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Lord Hunt of Kings Heath: My Lords, perhaps I may point out to the noble Lord that he has reached the end of his time. We must keep to the time-limits this afternoon.

Lord Winston: My Lords, perhaps I may be allowed to make my final sentences. There must also be a recognition of the time that will be needed to develop such matters into issues of public health importance. I hope that in future civil servants will at least visit some of the trusts which are conducting the research and development exercise because, so far, that has been signally lacking.

4.15 p.m.

Lord McColl of Dulwich: My Lords, I echo the thanks expressed to my noble friend Lady Gardner of Parkes for introducing this debate. I should like to deal

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with the question of morale within the NHS which seems to be at a rather low ebb. The Government's habit of attacking NHS managers is bad for morale. Soundbites such as "Heads will roll" simply induce despondency. That is not the way to manage a hard-pressed workforce.

Another example was the Secretary of State for Health telling senior managers that they were not to have private insurance for private health care. In fact, in the old days, it was common practice to admit senior managers to a separate room off one of the wards. They were treated like private patients because they were well known in the hospital and it was felt unreasonable to put them on the ward. As those senior managers are paid up to £100,000 per year, they thought that perhaps they should take out private insurance and pay for their care as they were being treated as private patients. That was a very civilised thing to do. The Secretary of State for Health's attack on them on that score, telling them not to have private insurance, hassled them quite unnecessarily.

That reminds me of the story of a lady Member of Parliament--I shall not tell your Lordships to which party she belonged--who went into a hospital not 100 miles from here. She was put into a separate side ward, off the main ward. Within a few minutes, she was out again, telling the sister, "I must be out there with my people, with the working people." She was put out on the ward. She had not been on the ward more than 15 minutes when the people rose up in revolt and said to the ward sister, "You put that woman back in that room or else we're all leaving."

Unfortunately, the Government find themselves in a bit of a mess because, as has been pointed out, they falsely raised the public's expectations that all problems would be solved. They also untruthfully alleged that the Conservative government had tried to privatise the NHS, which certainly is not true; that they had cut resources to the NHS, which is not true; and that they had cut more beds than the previous Labour government. They made many other completely untrue allegations. As Ann Widdecombe said yesterday on Radio 4, we have had 18 years of Labour lies about the NHS and now they are coming home to roost. Now the public and NHS employees realise that they have been misled.

The Government have made much of the pay award. But the consultants are very angry that the Government have rejected one of the most important recommendations which recognised the increased workload and intensity of the work of consultants. As the chairman of the BMA's consultants committee commented:

    "Senior hospital doctors will feel a deep sense of betrayal. We are working at breakneck pace, month in month out. The pressures on senior hospital doctors are immense. The Government has snubbed the review body and refused to play fair with the consultants on whom it depends to meet its waiting list targets and keep pace with rising patient need. Consultants will feel bitterly disappointed and will be highly sceptical of the Government's good faith in the future".

Medical staffing is another source of poor morale. We have had fewer consultant appointments in the past year in some specialties and that is giving rise to great

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concern. My question to the Minister is this: will the Government use some of the extra money--£22 billion which, apparently, they are going to put into the service--to create more consultant posts which are desperately needed? I should declare an interest. I have spent many years training potential consultants in the knowledge that there would be a reasonable number of consultant jobs for which they could apply.

In some specialties there are too few trainees and in others far too many. As the noble Lord, Lord Winston, pointed out in November last year--the Royal College of Obstetricians and Gynaecologists also did so recently--the worst problem lies in obstetrics. There are already over 100 fully trained junior staff waiting for consultants' posts which just will not materialise. At the end of this year there will be 200 fully trained obstetricians with no jobs to go to. They will be out of a job. They are in their mid or late 30s or early 40s. They have spent 20 years in training to be obstetricians and now they come to the stage where they are out of a job. That is a gross waste of public money and very demoralising for the profession and the public.

I am very much aware that no one should be guaranteed a job just because they have trained for 20 years. But the NHS is a monopoly employer and there is nowhere else for trainees to go. The NHS has a duty to maintain a reasonable relationship between the number we train and the number we need. I am told that the Department of Health has decided to try to correct that problem by training fewer people. It plans to do that by withdrawing £5.8 million which is currently being used to train junior staff in obstetrics. It plans to take the money away from obstetrics altogether and use it for something else. Why on earth cannot the money be used to create more consultant posts? We need 200 extra obstetricians in the next four years, as I am sure the noble Lord, Lord Winston, will agree. That will cost £14 million each year. Can the Minister give some hope to those trainees? Can the Government reconsider their decision and start creating far more consultant posts now?

There is another reason for acting as I suggest. The quality of the service is deteriorating because the number of consultants in obstetrics is decreasing. Of all the medical legal cases, 60 per cent. involve obstetrics. So we have a major problem on our hands. The bills in the law courts will rise and rise.

Many patients are demoralised. Thousands have been denied some operations for ever. They will not have the operations at all. It is not a question of rationing or keeping them waiting. They are operations for such things as varicose veins and the removal of sebaceous cysts and lipomas. The Minister said on 7th December that such operations are cosmetic. The patients do not agree. The condition for which they seek an operation is certainly hidden by clothing. The Government have refused to instruct NHS trusts to allow the operations to be done. I believe that this is the first Government to deny these treatments to the public. I wonder whether they realise that poor people cannot afford the £1,000 which is necessary for some operations. Is that not what the Labour Party used to describe as a government grinding their heel into the faces of the poor? I am sure

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that the Government would not like that description applied to them. Therefore, I wonder whether they will reconsider their decision and allow the people who cannot afford these operations to have them done on the NHS. The Government have a duty to restore NHS morale which has been so damaged in this past year.

4.24 p.m.

Lord Warner: My Lords, I, too, welcome the opportunity provided by the noble Baroness for us to debate the improving situation in the NHS. We should all be grateful to the noble Lord, Lord McColl, for his interesting suggestion that we could actually improve the discharge rate from hospital beds by admitting far more politicians to the public wards.

This is the first time that I have spoken in this House on health matters. I do so from a background of over 20 years with the Ministry of Health and the Department of Health and Social Security, or the Department of Stealth and Total Obscurity, as it was formerly known. As a former chairman of a health authority in East London I have seen at first hand the lack of relevance of an internal market to the health needs of people living in areas of great social deprivation.

The previous government's emphasis on better management in the NHS was right. Unfortunately, it became tangled up with their obsession for market mechanisms. The internal market was introduced in a haphazard way without regard to whether there were competent commissioners of health care, the transaction costs and any real understanding of the fundamental inconsistency of having both GP fundholders and health authorities as commissioners of care. No one disagrees with finding out the costs of procedures, as the noble Baroness mentioned. No one disagrees with comparing performance and having rigorous peer review. But to implement these efficiency mechanisms one does not have to introduce an internal market. The result has been that we have had an administratively expensive botched job in which the internal market has driven down the morale of many health professionals and from which the NHS has not yet fully recovered despite the extra money that the Government are pumping into the service.

In the area of nursing the problem has been exacerbated by the reduction of over 20 per cent. in nurse training places between 1992 and 1994-95. That was not the behaviour of this Government, but decisions taken some years ago from which we are still suffering. The previous government's approach to the NHS led to the fragmentation rather than the integration of care that patients need.

