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Baroness Farrington of Ribbleton: My Lords, the noble Lord identifies clearly and accurately one of the factors causing concern. There are a variety of factors. I am sure that my noble friend would wish to support the UK Government in drawing to the attention of the Commission and ensuring that it takes action against, for example, the French Government for their failure to implement UK policy in regard to the large number of migratory birds which are killed.

Nurses: Removal from Professional Register

3.1 p.m.

Baroness Ludford asked Her Majesty's Government:

The Parliamentary Under-Secretary of State, Department of Health (Baroness Hayman): My Lords, any nurse dismissed for gross misconduct should be referred by the previous National Health Service employer to the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC) to decide whether he or she should be removed from the professional register. The UKCC can impose an interim suspension from the register, pending a full hearing. While nurses who remain on the professional register are entitled to seek alternative employment, we expect all NHS employers to check thoroughly the employment records of prospective recruits. It would be highly unusual for a nurse sacked for gross misconduct to be offered employment with another NHS employer.

Baroness Ludford: My Lords, I thank the Minister for that reply. However, is it not unacceptable that the present situation allows nurses such as those sacked from Beech House and St. Pancras Hospital for hitting and giving cold baths to elderly and confused patients to slip through the net? Is this not merely the latest in a series of inquiries calling for effective government action? Is the Minister prepared to consider either greater powers for the UKCC--for instance, the civil standard of proof--or the mandatory transfer of employment records to a new employer, which does not presently happen? Will the Minister examine either of those more effective solutions?

Baroness Hayman: My Lords, the noble Baroness is right to draw to the attention of the House the very serious failures in care that occurred in those circumstances. Equally, she is right to draw attention to the difficulties that can arise when the proof available to a regulatory body such as the UKCC in terms of removal from the register is not up to the standard demanded under the current regulations in relation to criminal case standards of evidence. I understand that

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the UKCC's original advice was that there was not enough evidence to proceed with a case against those nurses. The council is now reviewing its advice in the light of the report that has since been published.

There are great difficulties in imposing restrictions on the ability to earn a livelihood of those who remain on a professional register. However, the noble Baroness rightly identifies areas in which we must make sure that professional regulation is married up with protection of the public. I am sure that during our debates on the health Bill we shall explore some of these issues.

Lord Campbell of Alloway: My Lords, put shortly, does the Minister agree that this is not a matter for Government at all? What is proposed?--establishing a register of sacked nurses, with details of their serious misconduct? It is an incredible idea.

Baroness Hayman: My Lords, the protection of the public is absolutely an area in which the Government should take responsibility. We must be responsible for ensuring that NHS employers exercise due diligence in reviewing those whom they appoint. There is a difficult area, referred to by the noble Baroness, where there are concerns serious enough to reflect on patient safety but not such as to deliver removal from the professional register. A revised system, agreed with the BMA, the postgraduate deans and regional directors of public health, of "grey alerts" has been in operation for public protection in regard to doctors and dentists. We are currently considering whether such a system could be extended to nursing and professions allied to medicine. As I said earlier, there is a balance to be struck between the rights of employees and protection of the public. We must get that balance right.

Lord Ewing of Kirkford: My Lords, does my noble friend agree that one way forward may be to give the health service ombudsman a right of appeal against such decisions, as in these cases they have clearly been unsatisfactory?

Baroness Hayman: My Lords, my noble friend refers to the decisions of the regulatory bodies. Concern has been expressed in a number of areas as to how regulatory bodies function. A report into the workings of the Nurses, Midwives and Health Visitors Act is due to be published. It should shed some interesting light on some of the areas about which concern was expressed.

Lord Clement-Jones: My Lords, in view of the Minister's very clear replies in relation to the UKCC, will she venture a view as to whether it was appropriate for the UKCC to engage as a consultant a chief nurse at Ashworth Hospital who was then under investigation by the Fallon Inquiry?

Baroness Hayman: No, my Lords, I shall not venture a view on that. When we discussed the Fallon Inquiry report in this House, I said that in each case where NHS employees were criticised in the report that criticism was drawn to the attention of their current employers, who will consider what action, if any, needs to be taken

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in the light of the inquiry's comments. Where those criticised in the report have left the National Health Service but work as independent consultants in the health and social services sector, it must properly be for the organisation contracting the services to consider their suitability in the light of information that is publicly available.

Lord Swinfen: My Lords, when a nurse is sacked for gross misconduct, is that fact reported to the UKCC, enabling it to advise a potential future employer when that employer checks with the UKCC on the nurse's pin number--which I understand should always be done?

Baroness Hayman: My Lords, when any nurse is sacked for gross misconduct, that fact is referred to the UKCC so that it can then take advice--and, as in this case, legal advice--as to whether to proceed against that member and remove his or her name from the register. I am not certain as to whether that fact is on the record that is passed to an employer checking on registration. I shall find out and write to the noble Lord.

Business of the House: Debate this Day

3.8 p.m.

The Lord Privy Seal (Baroness Jay of Paddington): My Lords, I beg to move the Motion standing in my name on the Order Paper.

Moved, That the debate on the Motion in the name of Baroness Gardner of Parkes set down for today shall be limited to six hours.--(Baroness Jay of Paddington.)

On Question, Motion agreed to.

Monetary Policy Committee of the Bank of England: Select Committee

The Chairman of Committees (Lord Boston of Faversham): My Lords, I beg to move the Motion standing in my name on the Order Paper.

Moved, That the Lord Roll of Ipsden be appointed to serve as a member of the committee.--(The Chairman of Committees.)

On Question, Motion agreed to.

The National Health Service

3.10 p.m.

