Lord Laming: My Lords, I thank the Minister for repeating that helpful Statement. It is absolutely right to pay tribute to National Health Service staff and, in doing so, to recognise that we are referring not only to hospitals and to the services associated with them, but also to primary care, which has taken a particular burden on itself in the past few weeks.
With that in mind, I should be grateful if the Minister could also pay tribute to the contribution made by local government, and in particular to those involved in the social care services and the home helps who have given intensive help and support to individuals, many of whom live alone and are bedridden. Will the Minister also acknowledge the help given through increasing respite care and through speeding up hospital discharge arrangements? Increasingly, health and social service providers are working together much better than ever before. Good health care depends on effective social care.
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