I accept that GP fund holding produced improved health care and quicker access to hospital in many middle class areas with relatively healthy populations. My own family has benefited from our excellent fund holding group practice. But I used to contrast my own experience as a patient of a fund holding doctor with the many people I saw in East London. There were few fund holders there accessing the extra resources that went with fund holding. The primary care services there were underfunded and overloaded with the resulting unavoidable, but inappropriate use of hospital services.

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In poor inner city areas where the majority of family doctors work in one or two-person partnerships, GP fund holding was a total irrelevance.

I was once unwise enough to tell a former health Minister that in the previous year I had seen a 100 per cent. increase in fund holding in East London--a rise from 1 per cent. to 2 per cent. I discovered at that point that the Minister had little sense of humour, as I believe many of us discovered as he ran the Conservative campaign at the last election.

I disagree with the suggestion of my noble friend Lord Winston that the Government were giving too much attention to primary care. I am very pleased that the Government have developed a sensible and practical way of enhancing primary care. They inherited a very difficult situation with 50 per cent. of the population in GP fund holding practices and 50 per cent. not. An impasse had been reached. I suggest that the new--nearly 500--primary care groups represent a huge step forward in responding to local health care needs on a co-operative, rather than a competitive professional basis, without doctors scrabbling for patients.

The new groups have been formed through local discussion between GPs, nurses, health authorities and local authorities. For the most part, local people have settled the local boundaries for these groups. I am particularly pleased to see local services involved with primary care groups. As they move from shadow form to becoming fully operational, I would suggest that the primary care groups will return the NHS to its underlying principles, with local frontline professionals working co-operatively to plan and meet the health care needs of local communities.

I heard the shadow Health Secretary speaking on the Today programme yesterday morning: it gave me a bit of a fright. She was suggesting that this Government should show humility about the NHS. I would suggest from my own experience that the shadow Front Bench should actually show humility for some of the actions that have been taken in the past.

One of the most attractive features of this Government's change of direction in health policy has been their willingness to pay attention to unfashionable issues. Of course reducing waiting lists is important and new drug therapies and surgical procedures are exciting. It is very easy for these to grab all the attention and all the new resources, but for many people in our society remedying health inequalities--better public health, mental health services and the funding of long-term care--is more important than the latest surgical wizardry or free Viagra. Rebalancing the health agenda, as the Government are doing, is an important contribution to social justice and a more cohesive society.

I am particularly pleased at the greater attention being given to mental health services. The previous government deserved much credit for the community care reforms that they introduced, and I was very pleased to be associated with pushing them forward in their early days when I was a director of social services. But in the Cinderella area of mental health the

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accelerated move to community care was too often well intentioned but flawed and under-funded. Discharging people into the community from the large impersonal psychiatric institutions has brought enormous benefits to many people and made us a more civilised society. But, as the Government have recognised, the network of community support and supervision was sometimes inadequate. Too often essential drug regimes were not maintained and in some areas, especially in the inner cities, there is inadequate access to hospital beds for people in crisis and needing medium-term care. The new strategy and the extra £700 million announced in December will go a good way towards rectifying the deficiencies in mental health services, providing it is implemented with energy and commitment.

I see from the BMA briefing that I have received for this debate that they want a public debate about rationing. I hope we can interpret this as meaning that leaders of the medical profession want to discuss more widely how we can tackle issues of ineffective medical practice such as unnecessary medical prescribing and the reduction of procedures found to be inappropriate. I would suggest that if many more of the inappropriate treatments were more rigorously rationed by the medical profession we would actually free up resources for more productive uses. Personally, I welcome this kind of public debate about rationing, especially if more leaders of the medical profession are willing to speak out consistently in public in favour of the policies that they often espouse in private, particularly in areas like having a great concentration of highly specialist services in smaller numbers of units, even if some local hospital units have to close. It will be interesting to see medical leaders speaking out vigorously in favour of that kind of approach.

In conclusion, perhaps I could mention that I have discovered in the latest edition of Social Trends that on average men can look forward to 59 years without some kind of disabling condition. I can assure my noble friend the Minister that the age for women is 62, so she has a long time to go! As I approach that milestone I am deeply relieved that we now have a Government who are willing to make a £21 billion investment in the NHS, to abandon the ill-conceived internal market, rebuild our hospitals, start paying decent salaries to nurses and invest in new technology and new approaches like NHS direct. These are the important issues, I would suggest, and not over-hyped media stories about the totally unsurprising fact that more people get sick in winter and make extra demands on hospitals, for which in any case the Government had made extra provision.

4.34 p.m.

Lord Chadlington: My Lords, I should first declare an interest. Between 1991 and 1995 I was a non-executive member of the NHS Advisory Board, actively involved in a number of NHS initiatives. My professional interest in communications should also be declared, as I am concerned in public relations and advertising. Today I shall raise a number of issues concerning the management of the reputation of the National Health Service.

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In the commercial world the proactive management of a company's reputation is now recognised as a central task for the board of directors. It brings real benefit to both workforce and customers. The reputation of a manufacturing company is largely determined by consistently making products of quality which meet the expectation of customers. Occasionally--just occasionally--these products fail, but success is constantly reinforced by corporate and product advertising and other communications methods. That is how, in the simplest terms, brand values are established. It is how confidence in a brand is built. It also leads directly to a strong and viable client-service relationship and, importantly, it indicates how customer expectation can be managed. Therefore it is absolutely central to the success of any organisation, internally and externally.

The public's view of the NHS brand is almost always based on personal experience of, or contact with, someone who has had first-hand experience, normally a friend or a family member. It follows therefore that the reputation of the entire NHS is carried on the shoulders of each individual nurse, every GP, ambulance driver and hospital porter. If that personal experience is favourable, then your view of the NHS tends to be favourable. The one million or so people, therefore, who work for the NHS are its ambassadors. They are the best or the worst advertisement at that all-important point of contact with the NHS: the patient. Low morale, resentment and poor management all lead to an undermining of this brand reputation, as the ambassadors no longer feel able or confident enough to promote the service they provide.

During the time that I worked closely with the NHS--and I can see no reason why this should have changed radically--the vast majority of those who actually used NHS services, as opposed to those who just criticised them, regarded favourably the service and treatment they received. In any commercial organisation this success would be regarded as a strong, and probably a very strong, base on which to build--a real opportunity to tell the good news, to accentuate the positive and to build the brand value. But in the NHS, too often that opportunity suddenly in a moment evaporates. A full-page photograph in a tabloid newspaper of an elderly patient on a trolley in a hospital corridor torpedoes all the accumulated goodwill and the central patient-service relationship is again threatened.

Furthermore, satisfied patients begin actually to question their own experiences. They begin to think that maybe they were the exception and that they were lucky to have had the treatment they regarded so highly. Even those working in the National Health Service begin to ask whether their efforts are the exception rather than the rule. Are they not more likely to believe the words they read and the pictures they see in the newspapers rather than what their bosses, or indeed politicians, tell them?