Baroness Gardner of Parkes rose to call attention to the state of the National Health Service, and to move for Papers.

The noble Baroness said: It is a privilege for me to have the opportunity today to introduce this debate on the National Health Service. The number of speakers indicates clearly the importance of the NHS to every individual living in this country. I thank those who are contributing today and know that the speeches will be wide-ranging.

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Throughout my whole working life I was a NHS dentist in general practice, in London, for 35 years and I was fortunate to serve on many health bodies. I care very deeply about the NHS and have seen it become a political football far too often over the years. What is the greatest problem facing the NHS today? There are many major problems, including staffing, skill mixes, pay, working conditions, pressures, verbal and physical attacks on staff, the high cost of new special drugs--I am sure your Lordships are aware of the current debate on the cost of combination therapy for Aids, Beta Interferon for multiple sclerosis and, of course, Viagra. My answer, in a way, includes all of them. I say that the greatest problem in the NHS today is that of unrealistically high expectations.

The present Government bear a heavy responsibility for raising public and NHS staff expectations to a point that can never be realised. Before the May 1997 general election I was Chairman of the Royal Free NHS Trust, and in that capacity I was one of the leaders of a marvellous team delivering high quality, low cost treatment in that outstandingly successful hospital. I attended many meetings of NHS groups outside the hospital and most of those present were convince that all they needed was a Labour Government to have money poured into the health service and all their NHS problems would be solved, almost overnight.

Those expectations have certainly not been realised. It is now 20 months since the Government took office, and the NHS problems continue. We now have waiting lists for waiting lists. There can never be enough money to keep up with the exciting new treatment discoveries, new technologies, and the new and very expensive drugs. All of these are of great benefit to patients, but can only be available within budget boundaries. Modern drug therapy could overwhelm the health budget. We delude ourselves if we imagine that every new treatment can be afforded for every patient who could benefit from it. Choices have always had to be made. Postcode prescribing is unjust and universally deplored.

I have seen too many re-organisations of the NHS. Each one has been disruptive, but each one has had some success. It is time now for new ideas. The new primary care groups (PCGs), to be introduced on the 1st April, are supposedly just a continuation of fund holding in a different guise, I dislike the element of compulsion in the new PCGs. Fundholding was a voluntary matter; GPs could choose not to participate. Sixty per cent. are fund holders and their patients have benefitted from this. GPs will now have no choice. PCGs will be compulsory for all GPs from 1st April. A great deal of extra bureaucracy will be added and the cost of this change is estimated at £150 million.

The transfer of responsibility to primary care groups seems to be a parallel to the transfer to the Bank of England of the setting of bank interest rates; it is a transfer of duty to a body remote from Government; so, if things go wrong the new body takes the blame, not the Government. NHS staff are faced with taking on ever more responsibility.

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In the White Papers--and we have had many of them--little mention if made of pharmacists, dentists, opticians, occupational and physio therapists, radiologists, nuclear physicists--the list goes on and on--midwives, health visitors and volunteers, whose input into the health service is quite remarkable. Here I would note the too often overlooked hospice movement, and the many voluntary organisations and charities. It is impossible to complete the list, but I give thanks to all who have contributed to the health service over the past 50 years and all who continue to do so. This is a time limited debate so I must be brief, many of your Lordships have indicated to me that they have specialised interests and knowledge and will speak on those subjects for which I am grateful.

In the 1948 original NHS leaflet it was made clear that full dental services could not be offered because of the shortage of dentists. Fifty years on, the Observer headline on 24th January says it all:

    "Kids teeth decay as NHS dentistry dies".
The Acheson Report, Inequalities in Health, points out that the growing gap in dental health of the more deprived children has risen from 17 per cent. in 1983 to 70 per cent. in 1993. Paragraph 22.2 is unequivocal:

    "We recommend the fluoridation of the water supply".
I support that recommendation. I leave other dental comments to my professional colleague, the noble Lord, Lord Colwyn, who will be speaking later in the debate.

The present Secretary of State comes over well on the media and I am impressed by the support that he gives to the National Health Service. I believe he genuinely cares, but he spends too much time playing politics. Many viewers--and certainly I am one of them--think that it is time he made a 1999 resolution to stop talking about what he "inherited" and carry some of the load himself. In his second year in the job, what was a credible line is wearing very thin.

When I was still a trust chairman I received a letter from the Department of Health--on smart notepaper and headed "Secretary of State"--enclosing a copy of a letter from a constituent of the Secretary of State. It was sent to him as an MP at the House of Commons, not to the Department of Health. The letter was virtually asking for his intervention to have a constituent patient moved up the waiting list.

Attached was a copy of the reply that the Secretary of State had sent to the constituent, in his capacity as Secretary of State, stating:

    "I was extremely concerned to read that you were obliged to start your wait for treatment again when you were transferred".
This reply was sent before the letter to me asking what the situation was. The reply was not accurate, and to pre-judge such an issue seemed to me to be very wrong. No doubt I did not endear myself to the Secretary of State in replying that clinical need and not political pressure was the basis of treatment in our hospital. It was not surprising that I was not re-appointed as chairman when my term of office expired the following November. The Government oppose a two-tier system. So do I. The Government should tell this to every MP who writes asking for priority for his constituents.

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Because a Labour government introduced the NHS in 1948, Labour has always--I believe unjustifiably--claimed "ownership" of the NHS, and it seems that the public are more willing to accept charges from a Labour government. My reaction to a Labour government and the NHS was the thought that "perhaps they will look at funding in a different way". I am sorry that they seem to have landed on the Lottery; the "new opportunities" fund does not seem to me to be the right way, any more than raiding the "modernisation fund" to meet the nurses pay award.