Of course--this cannot be over-emphasised--one patient on a trolley is one too many. So, too, are those who do not get the drugs they need or who are left for years on waiting lists. We must do all we can to invest in the NHS, improve it and cherish it. But we should also trumpet its day-by-day successes. Some are modest,

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some local and some breathtakingly brilliant. That is the commercial lesson: good news, particularly local good news, changes views.

In the corporate world we build brands and reputations through communicating success and achievement, building a reservoir of goodwill upon which one can draw when things inevitably go wrong--the commercial equivalent of the trolley in the corridor. But if this sustained promotion of success is not pursued, bad news can bring an organisation to its lowest ebb. That is precisely what happens in the NHS. Its "goodwill bank" becomes so sorely depleted that there is not enough to carry it through such crises unscathed.

Large multinationals know that promoting achievement, particularly with photographs in the media and on television, creates a favourable environment to deal with issues and problems. The NHS is constrained, some would argue wrongly, from following this model and promoting its success on a national scale. But surely we should still be putting much more energy into publicising the achievements of the NHS day by day. Every day, literally millions and millions of contacts are made by the people of Britain with NHS employees. There are comparatively few complaints and comparatively few moans; but lots of good experiences. A quality service. Yes, it could be better. So could every commercial organisation that I have worked for in the past 35 years.

I have one final point to make. Every time a commercial management publicly fights for the rights of its company, sometimes against unjust or unbalanced press comment, the employees rally behind it and fight, too. They want a management which fights on their behalf, publicly and with vigour. I suspect that those million or so working in the NHS would also feel the same way.

4.41 p.m.

Baroness Sharp of Guildford: My Lords, I join with other speakers in thanking the noble Baroness, Lady Gardner of Parkes, for providing us with the opportunity today to debate this important subject. I live in west Surrey. Our health authority, the West Surrey Health Authority, has the distinction of serving one of the healthiest areas in the country. It is not only healthy, it is also one of the wealthiest--and, as we all know, the two factors are not unrelated. Those with high incomes tend to be better housed, better educated and benefit from lower levels of unemployment than others. Because we are healthy and wealthy, the NHS, quite rightly, judges our needs to be lower than those of authorities of similar size which serve poorer, more deprived areas.

However--and here is the rub--being healthy and wealthy does not actually reduce the demand for healthcare services. On the contrary, it is a well-established fact that healthcare has what we economists call a positive income elasticity of demand; that is to say, that as incomes go up, so people want more of it. Expectations about the quality of care provided are high in west Surrey. The middle classes are

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health conscious, they make good use of the screening services provided and they visit their doctors readily if they are worried. That is good from a health point of view and is one reason why we come high up those health league tables, but it is disastrous from a funding point of view.

The statistics say it all. In 1997-98 our health authority had an income of £227 million, while expenditure was £246 million. "Misery," as Mr. Micawber would say. We ran a deficit of £20 million. Inevitably there were successive rounds of cuts. The chief executive resigned and the new chief executive has been conducting a wide consultation exercise on priorities, urging us all to fill in forms with what we think are the most important things. He has been searching desperately for further areas of economy. But even in this coming year with higher levels of income--thanks to the generosity of the new Government--we still face a deficit of £5 million and need, over the next three years, to find further savings of £14 million to pay back previous debts.

I tell this story because I think that it demonstrates well the dilemma facing the NHS today. Detailed studies on where we have gone wrong and where expenditure has overshot show that with the exception of mental health (which perhaps reflects the degree of stress associated with making all that wealth in west Surrey), expenditure is not excessive. The problem is one of demand. We just cannot stop people from going to the doctor. Although NHS Direct has shown that there are perhaps ways of screening that demand, which could make use of resources rather more efficiently, for the moment, there seems very little that we can do about it.

Looking at the situation from a national point of view, this suggests that increasing amounts of money in the system may help, at least temporarily, to relieve the problem. But as the nation grows more prosperous, so we shall demand more and higher quality healthcare services generally. Whether we like it or not, we have to face up to the fact that spending more money as a proportion of GDP on healthcare is a likely future trend--and, if we want to retain a publicly funded service this means more government expenditure on the NHS--and that some form of rationing of services is here to stay.

In many ways it is amazing how much we do manage to squeeze out of the system with the NHS. When I lived in the United States--where health spending is now a massive 13 per cent. of national income--I took great pride in telling my American friends that the National Health Service gives everyone, overall--both rich and poor--a better quality of service for less than half the cost. In this country we currently spend 6.9 per cent. of GDP on health. If one looks at the statistics, it will be seen that that figure shot up by 1 per cent. in the early 1990s when we introduced the disastrous internal market experiment. Nevertheless, we still spend less than most of our EU partners. Germany is now spending over 10 per cent. of its GDP on health, while France is spending over 8 per cent. Among the more advanced countries, only Denmark manages to get away with as little as we do in the United Kingdom.

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What does Denmark do that we do not? Next to Luxembourg it is by the far the wealthiest country in Europe in terms of GDP per capita. I believe that the answer is that what Denmark achieves much better than we and many countries do is "joined up thinking" in relation to health--that is to say, health, housing, jobs and education are seen as interlinked. It uses the GP service, as we do, as a screening service but makes much wider use of paramedics. It also puts a lot more emphasis on health education and promoting healthy lifestyles.

From these Benches we applaud the Government's shift away from the wasteful fragmentation of the internal market in health to a more co-operative style of management. We welcome in particular the emphasis now being given to primary care and the degree to which GPs will now act as surrogate consumers, driving the system. As my noble friend Lady Thomas made clear, we also welcome moves to bring together the health and social services. But we are not yet convinced, if I may say so, that enough "joined up thinking" is going on in Government circles.

Waiting lists, for example, may have come down, but between March 1997 and September 1998 the number waiting for out-patient appointments has, according to the Department of Health's own statistics, increased from 248,000 to 437,000--an astonishing increase in pre-waiting list waiters of 76 per cent. Similarly, although waiting list numbers are down, waiting times are up. In west Surrey, we have nearly 1,500 patients who have been waiting for more than a year for their operations. That number is up considerably compared with last year's figures. If I may say so, there is still too much attention being paid to one set of statistics and not enough to the overall quality of care.

Above all, it seems to me that the Government are still thinking too much in terms of a national sickness service and not a national health service. Yes, I welcome very much the initiative to set up the healthy living centres described by the noble Baroness, Lady Pitkeathley. But they are not yet in being. In too many different areas--for example smoking, diet, pollution, housing and exercise--the Government seem to have gone soft on the targets that were set by the previous government and which the present Government promoted in their White Paper Our Healthier Nation.

We all know that a healthier nation has healthier lifestyles. As the west Surrey experience illustrates, that will not alleviate the pressures on the health service but it may in the long run enable us to find some mechanism for containing some of the costs, as the Danes have done. I look forward to the day when a debate in this Chamber on the National Health Service is genuinely one about health and not one about crisis management.

4.50 p.m.

Lord Butterfield: My Lords, I join those who have expressed gratitude to the noble Baroness, Lady Gardner of Parkes, for initiating this debate. I wish to make a few general opening remarks about the Health Bill. I am impressed with the enormous range of measures which the present Government are intent on introducing. I am

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interested in and share the concern that the noble Lord, Lord Winston, expressed about the fears he has that specialist services may become submerged in relation to community and primary care work. However, he need not worry too much about that as I believe the Royal Colleges will take an interest if consultants are left standing on the shore.

It is clear to me that the Government have a huge agenda. An enormous number of people will have to be drawn in to help the 500 primary care trusts. I am not alone in thinking the agenda is enormous. The NHS confederation has stated that it is a huge agenda which is supported by NHS organisations but will require an NHS cultural revolution. I believe the noble Lord, Lord Chadlington, mentioned that in his speech this afternoon, which I admired greatly. We must all realise that we need to support each other and that we must try to make the most of the good aspects of the health service. We should frown on the man who makes some nasty snide remark in the newspapers about either the performance of the previous government or the present Government in this regard. I have been involved in the health service since the beginning. All the people in the health service I have met have always wanted to do something good. They may have been misguided here or there, but let us for goodness sake put our oars in the water and pull together for the sake of the health service as a whole. It really should not be a party political issue.

In preparing for this debate I have not spent as much time as I should have done on the subject of dentistry. Many years ago I was keen that more research should be carried out into dentistry in this country. That matter was investigated and I was pleased when academics supported the idea of carrying out more research in this country into dentistry. Dentistry does not feature in the Health Bill. I encourage the Minister to make a little note perhaps on the bottom of a piece of paper and preferably in red to the effect that we must help dentistry. Information I have received from the British Dental Council indicates that there is an enormous amount of work to be done. Many people are concerned that they cannot obtain dental treatment on the NHS. However, there are difficulties in attracting young people into dentistry. I hope that we can do our best for dentistry because it is so important to health generally. If one's mouth and teeth are in good order, one has a chance of being healthy. If they are in poor order, one does not stand a chance of being healthy.

I suggest that we pay a little attention to the famous parable of the dying peasant farmer. He calls his boys around his deathbed and tells them that there is a treasure on the farm. He tells them to go out and find it. However, he does not tell them where the treasure is before he dies. As we all know, the boys worked hard on the farm. They tilled the soil and their crops were incredibly good. Only then did they realise that that was the treasure their father had talked about. To my mind that is generally true of the NHS.

I note that the noble Baroness, Lady McFarlane, is present. She will doubtless be concerned that the Health Bill does not adequately incorporate the nurses' point of view as regards the primary care trusts. We must wait for the wave of nurses' interest in administration to

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break into the health service. I note that the noble Lord, Lord Rea, is also present. He was in general practice before he came to this House. He brings many good messages to us about what is going on in general practice. I hope he will not mind if I reflect on the good aspects of the health service and consider the work that was done in Thamesmead by a colleague of mine who had a clinic there. He was raised to a professorship, if that is an appropriate way of expressing it. My colleague, Peter Higgins, set up an exemplary pilot NHS project for the students at Guy's. I am aggravated that people do not realise there are pioneers in the health service who have done wonderful things.

My colleague told me that the first important thing he did at that clinic was to form an alliance with a lady psychiatrist. They agreed that if he looked after the neurotics in the practice she would take care of the schizophrenics and the manic depressives. My colleague told me that he learnt how to manage the neurotics and it was a great relief to him that he did not have to take care of the completely disorganised thinking of the schizophrenics who needed so much care and attention. He asked consultants to come to the clinic. He set up training schemes for social workers. There has been a dreadful gap as regards people making a connection between social work and medicine. However, Peter Higgins managed to train social workers in his outpatients clinic in Thamesmead. He discovered that the student social workers could offer support to patients while he dealt with the next problem that faced him. He also had nurses working and training in the clinic. He had a strong philosophy of openness. He talked about transparency in medical services before that word was coined. He was keen that patients should feel they could ask questions openly. That is all written up in a 1982 edition of the British Medical Journal. I have reread that document and I am delighted to see how much he achieved.

I wish to mention another series of people digging away in the soil of the NHS; namely, those concerned with health promotion. I became involved with the Health Promotion Research Trust. I got into terrible hot water because people could not understand why the money that we distributed came from budgets for tobacco advertising, not from the tobacco industry itself. Certain people in the industry used to boast that they supported the Health Promotion Research Trust. I maintained they did so because we were carrying out good work. However, many people said that we were receiving money from a bad and evil source.

I wish to refer to both good and bad news that has emerged from ongoing research. First, I shall mention the bad news. It appears that the nation as a whole is becoming more and more obese. Therefore there will be more and more cases of diabetes and rheumatism for the NHS to treat. I have graphs which indicate that we are all gaining weight. That was revealed in a survey involving 10,000 people. The good news is that people who eat salads and fresh vegetables all year round have much better health records and much less cardiovascular disease and cancer than those who do not. So when

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noble Lords go off to their markets or supermarkets, they should stop first at the healthy foods and buy some fresh vegetables and fruit.

I thank your Lordships for listening to my speech. I want you to know that I have every expectation that the health service will fulfil all the feelings that the people in America, when I was a medical student during the war, had about it. The forward thinking ones used to say, "You are on to a very good thing".

5 p.m.

The Countess of Mar: My Lords, I am very grateful to the noble Baroness, Lady Gardner of Parkes, for once again giving me an opportunity to ask the Government to recognise the plight of many National Health Service patients and their families. The patients all suffer from illnesses which have what are known as ill-defined symptoms. They have been variously diagnosed as suffering from ME/chronic fatigue syndrome, fibromyalgia, multiple chemical sensitivity, sick building syndrome, and of course the two in which I am particularly interested, OP poisoning and Gulf War illnesses. That is not a comprehensive list. The National Health Service has not served them well, though there are a few notable and heartening exceptions, of which I am one.

I have a certain amount of sympathy with the doctors practising in the National Health Service. Because of the polysymptomatic nature of these illnesses and the traditional specialist divisions in the NHS, they fall into no particular specialism. With the exception of ME, which has a well-documented history covering nearly 50 years, these are all relatively new illnesses. Their origins are, more often than not, attributed by mainstream medical and scientific researchers to psychogenic rather than chemical or biological causes. This attribution is frequently regarded as insulting by those individuals suffering from a range of symptoms which often prevent them from working or functioning socially on a day-to-day basis. The medical practitioners responsible for their treatment often scorn them when they do not respond to drugs or cognitive behavioural therapy--the standard treatment offered to this group of patients. They blame the patients rather than the treatment for the failure of the patients to recover. All too frequently patients are sectioned under the Mental Health Act or, if they are children, they are placed on the at risk register, made wards of court and are forced to accept psychiatric treatment. You do not need much imagination to visualise the damage this does to patients and their families.

Most patients have some idea of the origins and cause of their illness but their doctors refuse to listen. Sufferers' organisations have been formed in an attempt to obtain recognition of, and research and treatment for, these illnesses. Their members have developed a very special expertise in counselling, informing themselves of research results which point to possible causes and finding their own treatments for their illnesses. In my work with these groups I have observed that their illnesses have many common features.