Today prescription charges are £5.80 per item. The first NHS charges were introduced by a Labour government in 1949 to discourage overuse of the health service. Prescriptions cost one shilling, I believe, for any number of items. Other charges for dental and optical services came soon after, and very necessary they were. Some patients, toothless for years, had as many as forty sets of false teeth made at public expense--and never managed to use any of them.

The previous Conservative government would have been attacked if they had reviewed the whole issue of charging in the NHS, and my views differ from official conservative policy. Conservative spokesmen have said that they would not introduce patient charges--I would. The usual protection for children and certain vulnerable groups would continue to apply, but the introduction of some charges would provide a great deal of necessary extra funding for the NHS. I am not talking about the old chestnut of hotel charges for hospital stays; that has been considered many times over the years and has always been rejected on a number of grounds--not least that at a time when a patient needs hospitalisation there are great anxieties already, and the burden of worry about meeting costs should not be added.

In-patient treatment, and most hospital out-patient treatment, should remain free. There are, however, a number of people, particularly in London, who misuse the accident and emergency services for their own convenience. I believe the charges that should definitely be reviewed are for visits to or by a GP and for prescriptions. The press have floated the idea of £5 per GP visit which does not seem unreasonable with the appropriate exempt categories that I have mentioned. I have asked many Questions in this House about prescription charges. Answers reveal that 85 per cent of prescriptions are exempt from charges. This is far too high at a time when prescribing costs are constantly rising. Many people who receive free prescriptions from the age of 60 can well afford to pay a prescription charge and the new guaranteed income for pensioners that the Government quoted yesterday in your Lordships' House should allow for this.

I have never had private health insurance so the Government's abolition of tax relief for pensioners with private health insurance does not affect me personally, but it is both mean-minded and short sighted. Those with limited means are being forced to bring all their health problems back to the NHS, and add to the overall burden. The rich are unaffected. Middle-class pensioners have had a double hit with the abolition of tax relief on health insurance premiums and adverse changes in the tax on their dividends. The Government

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like to tell us that the Conservative years damaged the NHS and in particular they cite the internal market. In the Commons debate on rationing a Labour MP made the vintage Labour remark "hospital versus hospital and doctor versus doctor". A very dramatic soundbite, but not supported by reality. It is not a scenario that I recognise at all.

The internal market, as the Government constantly call it, was a way whereby those in the NHS and the public developed an understanding of what was cost-effective, what was not, and how hospital procedures were priced in different hospitals. It was important to identify these differences and the reasons for them and to work on from there to obtain the best value for the NHS. With the introduction of the National Institute for Clinical Excellence the Government appear to be following the same path. I welcome the increased recognition of clinical audit. Many of the supposedly new ideas that the Government are about to introduce are simply follow-ons from the Conservative government's health policies with new names attached to them. Warning bells ring about the possible loss of clinical freedom under the NICE proposals. The document A First Class Service--Quality in the NHS states that appraisals will be "before" introduction into the NHS and that,

    "clear authoritative guidance on clinical and cost effectiveness",
will be offered to front line clinicians. Surely, this means that the introduction of any new treatments or drugs will be by a slower process. The words "cost-effectiveness" are repeated too many times. My fear is that this will be a levelling down rather than a levelling up. The degree of central control presently being exercised is made clear from the fact that 242 health circulars were issued by the department in 1998. It is nonsense for the Government to talk about less bureaucracy when they are spewing out a multiplicity of central directives.

Another alarming aspect of the health service is the dramatically increasing budget that health bodies have to set aside to meet the costs of litigation in the health service. Clinical audit and better practice may help but it will certainly not stop this escalation. Recent press warnings are that Britain may become the most litigious country in the world. Do the Government have any plans to reduce litigation costs in the National Health Service? I uphold a patient's right to claim for medical negligence but I find the amounts being paid out as damages by courts today frightening. Will the Government look carefully to see whether there is anything they can do, while protecting the rights of the individual, to limit the cost of payments to meet claims presently being made by NHS patients?

Many tests and many medical treatments are now carried out, not because the patient needs it but for defensive medical reasons. On arrival at hospital a patient may have 100 or more routine tests. Some have no diagnostic relevance and have become outdated. Will a decision by NICE that certain tests are no longer advised as being appropriate act as a defence in a legal case brought against a hospital or practitioner? There would be a considerable saving of time and money if numbers of pointless tests could be discontinued. At the very least will the Government draw up guidelines as to

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settling some legal cases at an earlier point before the legal taxi-meter bills run up and up? In this country compensation is paid out as a lump sum. In some countries the compensation is paid on an annual basis for the care of the patient. A change to this type of system for NHS payments is certainly worth detailed examination.

On Monday the Secretary of State made his pitch for new nurses to enter training and for others to return to the NHS. It is time that government departments started talking to one another. How will nurses, doctors and other health professionals with young families be able to return to the NHS, as the Department of Health would like, when on April 1st the Department of Trade and Industry will place so many mothers, and perhaps fathers too, in a position where they cannot possibly afford to keep the "au pair". Au pairs (foreign students living with a family) enable a parent to take on some work. Many in the NHS rely on this support. When this situation is changed it may be that more will leave rather than return to the health service. We hear of low morale in the health service, and certainly public sector pay is well below the private sector even after the pay awards announced this week. Nevertheless, there is great satisfaction in working to help others, and those who work in and with the NHS are genuinely dedicated, as individuals and in teams, to the improvement of patient care.

The Government have a large majority. They should be brave enough to make the changes necessary to provide adequate funding to ensure a strong base for the National Health Service in the 21st century by the charges that I have proposed, by a separate health tax, or by moving to an entirely new basis for funding health care such as the successful Australian system. This debate today is exactly a year after an identical one. We are still waiting for real improvement and the White Papers do not have the answers. It is time for a radical re-think. My Lords, I beg to move for Papers.