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Noble Lords may be aware that the practice of medicine is very vulnerable to fashion. I recall that, during my childhood, it was fashionable to have one's tonsils removed as they were thought to be a nuisance and to serve no useful purpose. Before that I understand appendectomies were all the rage. There were also fashions for the nomenclature of diseases. Between the two world wars, that all too distressing disease, multiple sclerosis, was called the "idle man's disease". Psychologists are now in fashion. They are able to attribute all the subjective bodily symptoms to psychological causes. I recognise that emotional stress can cause somatisation. We all know that fear causes our hearts to beat faster and may, for example, make us feel sick. However, can the researchers be so sure that the neuro-psychological symptoms displayed by patients with these new illnesses are not caused by chemical or biological factors? After all, drugs, which are chemicals, are prescribed deliberately to alter the chemistry of the brain.

It is now known that the human olfactory system, for nearly a century thought to be defunct, does, like our tonsils, have a major part to play in our physical and psychological well-being. Research has shown that chemicals which are inhaled have a direct route into the limbic system of the brain through the olfactory bulb. The limbic system controls many of the bodily functions for which this group of patients reports malfunctions. The blood/brain barrier was, until recently, thought to be inviolate. We now know that, under conditions of physical or mental stress, the barrier may rupture, allowing chemical and biological toxins to penetrate all regions of the brain. On the whole the body is exquisitely designed to be able to deal with toxic assaults, but we do not all come off the same computer controlled production line. Some of us have design faults which make us more vulnerable to chemical and biological exposures.

Those who say that these illnesses are "all in the head" may not be so wrong. Those who say they are "all in the mind" may have to eat their words. Could it be that the symptoms of those suffering from ME/chronic fatigue syndrome, fibromyalgia, sick building syndrome, multiple chemical sensitivity, OP poisoning, Gulf War illnesses and maybe schizophrenia and other mental illnesses have much in common and that it is only the original trigger which is the differentiating factor?

I have come to the conclusion that there are a number of reasons why this area of research is so poorly funded. Most of them revolve around money. The past 50 years have seen thousands of new chemicals and chemical compounds used in industry, agriculture and in our gardens and homes. No toxicity data, or minimal data, are available for 66 per cent. of pesticides, 64 per cent. of drugs, 84 per cent. of cosmetic ingredients, 81 per cent. of food additives and 88 to 90 per cent. of the chemicals used in commerce. Very little is known about the synergistic or potentiating effects of combinations of chemicals. Little, too, is known about vulnerable populations. All we do know is that reporting of these kinds of illnesses is increasing. If chemicals were to be

3 Feb 1999 : Column 1527

implicated as the cause of so much ill-health, the repercussions on the chemical and pharmaceutical industries and on employment would be enormous.

Another likely reason for the lack of research is that those individuals and bodies who are responsible for recommending research proposals and for funding are either the same as, or are very closely allied to, those who have been responsible for the manufacture, safety and licensing matters in the past. It is a common, and very human, failing to be reluctant to admit that you have made a mistake. It must be particularly difficult for scientists who are held in such high esteem by the rest of the population. Is it not much easier and, I would suggest, perfectly natural to fall back onto the psychologists, who appear to be able to provide very logical explanations?

There are many independent researchers, working on shoestring budgets, who have found physical abnormalities in these patients. In the light of the failure of mainstream science and medicine properly to investigate possible organic causes for this group of illnesses, perhaps I may ask the Minister two questions. Would she and her colleagues in another place be prepared to fund an international conference of a cross-section of independent researchers in this field to discover whether there is any common ground between them? If there is, would she consider joint departmental funding of research proposals based on this common ground? I am certain that in the long run this would save the NHS a great deal of money.

Politicians are primarily the guardians of their nation's security and the well-being of its citizens. I would suggest that this is a problem which may require political intervention. Do we really value the health of our national bank balance and chemical industry above the health of our nation's citizens, particularly our children?

5.9 p.m.

Lord Rea: My Lords, I am not sure whether it was by accident or design, but the debate introduced by the noble Baroness, Lady Gardner, for which I thank her, has enabled us to take a preliminary canter round the Health Bill which will shortly occupy much of your Lordships' time. I hope that that Bill will lead to a better National Health Service, containing as it does proposals for the NICE and the attributes of a CHIMP. It will naturally be enhanced by the critical attention that your Lordships always give to such Bills. In this debate I wish to step back further and examine the way in which the National Health Service is coping, and will cope in future, with our most intractable problem, that of social inequalities in health.

The health of any nation is more important than the health of its health service. The two are not synonymous. In the developed world, the United States, which spends the highest proportion of GDP on health, has the worst health statistics; while Greece, which among European Union countries, spends the least on health, has an expectation of life which is near the top of the range. In the United Kingdom, which spends only 6.9 per cent. of its GDP on health, as the noble

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Baroness, Lady Sharp, has just pointed out, our health statistics are in the middle of the range. They include some rather bad areas. I refer in particular to heart disease and breast cancer--and on a less serious, but nevertheless socially serious, level, teenage pregnancies are very much in the news. Some noble Lords may have heard Professor John Guillebaud's controversial suggestion of contraceptive implants. It is a solution that is not acceptable to most opinion, at least judging by the knee-jerk responses so far.

In a most welcome change, this Government have fully recognised the importance of health inequalities in contributing to our relatively poor health statistics. If all our people were as fit as those who are reasonably well-off and well educated (those who live around Guildford, it appears) our health record would be the envy of the world. A top priority must be to improve the health of the less well-off and less well educated.

With commendable speed, soon after the election, the Government asked Sir Donald Acheson, the former Chief Medical Officer, a very respected epidemiologist, to review the evidence on inequalities in health. His report was published two months ago. Like the report of his predecessor, Sir Douglas Black, but now able to cite much more scientific evidence, the report emphasises that health inequalities have wide social and economic causes which concern almost all government departments.

But the National Health Service plays an important role in dealing with the consequences of those inequalities. As Frank Dobson has said, very directly--one might say frankly--poor people are sicker people. They die earlier and, more important to the National Health Service, they are more subject to many chronic ailments, both mental and physical, which imply additional costs for the NHS. Poor people see their GP more often than those from professional backgrounds. However, the quality of the consultation that they receive may be less thorough because of the greater time pressure on GPs in deprived districts. There are other reasons that make for a lower quality of consultation as well. Poor people attend hospital casualty departments more often, as was pointed out by my noble friend Lord Warner, and have more emergency admissions. There is some evidence that they do not have more planned in-patient admissions and operations, taking their greater burden of chronic illness into account. That is particularly true in the case of coronary heart disease.

In his Recommendation No. 37, Sir Donald Acheson states:

    "We recommend that providing equitable access to effective care in relation to need should be a governing principle of all policies in the NHS. Priority should be given to the achievement of equity in the planning, implementation and delivery of services at every level of the NHS".
He goes on to make specific suggestions, one of which is,

    "extending the remit of the National Institute of Clinical Excellence (NICE) to include equity of access to effective health care".

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I believe that the Government are aware of these problems, but it will clearly not be possible, as my noble friend Lord Winston pointed out, to turn matters round in one Parliament. That will certainly not be enough time.

However, a start has been made, with the decision, for instance, to implement the first wave of health action zones in 11 deprived parts of the country. That concept is close to the recommendation of Sir Douglas Black in his 1980 report, which suggested the setting up of,

    "a special health and development programme in a small number of selected areas".
He went on to suggest that a proportion of the funding should be reserved for evaluative research and statistical and information units. In replying, will my noble friend give the House a progress report on the HAZ initiative? It was always intended that there should be pilot schemes and that their experience would be built on more widely. To do that effectively, evaluation needs to be built in from the start, as Sir Douglas Black suggested 20 years ago--a process that was notably absent during the introduction of the 1990 health reforms by the previous government. I hope that my noble friend will assure the House that this necessary evaluation is taking place.