3.27 p.m.

Baroness Pitkeathley: My Lords, like other noble Lords who are to speak in this debate, I am most grateful to the noble Baroness, Lady Gardner of Parkes, for giving us another opportunity to debate a subject that is so dear to the hearts of many of us. The NHS is certainly very dear to me. I literally owe my life to it through swift diagnosis and intervention. I was employed by it for 12 years and have had the closest possible connections with it in my role as a campaigner for carers and currently as chair of the New Opportunities Fund to which the noble Baroness referred.

I find it difficult to recognise the NHS that I know and love so well from the somewhat negative and even alarmist picture with which the noble Baroness presented us. The phrase "the state of the NHS" is open to many different interpretations and misinterpretations. I hope that today we shall avoid the two main misinterpretations: first, that the NHS is only about hospitals; and, secondly, that it is about sickness when its primary purpose is about keeping the nation healthy. Only a tiny proportion of NHS care is about hospitals,

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although it is true that they have always taken up a disproportionate amount of money and certainly are the headline-grabbers. The result of this is what I refer to as the iceberg syndrome: we concentrate on the bit that sticks out at the top--the hospitals--while we ignore the seven-eighths submerged beneath.

For most people their experience of the NHS is about their family doctor, the school nurse, the health visitor who calls when the children are small and the district nurse who dresses an elderly relative's leg after an injury. Even when people go into hospital their experience will be limited because of the huge progress that has been made in shortening the length of stay. In 1951 the average length of stay in hospital was 45 days; now it is less than seven days because of the dramatic increase in day surgery and other forms of swifter treatment. There are those who would say that this progress is unwelcome because people are discharged too quickly. While it is certainly true that successful discharge is dependent on follow-up services, ask any patient whether he welcomes the opportunity to go home earlier rather than later and the answer will not be in doubt.

Most people's experience of healthcare is at the primary care level and here huge changes are under way, as the noble Baroness reminded us. Unlike the noble Baroness, I believe that those changes will produce enormous benefits. Local doctors and nurses are the ones who know about local health needs. They see patients regularly, and for the first time in the history of the NHS they will be making decisions which will ensure that their patients receive the best possible care and treatment. The establishment of primary care groups will cut the number of bodies commissioning local healthcare from about 4,000 to 500, cutting the waste and bureaucracy of the internal market and the two-tier fundholding system. That will mean better plans linking hospitals, GPs and community nurses, enabling them to work together to manage local pressures and to make the best use of local resources.

Moreover, there will be strong emphasis on links with local authorities, especially social services departments, an area where lack of communication between departments has caused much distress and confusion in the past. One feature of primary care groups which will please patients' representatives is the inclusion of a place for lay members and non-executive directors on the managing group. In many area good systems for ensuring that those lay members can communicate with local pressure groups are already emerging and will ensure that the PCGs are fully in touch with the real concerns of the population.

We should also remember that healthcare must include community care. I do not subscribe to the view that community care has failed. On the contrary, many aspects of community care have been a resounding success, enabling people to live independently or with their families with the support of packages of care provided in new and innovative ways by health local authorities and the voluntary sector. Improvements are of course necessary but many of those are now under way thanks to the radical reforms of social services and mental health services proposed by the Government. For

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the first time in a lifetime spent working in either health or social services in this country, I begin to see real evidence that the so-called Berlin Wall between health and social services is being broken down. The unseemly competition to offload responsibility to another service in the interest of meeting budgetary targets is changing. The use of pooled budgets and the establishment of local health improvement programmes means that local services are focusing above all on the needs of the local population.

That brings me to my second theme. The NHS is not, or should not be, about sickness but about health. It is about maintaining our population in the healthiest possible state by taking the broadest possible view of what constitutes health. No health service, however well funded, can achieve that except by ensuring that each individual takes as much responsibility as he is able for his own health. I believe that we should be rightly proud of the huge strides which have been made in recent years in involving patients in their own healthcare. We now understand that engaging the patient and, where appropriate his or her family, in the patient's healthcare is the most desirable, not to mention the most cost-effective, way of dispensing treatment. There are, I am sad to say, still those who think that patients knowing too much about their illness or looking up alternative forms of care on the Internet is not to be welcomed. It may certainly make patients less acquiescent and more demanding, but it also makes them more responsible, more aware of their own part in their treatment, and, above all, it acknowledges the fact which too many professionals are prone to forget: that the patient and often his family are the key players in any healthcare system. Most healthcare is not administered by doctors and nurses or even pharmacists or dentists but by one's own family.

The progress which has been made on the public health agenda in terms of healthier living programmes, healthier schools programmes and healthier workplaces will therefore have a huge influence on the health of our nation. Far from making people more demanding of an overstretched system, as the gloom and doom scenario would lead us to believe, it will make us more responsible for our own health and that of our families. Information is the key to that. If people are well informed, they will take responsibility for themselves. That is the way in which we shall deal with rising expectations. I believe that rising expectations of the health service are a matter for rejoicing not sorrow.

The success of NHS Direct, which was reported to us yesterday, is proof enough of that. It is good news indeed that the service is to be extended so that 60 per cent. of the country will be covered by the end of year.

I wish to draw attention to one other welcome development. I refer to the establishment of a network of healthy living centres throughout the United Kingdom through funding through the New Opportunities Fund, of which I am chair. Perhaps I may remind the noble Baroness that the use of lottery funding for the purposes of new initiatives in health education and environment was widely publicised before the last election, has been the subject of extensive consultation since and enjoys huge public support.