Apart from the health action zones, there are relatively deprived people in all parts of the country, including pockets in the midst of quite affluent areas. I hope that the existence of HAZ schemes will not exclude attention to their needs too.

One of the most worrying problems presently facing the National Health Service is the difficulty of recruiting and retaining GPs and nurses, particularly in inner-city areas. Some progress was made in London by the London Implementation Zone (LIZ) initiative of the previous government. But there is still a long way to go. Many inner-city GPs are approaching retirement, when the situation will become more acute. A paper in this week's BMJ illustrates the problem graphically. It examines the age structure and distribution of GPs who were trained in the Indian sub-continent and who came to work in Britain in the 1960s when there was a shortage of UK-trained doctors choosing to work in the less attractive areas of the country. The paper, by Taylor and Esmail, indicates how over the next 10 years some deprived areas will lose up to 25 per cent. of their GPs through the retirement of south Asian doctors, while more affluent areas, not having a high proportion of overseas doctors, will experience the loss of very few and will more easily replace them. The problem is made more serious by the fact that these are the very areas that should receive extra resources in view of their worse health problems. I am not sure that the Government are doing enough lateral thinking on ways and means of attracting young and idealistic doctors and nurses, who still exist and want to work in those areas where they are most needed.

My noble friend often says that money is only part of the answer. That is true. Purpose-built or imaginatively adapted buildings, good and affordable housing, better schools for the offspring of health workers and good

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support services all need to be part of the package. They would make working in the inner city a challenging opportunity rather than a depressing and demoralising experience from which most professionals want to escape.

The recent public sector pay settlement has been relatively generous, particularly to newly qualified nurses. However, there is still a long way to go before the general level of nursing pay becomes high enough in relation to other occupations of similar status. Will the Government state that over a period of years they intend to rectify this position, to bring nursing salaries more into line with those of other professions? Would that not be the best way of reassuring nurses that the Government recognise that their role is central to the National Health Service?

Like the noble Baroness, Lady Masham, I wonder whether nurse training--not only in relation to state enrolled nurses but Project 2000 based and degree courses--is sufficiently hands on. Nurse training has traditionally depended on a high proportion of apprenticeship experience, with block releases for theoretical teaching. Are the Government satisfied with the current arrangements for nurse training? I declare an interest, as one of my daughters is now in her second year of training at Bart's.

5.20 p.m.

Baroness Fookes: My Lords, those of us who have come here from another place may well remember the late Sir Michael McNair-Wilson. He was a Member of Parliament who thought his career was coming to an abrupt end because he suffered kidney failure. With great courage and ingenuity, he contrived to keep going, partly by using the time when he was chained to a dialysis machine to deal with constituency correspondence, prepare speeches and the like. Like so many others before and after, he had to wait for a transplant, but he eventually had one. That brought its own difficulties, but he secured a much better quality of life for some years. It was always very instructive--and, indeed, very moving--to talk to him about what it meant to be a patient in those circumstances. It made me very sensitive to the needs of those who require a transplant--whether of kidneys or other organs--and to this day I carry a kidney donor card. I hope that many others also carry cards.

The transplantation service faces a serious situation. In 1997 the Royal College of Surgeons felt moved to set up its own working party to look into the difficulties. It issued a report a few days ago, in late January. Its chairman, Professor Sir Peter Morris, was obviously extremely anxious about the situation. He referred to the service being on, what he called, a knife-edge--not, I thought, the happiest phrase for a surgeon to use. He pointed to two great difficulties: first, the shortage of organs; secondly--and just as worrying--a shortage of surgeons with a specialty in transplantation at their fingertips. As I listened to my noble friend Lord McColl, it struck me that here was an extraordinary irony: apparently there are too many obstetricians and too few transplant surgeons.

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The report set out a number of recommendations, chief of which was an idea for a national transplant service which would have some overview and strategic planning in this area. The service would seek, among other things, to increase the number of donors through a national campaign--it wants virtually to double the number to 10 million--and to bring forward more transplant surgeons by extra training, research fellowships and any other means. That is all admirable stuff. But the report contained an idea which worried me somewhat. It referred to the need for "rationalisation of units". In plain English, that means it is necessary to shut a few units. I would not be able to comment on what this might mean nationally--or even whether or not it is wise--but I know about the position in the west country, where I represented a constituency in Plymouth for some years. In the west country there are two renal units--one at Derriford Hospital in Plymouth and another at Bristol. The report of the Royal College of Surgeons suggests that one unit should be closed. I wish to make a strong plea tonight that both units should remain open.

Strangely, the unit in Plymouth--about which I know rather more because I am the president of the Friends of the Kidney Unit, as they call it in Plymouth--meets the criteria set out by the Royal College of Surgeons: that there should be four surgeons carrying out at least 50 transplants a year and serving a population of some 2 million. Plymouth can provide all of that.

It is an excellent unit within an excellent hospital. When I toured the unit a few months ago and began to get an inkling of what might happen, I was very struck by the quality of those running it and by the very real feel that the patients had for what was being done for them. The unit is in a very up-to-date, go-ahead hospital, which already has a most successful cardiac unit. In the old days patients had to go from Plymouth to London or Bristol; now they are treated on the spot. I would hate to see something which is already working well dissolved and disappear. It is hard enough to make things work well without getting rid of them.

Let me make another important point. I am not sure whether the working party fully appreciated the dispersed nature of the population and the geographical spread of the area currently served by Plymouth. The area runs from the Scilly Isles, through the long leg of Cornwall and Devon and beyond. In terms of travelling time, it is extremely difficult for both patients and families and friends who want to visit them. That alone makes the need for the renal unit to stay at Plymouth absolutely vital. It is not all that easy if you are living in the Plymouth area, but just imagine what it must be like when you are sick to come over from the Scilly Isles, or from north Cornwall or through the Devon lanes for hospital treatment, and then having to go back again and again for check-ups.

It is absolutely essential that the unit remains open. I have great faith in it. I am not sure who will make the final decision but, in so far as it relates to the Department of Health, I hope the department will take on board what I have said. Now that it is known, I can tell the Minister that tremendous feeling is working up

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in the west country about this. It adds a very real element of anxiety and worry to those already in a very difficult position. I hope that any decision will be made as quickly as possible and that it will be the right one, not only for the city of Plymouth but for the whole of the west country.

5.27 p.m.

Lord Morris of Castle Morris: My Lords, do your Lordships remember Five Boys chocolate? On the wrapper were five pictures of a boy in various stages of anticipation and delight. It came to mind yesterday when I went back to the Chesterfield and North Derbyshire Royal Hospital for the opening by the Prince of Wales of the new cancer care suite, for which they had raised more than £260,000 by sheer hard work. Everyone looked pleased, but some newly qualified nurses looked delighted--like the boy on the chocolate wrapper--at their 12 per cent. pay rise. Others, who had served many years on the wards and in the sluice rooms, were less impressed by their 4.7 per cent., which some said would not be enough to prevent the continued haemorrhage of experienced nurses from the profession; nor would it attract those who had left to return. Senior nurses, with many years of experience, told me that there was still no real incentive for nurses to move up to the higher grades, and that once you were at your grade ceiling there was still little chance to progress except by moving into management, education or research. So although they were truly grateful for the pay settlement announced on Monday, they felt that it alleviated the agony without fully solving the problem.