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Healthy living centres will promote good health in the widest context. They will help people of all ages to improve their well-being, both physical and mental, and thereby improve their quality of life. They will present health positively. And while there is no blueprint for a healthy living centre, it will probably include screening services, food co-operatives, activity programmes, stress management, parenting classes and employment training and skill schemes. The sum of £300 million is available for the initiative and we opened our application line for business last week. I am sorry that I do not have my cheque book on me today, but I am sure that many noble Lords will ask me about the initiative.

One important feature of that and other New Opportunities Fund initiatives is their focus on reaching the most disadvantaged people in our society. For too long the link between poverty and health has been ignored. Indeed, the previous government denied its existence. The Government have grasped that nettle courageously and vigorously. Healthy living centres are one of the most important ways in which we acknowledge that we need to counter inequalities and reach out to people who experience poor health and earlier death as a direct result of social exclusion. So we shall be targeting areas of deprivation, including rural areas, and particular ethnic communities and of course linking with other vital initiatives such as health action zones.

In summary, notwithstanding the undoubted problems which exist, and no doubt will be dwelt on at length by other noble Lords, my perspective on the NHS is optimistic. I believe that we have every reason to hope and believe that the next 50 years will create an even prouder record than the first 50 years; and that the result of the changes currently under way will not only be a healthier NHS but a healthier nation.

3.37 p.m.

Baroness Thomas of Walliswood: My Lords, I thank the noble Baroness, Lady Gardner of Parkes, for her wide-ranging introduction. I did not agree with all she said; neither did I agree with everything said by the noble Baroness, Lady Pitkeathley. There are many views on the subject. I think that by the quality of the speakers, the debate is likely to give us a wide range of views on a wide range of topics. Not withstanding the fact that I have been a user or a patient of all the community and primary healthcare services to which the noble Baroness, Lady Pitkeathley, referred, I shall concentrate on shortages of hospital beds and nurses. I do so because I spent some time as a non-executive director on an NHS trust in the early days of those trusts.

Bed shortages in NHS trusts came to prominence last month--not for the first time--during what was publicly stated not to be a flu epidemic. It demonstrated what many people had always feared; namely, a lack of any slack in the system which has been caused by the run down in numbers of hospital beds since the NHS reforms of the hospital system. A health professional stated at the time that since hospitals are working increasingly to full capacity all the year round one does not need much of an upturn in demand to create real problems.

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The difficulties of the normal winter situation, plus a flu outbreak of the same severity as in 1996-97, was most serious, as one might expect, in respect of intensive care beds. News items around 7th January reported many healthcare professionals expressing serious concern. I quote:

    "Intensive care in this country is in crisis at the moment. The problem with intensive care beds was predicted but unfortunately too little was done in time."
That is to say, the right investment was not available early enough to satisfy the lead time to set up more intensive care beds.

    "It is impossible to keep the full complement of 50 nurses needed to run a seven-bed unit."
That was from a manager in one of the major provincial hospitals.

    "It is not unusual for a London patient to travel to Manchester."
That was from an officer of the emergency bed service.

A longer term context was given by one official who said that while the UK had pioneered the whole concept of permanent intensive care beds the UK now spent less on them than any other developed country except Greece.

The problem of bed shortages was clearly exercising the Secretary of State as long ago as last September when he set up an inquiry into provision of beds which is due to report in "the spring". Early results show, apparently, that there are not enough NHS hospital beds. Now there is a surprise! Can the Minister reassure us that this report is on course for completion and that it will be published?

The Secretary of State has also declared,

    "Our extra investment will ensure that we can respond rapidly when we have the final report".
I do not often venture into financial fields, but it does appear--even to me--that that extra money is in danger of being spent many times! Nor can we be certain that the various factors other than pressures for efficiency on hospital trusts can be dealt with so easily.

I shall turn to what I believe is the most significant--a shortage of nurses--in a moment, but meanwhile there are a couple of others which may be harder in some ways to deal with. First, there is the unfortunate prominence given by this Government--as by their predecessors--to the PFI initiative as a way of financing investment in hospitals and their facilities. Without going into a lot of detail it is widely claimed that this approach will result in a further reduction in the number of hospital beds.

Meanwhile, on the demand side, there is a new phenomenon, to which the Chair of the General Practitioners Committee of the BMA has drawn attention; namely, the self-reference of flu sufferers to hospital when they could sensibly dose themselves with hot drinks, paracetamol and a couple of days in bed. This is rather like the phenomenon of increased demand for doctors' visits, which in the opinion of the professionals are often unnecessary.

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Finally, there are the many problems under the heading of bed-blocking caused by the divide between social services and the NHS. I could give a dissertation on that subject, but I shall save it perhaps for the Second Reading of the forthcoming Bill.

My conclusion is that shortage of beds will not be so easy to eradicate, at least in the short term, even though I am fully aware of the arguments around new forms of treatment and the changing role of GPs.

A major cause of bed shortages is, of course, a shortage of staff, which ensures that beds which are theoretically available for the care of patients are in fact closed.

    "I can't remember a time in the last few years when it has been so difficult right across the country. The Government has given us more money but in some parts of the country we just can't recruit the staff".
Those were the words of the Chief Executive of the NHS Confederation. The current 8,000 shortfall of nurses in NHS hospitals, made worse by the shortage of therapists, is ascribed by observers, and by the nurses themselves, to a number of causes: low pay; staging of awards; poor working conditions; a lack of newly qualified nurses to take the place of those who resign or retire; and the over-emphasis in the new training programmes on a graduate calibre of nurse which can discourage less intellectual would-be nurses. And ahead there is the prospect of about one-quarter of existing nurses retiring over the next two years or so, reflecting the dangerous imbalance in the age structure of the nursing profession.

Again the Government have made a start, via the recent wage settlement, in solving some of the pay issues, though they are putting some of that extra £21 billion to work here as well. And it is a bit much to blame "previous governments", as the Secretary of State so often does, for staging pay rises when this Government did the very same thing last year. Then the line was that service staff recruitment and retention in the public sector remained good and that, while there might be some specific shortages, these were not necessarily wage related. Hence the staging in the name of budgetary prudence. In the event, government expenditure undershot estimates so the staging, which in the NHS certainly worsened the staffing situation, was unnecessary.

Of course, the problem for the Government next year will be to sustain their new approach. Stop-start in the annual pay round will not help to retain staff. Have the Government calculated the ongoing cost of the settlement for the next five years or so? Will the commissioning budgets be adjusted to meet the cost of labour in the NHS?

Another welcome initiative by the Secretary of State is the increase in the number of training places that has been announced, although it must be noted that last year there were more places than trainees to fill them. The trouble for the Government is that they made major, popular, and correct, promises to the people about improving the NHS after the locust years of Tory administrations. So far it is difficult to see any improvement; indeed, in some respects things have continued to get worse. Now we need to be reassured that the Government have acted in a carefully considered and cost-effective way in their current wages

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packet for NHS staff. I certainly saw no analysis of the effect on staffing of the high percentage rise given to the most junior nurses. I do not object to that approach; indeed, there may well be a strong case, quite independent of the matters I have been considering in this speech, for re-structuring nurses' pay. But can the Minister give me any figures for the increase in the number of NHS hospital nurses which they expect will result from this pay settlement? And can she tell us what consideration the Government have given to the shortage of both hospital and primary care doctors which some analysts are now predicting?

The Government, as I said, have some promises to live up to. More important, they have the health of the nation in their care. Some of their thinking in their first year of office was hopeful and there is an important Bill on its way to this House. But it is by the quality of decision-taking, and the actions that result, that governments are known. This debate will, I am sure, demonstrate that there are many in this House both able and willing to submit these to close scrutiny, among them Members on these Benches.

3.47 p.m.

Baroness Masham of Ilton: My Lords, I thank the noble Baroness, Lady Gardner, for instigating the debate. The interest in your Lordships' House so often mirrors the interest of the public at large. That is illustrated today by the number of your Lordships wishing to speak.

Over the years, I have served on a community health council, the Yorkshire Regional Health Authority and the North Yorkshire Family Health Service Authority. During that time, every few years there seemed to be a reorganisation. No sooner had people become organised and in a working routine than there was a general post, jobs changed and people became unsettled.

Hospitals seem to be working with no slack in the system. The shortage of nursing staff means that sometimes young, inexperienced nurses are having to take too much responsibility. With so many nurses coming from abroad and working for short periods while they travel around Europe and the world, there is a lack of continuity. Although, with high technology and medical advancement, one needs well trained, highly educated nurses, there is also a need for less academic but dedicated practical nurses. I believe that doing away with the two-year trained state enrolled nurses was unwise. Many of those practical nurses worked well and complemented the fully trained three-year general nurses. Now the less academic people are lost to the NHS and work in supermarkets and shops and as secretaries. In their place are nursing assistants who are dressed up in uniforms and whom patients take for trained nurses although they have little training. Using agency nurses and bringing nurses from abroad is expensive.

It is not just pay that has exacerbated the shortage of nurses: it is the expense of accommodation in cities; violence in A&E departments, which has increased due to drinking and drugs; and abuse from patients. Nurses need to be valued. Large hospitals are busy places and

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need extremely good management. The NHS needs stability and patients need confidence that they will receive the best treatment. I spent time recently with some people who had undergone major surgery and their praise of the National Health Service was immense.

Having had my life saved by blood transfusions, perhaps I can ask the Minister to say whether she is confident that the blood transfusion service is thriving. It has to be vigilant in relation to the problems of HIV and hepatitis. It has to ensure that there is an adequate supply of blood.

I should like to raise a few points following my Starred Question on meningitis last Thursday. Although it is such a serious condition, there is still not enough known about it. One in 10 cases results in death; one out of seven survivors is permanently disabled. Anyone can contract meningitis but those at greatest risk are the under-fives--especially those under one--16 to 25 year olds and the over-55s. It is often not known by the general public that older people can be at risk.

The noble Earl, Lord Dudley, asked a question on Thursday about identifying possible contacts with carriers. As meningitis is a notifiable condition, is there a follow-up with contacts? Could they be detected by taking a swab from the back of the nose or throat? Also could more be done on prevention?

The noble Baroness, Lady Ludford, asked about parents recognising the symptoms. A few weeks ago parents twice took a baby to a hospital in the north of England and were sent home. On their third visit the child was admitted, only to die in intensive care. In such cases there should not be a cover-up of those responsible. To wait until a rash appears may be too late; septicaemia may already have developed.

A few days after asking the Question I was telephoned by a doctor from south Lincolnshire. He was concerned that because there was no 24-hour paediatric cover in the hospital at Grantham the maternity unit had closed. Should children contract meningitis, they would have to travel long distances for treatment. One of the doctor's own children had contracted meningitis in the past; he knows that every second counts.

Does the Minister agree that there should be a monitoring system for the whole of England run by the Department of Health so that sick patients need only travel safe distances to obtain treatment. If doctors feel the risk is too great for patients, there should be a safety net to oversee health authorities. Can the Minister say whether the National Institute for Clinical Excellence--NICE--will do that?