The nurses and administrators looked forward to the promised radical review of NHS pay and gradings and hoped to see a real simplification of the system which has reigned unchallenged and unchanged for nearly half a century, with separate scales for everyone, and grades running from A to I. There was enthusiastic support for an integrated system for all healthcare professionals--with perhaps three strands covering medical, nursing and PAMs; with far fewer alphabetical grade divisions; and a sweeping away of the "add-ons" for training courses and the like, which lead to complications, bureaucracy and discontent.

Similarly, they were profoundly unimpressed by rumours of "performance related" increments which they felt in their profession could only be divisive, selfish, unquantifiable and unworkable, and I had to agree. I have seen what a dog's breakfast such schemes have brought in universities and all such vocations--"when service sweat for duty, not for meed".

So, three cheers for promises fulfilled and cash duly awarded, but nurses still have a long way to go. Next time your Lordships re-read Dickens's Oliver Twist consider chapter 2, where Oliver aged 9, in the workhouse, half-starved on one small bowl of gruel, bravely goes back to the man at the cauldron with the words,

    "Please, sir, I want some more".
So do nurses. Pay is the single most important way in which the morale of NHS nurses can be raised.

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But there are other issues which the NHS and the Government can and must address. Perhaps I may address just four of them. First, with family-friendly employment policies. The RCN reports that 85 per cent. of nurses responding to an ICM poll last February said family-friendly policies would encourage them to stay in nursing. The implications of Bristol Employment Tribunal's ruling in the case of in Alison Hale and Christine Clunie v. Wiltshire Healthcare NHS Trust are quite clear: nurses are becoming ever more ready to stand up for their human rights as women, wives, mothers and carers. Three cheers for that. Yet when I have inquired of the Department of Health about the progress of pilot schemes evaluating the Swedish scheme called Timecare, I have not been reassured. One official said that there had been complications with the software; another said that currently the report was being considered by Ministers, and we all know what that means. That was last October, the month when it was planned to publish the results. May I ask my noble friend when we can expect them, please? One thing is certain: if and when the report appears, it will bear none of the distinguishing stigmata of being a rushed job.

Second, let us salute the success of the Government's encouragement of specialist nurses. These are not "failed doctors" or "mini-GPs" but nurses who have undertaken advanced training in areas take gerontology or cancer care without in any way sacrificing their central basic nursing skills. They are nurses with additional knowledge and skills whose first concern is still patient care. Will noble Lords pardon a personal instance that makes the point? When I was receiving chemotherapy in hospital last spring a specialist haematology nurse was assigned to keep an eye on me. Her name was Carolyn. One morning she set up on my drip stand a bag containing brilliant royal blue liquid and attached me to it. Modestly averting her eyes, she said "When that finds its own way out it will be a bright emerald green. "Dont worry" she said I only mention it because the fact is more evident and more alarming to gentlemen than to ladies". That is a small example of patient-centred, specialist, expert nursing care. There must be more of it, and soon. We welcome what has come but how much more and how soon will it come?

Third, let us rejoice with exceeding great joy at the success of NHS Direct. It was a huge delight to listen yesterday to the Statement read out by my noble friend. But let us not forget the implications of that success. Increased use of NHS Direct will lead to a nurse being the first point of contact between the patient and the NHS, not the GP. Not only will some patients and some GPs resent this and require careful reassurance, but there will also be resource and funding implications which will require control and monitoring. Even though these nurses will be paid at F or G grades, is my noble friend quite sure that enough can be recruited? It is estimated that in the Yorkshire district alone 50 nurses will need to be employed to do nothing else. I hope that my noble friend can reassure us on those points.

Fourth, a word on the vital matter of nurse education. Melanie Phillips wrote recently in the Sunday Times:

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    "Women are turning away from nursing in large measure because it has changed. Its leaders decided it had to gain higher status by becoming more professionalised. So during the 1980s nurse training was taken away from the hospitals and turned into an academic subject taught in universities. As a result, it has driven away people who would make excellent nurses but have no academic bent. Conversely, why should people who are degree material choose such a low-paid job?"

How much truth is there in that view? Not much I think but some. That is a very difficult problem at the centre of nurse training. She goes on to state that those student nurses studied courses such as matters as sociology, politics, psychology and, management, and gender studies. I would have thought that in an accident and emergency unit on a Friday night a course in gender studies would be of rather less use than a course in unarmed combat. No my Lords. My dream is of an integrated, modular course which will involve all nursing students, and allowing some to drop out and start work with a diploma at approximately the old SEN stage while others go on to a degree and postgraduate degrees. Why should a nurse not have a Ph.D? Perhaps the UKCC review will consider this before September.

My daughter, a health visitor, tells me that when she was a nurse on a busy ward a group of student nurses came, instructed to observe what went on. The ward sister was explaining when the buzzer went--as it always does--and she asked one of the students if she could take Mrs. Jones to the loo please. The student said, "No", said the student, "I have already observed that procedure". "Well" said the sister coldly, "if ever you become a nurse you will observe it a lot more. Now, please, take Mrs. Jones to the toilet". Nursing is still, and always will be, about caring for patients. Nurses must be valued for doing that.

5.36 p.m.

Baroness McFarlane of Llandaff: My Lords, I too thank the noble Baroness, Lady Gardner, for giving us an opportunity to hold a wide-ranging debate on the National Health Service. I also thank the noble Lord, Lord Morris, for championing nursing in his usual wonderful and human way. We identify with so much of what he said. I focus on the state of nursing education. When we entered the House together I told the noble Lord that I was so glad to see that he preceded me in the order of speakers because he would pave the way. His response was, "Yes--like John the Baptist". I rather fancy that in his speech he may have been calling for repentance, but I am not sure.

In focusing on nursing education I declare an interest. I was the first professor of nursing in an English university. Therefore, I witnessed the early developments of nursing within the higher education sector. I believe that I must accept consequent responsibility for some developments since then. In the light of what I believe to be the positive contribution made by higher education to the quality of nursing care, I should like to examine some of the misconceptions and myths that have been voiced about nursing education. At the moment nursing education is subject to a good deal of "scapegoating" and almost every ill in the profession is blamed on the new system of nursing education. I refer to such matters as the shortage of nurses. It is

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asserted that potentially caring young people are deterred from entering nursing because it is perceived as being too academic and that caring people do not want to have their heads filled with knowledge. What price doctors? It is asserted that the products of the courses are not clinically competent and have lost the sense of identity with the health service that they once had when they were hospital-based students.