I am president of a spinal injury association which deals with some of the most disabled people in society--many paralysed from the neck down. We are a self-help group and know only too well the specialist help our members need. We welcome the creation of NICE. We hope that it will offer opportunities for achieving high standards of quality across the NHS. We hope that services will be provided with the user perspective in mind. We believe that NICE should establish national protocols and care paths in speciality areas from acute care to rehabilitation; publish measures of its success; and disseminate its findings to the wider

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public, organisations and patient-user groups. The audit and monitoring of specialist provision throughout the country is extremely important.

I conclude by bringing to your Lordships a difficult section of society who need help from the NHS; these people fall between two stools. I refer to adolescent health. Adolescents do not fit into paediatrics nor are they catered for satisfactorily in adult facilities. There are no adolescent educational programmes for professionals such as nurses, social workers and health promotion officers in Britain. Many adolescent young girls with health problems are residing in prisons. Also, the terrible problems relating to drug and alcohol abuse in that difficult age group are getting worse.

On the whole the NHS does a wonderful job in difficult circumstances, such as in relation to the spread of infections resistant to antibiotics, the relentless flow of patients with high expectations and the growing elderly population who need and deserve better care. Health and social services need to co-operate and co-ordinate. The National Health Service should always be at the top of any government's agenda; it is the most important commodity we have.

3.56 p.m.

Baroness Knight of Collingtree: My Lords, one could make many criticisms of government Ministers on the way in which they are handling the health service. But those Ministers would perhaps not be such an easy target if they had not attacked the Conservative government so ferociously and not claimed repeatedly that voting Labour would magically end all the problems in the health service. Instead, they should attempt to understand the difficulties that will always exist in the biggest multi-service business in Europe. They would then not be so vulnerable.

We must accept that, whoever is in charge of the health service, we can never satisfy every patient. We cannot all be treated by the doctor of our choice wherever we want because the problems are too great. All we can do, wherever we sit in this House, is the best we can and try to understand the difficulties faced by those who are confronted by the problems.

Many noble Lords are anxious to speak tonight so I shall touch on one part of the health service only; that is, eye care. My husband was an optometrist. He died 13 years ago and I hasten to say that I have no financial interest in any business connected with optics. However, I have a strong interest in good eye care for our people.

Your Lordships may not be aware of the present and growing fashion for "plano cosmetic contact lenses"--the street name is "party lenses". Those interested in acting, advertising or merely in creating a sensation are going in for party lenses in a big way. They can turn one's eyes bright blue, green or perhaps even spotted. One can obtain a contact lens imprinted with a union jack, a bicycle, a bed, a belly-dancer or whatever takes one's fancy. Linford Christie wore a puma on his for an advertising stunt and no doubt it will not be long before a millennium logo appears (though please God, not the Dome!).

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Because the lenses have no optical correction, they are not covered by medical restrictions as are normal contact lenses. They can therefore be sold anywhere--in garages, on market stalls or in joke shops. They can be sold by people who have no knowledge and who can give no advice about their use. "Does that matter?" I hear you say. Yes, it does. There is a great deal of evidence, both here and abroad, which indicates that those lenses pose serious risks to wearers. I am not talking about the tiny risk of contracting BSE from eating beef-on-the bone. I understand that one is 10,000 times more likely to be struck by lightning than to get BSE from eating beef-on-the bone, but the Government have legislated against it.

I am talking about a real risk. In such lenses there are toxic dyes and paints. The designs are painted on and then the lenses are slapped on what are arguably the most delicate and sensitive parts of the body. Surely, it is wrong that they can be sold freely, without any clinical guidelines, by totally untrained retailers.

When trained optometrists fit lenses the patient does not only have his eyesight corrected, but he is also shown exactly how to clean, handle and wear those tiny bits of plastic. The law ensures it. Nobody tells wearers of party lenses anything, although they carry serious risk of infection, and I am told that they can threaten one's sight.

The optometric profession and the lens manufacturers have warned the Department of Health repeatedly of the dangers. Of course, they have. What would you expect? Would you not think that the department would, with such evidence available, instantly have rushed to impose restrictions on them. Not a bit of it. Nothing at all has happened. It is perfectly fair to say, "Why not?".

The second point that I wish to make is that today optometrists play an important part in treating certain eye conditions with drugs, much more so than they used to. More and more universities are offering optometric courses and training in ocular treatments and how they can be administered. However, some of the drugs needed can be obtained only through a GP or a hospital. GPs readily admit that they are not as highly trained in eye conditions as optometrists. How could they be? Doctors train for seven years to treat the whole of the immensely complicated machine that is the human body. During those seven years they have one week in which to train in the complications of the eye--one week out of seven years.

Optometrists train for at least four years purely on the eyes, and nothing else except the eyes. However, when a patient of an optometrist needs certain medication, the optometrist has to send that patient to a GP or an hospital eye department to get the prescription. It would be a useful saving of a doctor's time and it would reduce pressure on hospital eye departments--it would also save the patient time and trouble, which is worth considering--if an optometrist could give the prescription that, after all, he had prescribed. I do not believe that the BMA, or anyone else, would object. It is a perfectly reasonable suggestion that would save time for hospitals and GPs.

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Therefore, I offer the Minister, in my friendly, helpful way, not one, but two suggestions for small changes in the law, which together could produce big benefits to the health service and might even save it some money.

4.4 p.m.

Lord Winston: My Lords, I should first declare an interest as a practising academic at Imperial College, as a consultant in West London, as research and development director for the Hammersmith Hospitals NHS Trust and as a member of the council for the Imperial Cancer Research Fund.

Listening to the debate so far, I wondered whether a mere man would get a word in sideways. I suppose I have been following the ladies for most of my professional career, so it is only reasonable that I should speak at this point.

We are grateful to the noble Baroness, Lady Gardner of Parkes, for introducing her Motion. However, I am puzzled by the criticisms that she produces. While I feel that political speeches are not as appropriate in the House of Lords as in another place, I believe that there are some basic points on which I need to set the record straight.

The noble Baroness spoke about waiting lists for waiting lists. The truth is that waiting lists for waiting lists started under the previous government because of the inevitable rationing that occurred at funding authorities. In my own service I saw the cruelty of that and the inequality that it produced. We were able to treat some patients from one area and not from another because of the stipulations of particular waiting lists within waiting lists--even before patients could get on a waiting list!

The noble Baroness talked of the depressing lack of new ideas. I have not heard many new ideas from the other side of the Chamber yet, but perhaps 20 months of opposition is not quite long enough. The wealth of new ideas that the Government have brought in to the health service are beginning to bite and we are beginning to see them as of great advantage. The noble Baroness spoke as if we had transferred responsibility away from government. That did not happen under this Government; that happened a long time ago. Rationing was blamed on the purchasers in the old internal market system. The praise for the care given by nurses seems to be somewhat faint, given the terrible time that nurses had for so many years with inadequate funding, with the huge amount of paperwork necessitated by the internal market and by a career structure that devalued nursing at the bedside and devalued clinical access to patients.

Let us be positive and make one thing clear. The truth is that it is not possible to turn round a major supertanker--the largest industry in Europe--in 20 months. It will take a great deal longer. However, there are signs that the turnaround is taking place. In this short speech I want to try to hold the Government to account for a few areas in which I am particularly interested and I hope that the noble Baroness, in her summing up, will address one or two concerns that I have. I believe them to be far-reaching and important ideas that the Government undoubtedly have in changing the way that healthcare is delivered in the British Isles.

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As a specialist physician, I am concerned by the strong emphasis on primary care. Of course, nobody for a moment denies the importance of primary care. It is the front line of medicine, it is where patients first come and it is where the first sifting, the first triage occurs and where the public has the most contact. However, the truth is that the NHS, like any healthcare system anywhere in the world, must be delivered, maintained and improved by specialist input. When we are very ill, specialist input is most important to us.

All the speeches so far have, effectively, pointed out in different ways the importance of that specialist input. I have no doubt that more and more speakers will add to that. The noble Baroness, Lady Masham of Ilton, talked about her own experiences and they are typical of so many of your Lordships' experiences in terms of specialist input.

The noble Baroness, Lady Thomas of Walliswood, made a crucial point about hospital beds. That is another area in which there is a great need to ensure that we get the balance right between what happens outside hospitals and what happens inside them.

One problem that we must face--one does not want to apportion blame to any government, whether Tory, Labour or whatever the party may be in the future--is that the specialist services in the health service are now threatened in all sorts of ways as they have never been before. That should be a matter of great concern to this House and, indeed, the Government. The nature of the internal market, for example, left a great deal of fragmentation in the health service. When I started as a specialist, I could treat patients irrespective of whether they came from Carlisle, Cardiff or Truro. That did not matter because we had an NHS budget. We were able to develop expertise in dealing with particular conditions. That could then act as a paradigm, a model, for development in that area within the whole health service. That is no longer possible. If we are not careful, I am concerned that instead of abolishing the internal market, we might, in effect, exchange it for another kind of market. I hope that the Minister will take some time to address that issue.

It is very important, for all sorts of reasons, that patients requiring specialist care have access to such care at the best level. That has always been a great tradition of the NHS. Indeed, it is one of the reasons why clinical research in this country frequently--usually--outstrips that of the Americans. In the past, the Americans have often been greatly envious of the sort of work that we have been able to do.

We are also facing a failure of specialist training as never before. The Calman reforms added to that. Trying to get into line with Europe in terms of medical training has meant a reduction in specialist training in this country. We are perilously close to training consultants who are of inadequate experience and who possibly are inadequate in terms of their medical backgrounds. That is a potential disaster for the health service.

The lack of concentration of specialist expertise has meant a failure as never before in our ability to find an adequate research basis--that is, a collection of patients with particular conditions to use as a model. Patients

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often end up receiving mistaken treatment because they are not receiving the best specialist advice. On average, I receive two letters a day from patients who say that they do not understand the working of the health service. I have with me a letter from a lady in Middleton, near Manchester, who has had an appalling history. I shall not recite it to your Lordships, but that lady lost a child and has probably had inappropriate surgery. She is now damaged and wants to come to us, on an NHS basis, but that is impossible under the current structure.

In the last couple of minutes allotted to me for this speech, I should like to address the related question of research and development in the health service. I announced earlier that I am a research director, so I am somewhat parti pris and have a definite interest in this. I am concerned that the current exercise on evaluating research and development in the health service should be conducted along the best lines. It has been stated that we shall concentrate on certain issues within the health service: cancer; heart disease; mental health; ageing; primary care; prevention; and public health. Those are excellent areas for research, but I am concerned that we do not lose sight of the important need also to build in a major component of basic research in the hospitals that are geared to carry out research and development.

I hope that the Government will agree that, for example, although the research and development may be unevenly spread across the country, there are very good reasons why that position should not change too hastily and why it should continue to follow the general HEFCE model. I am sure that the way to get the best value for money is not to destabilise cities such as London, which appear on paper to be over-funded, but which actually provide the greater part of the development that is needed.

It would be unwise to remove the NHS research and development assessments from HEFCE assessments. More encouragement must be given to universities and we must recognise their importance to the NHS. In my own trust at the moment, for example, we want to employ an obstetrician who ought to be an academic. However, the NHS will have to supply that post. There must also be a recognition of the length of time--

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