We should do well to consider why Project 2000 was instituted. It was initiated by the late Dame Catherine Hall when she was chairman of the UKCC. She had a profound appreciation of the needs of the health service and the place of nursing within it. The committee attempted to look forward to the education required by nurses for practice in the year 2000. A number of project papers--I believe eight--were prepared, and there was the widest consultation, with over 1,000 responses analysed. The report, Project 2000: A new preparation for Practice, was a careful analysis of the kind of practitioner of nursing who would be needed in the new millennium, the range of skills that nurses would need, and the knowledge basis to be safe practitioners of those skills. It took into account the range of situations in which nurses would find themselves. We do well to remind ourselves of those objectives since Project 2000 is often vilified--it was so vilified in the article quoted by the noble Lord, Lord Morris--as a flight into academia for status seeking nurses. It was not. The project was an attempt to seek a better basis for practice.

Some cardinal principles were laid down. Student nurses should not be exploited as cheap labour, as they had been in the past, with work allocated to them which had nothing to do with their education. They should be learners of nursing. The reforms should take into account the changes in medical science and the consequent differences in the nursing role. The programme should provide an introduction to nursing in a variety of settings. No longer would a nurse have to return to the beginning of a course to train for a new register; and therefore their deployment in the National Health Service could be more flexible. At that time there was evidence from school leavers that they wished to have the right of access to higher education along with their school-leaving colleagues. The hospital-based school was seen as a deterrent to the recruitment of school leavers. The hospital based schools did not have the stimulation of a multi-disciplinary learning environment that a university had.

The committee recommended that there should be one level of trained nurse. Many people lament the passing of the enrolled nurse. However, because of the shortage of registered nurses, enrolled nurses were asked to undertake skills and tasks beyond their knowledge and competence. The same is happening now. Nursing auxiliaries are being asked to undertake tasks far beyond their knowledge and competence.

Research showed that in the hospital based programmes--it was indicated in some of the research with which I was occupied in the 1960s on the quality of nursing care--many nurses used rigid, procedurally-based approaches and were incapable of

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adjusting their practice to the individual needs of the patient. Those are some of the many reasons that Project 2000 was recommended.

The Project 2000 report recommended links with higher education for diploma level courses. In fact the vogue at the time was to give far wider access to higher education; hence the whole lock, stock and barrel went into higher education for diploma courses and degree programmes. It may surprise some to know that the minimum entry requirement into nurse education has remained unchanged with the introduction of Project 2000. I can read a long list. It requires five GCSEs (Grade C or over); NVQ/SVQ level 3; GNVQ advanced; NVQ/SVQ level 2, plus one GCSE (Grade C or over); or GNVQ intermediate plus one GCSE (Grade C or over). There is no evidence to suggest that large numbers of young people are being denied access to training because of entry requirements. Nursing education now has wide entry requirements. Let us look at the figures. Twenty six per cent. come without traditional entry requirements. The average age is 27. Accessing nursing education through vocational courses is increasingly popular; and that is educationally desirable.

The proportion of practice to theory originally recommended was 60 per cent. practice to 40 per cent. theory. The figure has now become 50:50, so there has been a slight addition of theory to the course. At present 90 per cent. of nurses enter through diploma courses, and 10 per cent. through degree programmes. I think that there is in some places a perception that everyone is becoming a graduate. That is not the present truth.

I believe that it is now time to review Project 2000. The four government health departments have commissioned a review of the Nurses, Midwives and Health Visitors Act which is expected to report in June this year. The UKCC has commissioned a review of pre-registration education and training. That is due to report in September. I plead that we wait for those reports and reviews, and link them carefully to the skill mix required not only in nursing but medicine and other health professions. For instance, the Campbell report has profound implications for the skill mix needed in nursing. We need "joined up" thinking in planning for the health service and a way of keeping that under review.

I believe that clinical competence is the most important factor in nursing education. We need strategies. Many suggested strategies, such as joint appointments, point in that direction.

5.47 p.m.

Lord Vivian: My Lords, I, too, am grateful to my noble friend Lady Gardner of Parkes for introducing the debate. However, I must declare an interest as I am Honorary Colonel of 306 Field Hospital Territorial Army, a Commissioner at the Royal Hospital Chelsea and a Special Trustee at the Chelsea and Westminster Hospital.

In today's debate we have been invited to comment on the state of the National Health Service. I wish to draw to your Lordships' attention that in the future the

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state of the National Health Service will be affected by the dependence on it of the Defence Medical Services Secondary Care Agency. However, before commenting on that, I should like to record that a vast debt of gratitude is owed to the doctors, nurses, clinicians and all supporting staff and employees at those hospitals. They are dedicated to their profession and loyal to the system, and compared with other countries it is a truly wonderful and remarkable service.

I was going to focus on National Health Service funding, nurses' pay and waiting lists, but time does not allow me to do so if I am to deal in a broad manner with the Defence Medical Services. However, I should like to say how disappointed I am that part of the capital investment fund is to be used to fund the nurses' pay award. That will inevitably reduce investment in mental health care, modernisation of hospitals and technology, more education and training for NHS staff, reducing hospital waiting lists and providing information technology for GPs. I believe that even with the pay rise on 1st April nurses' pay is still too low. Their pay should be increased further and their conditions of service improved if we are to recruit new nurses, retain nurses and attract nurses back to the National Health Service. But funds to rectify this should come from another source and not from investment capital. Should not more nurses' living accommodation be made available and should there not be a residence to place of duty allowance? Why should not interest free mortgages be offered to those working in the nursing profession?

I now come to the Defence Medical Services, whose secondary care system deals with Service personnel on admission to hospital. Some years ago there were a number of military hospitals in this country and overseas which the Armed Forces used. Currently, Armed Forces personnel are already cared for at Frimley, Derryford and Peterborough NHS hospitals. From 1st July this year, they will also be cared for at Northallerton, when Catterick Military Hospital reduces its capability and more or less becomes a medical reception station.

It is essential that the National Health Service and the Defence Medical Services complement each other's efforts and make best use of the vital national resource that defence medical personnel possess. Greater consultation with the National Health Service at the highest level is required and it will be very necessary to take steps with the National Health Service to ensure that military standards and ethos are maintained for military people working among civilians in NHS hospitals. The National Health Service must be asked to agree that these military detachments are allowed to have time to carry out their military skills, adventure training and sport in order to retain the necessary Army team spirit in addition to their clinical duties.

The military hospital, known as the Royal Hospital Haslar, near Gosport, is going to close and its place taken by another Armed Forces unit in a National Health Service hospital, but not before a centre for defence medicine has been established and is up and running satisfactorily. This centre for defence medicine will be the focal point to provide a professional lead, a centre for training and a centre for excellence for research. It

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should be closely integrated with an NHS hospital, preferably a teaching hospital. Expressions of interest from NHS trusts around the country will be sought, looking for new ideas on how and where the centres should be formed.

In many areas the relationships between the NHS and the Defence Medical Services are good, but this is not the case in every area and there is a serious gap in the higher level of the strategic area. It is very much hoped that the NHS will give very careful consideration to selecting two NHS candidates for the two top-level board appointments. Their roles would be giving an NHS perspective on the decisions of Defence Medical Services; seeking ministerial approval for interdepartmental initiatives; and targeting the right expertise within the NHS to address specific questions.

The issues on which their advice would be essential include the options for a future Centre for Defence Medicine; guidelines for negotiating National Health Service contracts for secondary care; and the co-ordination of recruitment and retention. The overall intention is to ensure that the National Health Service and the Defence Medical Services work closely together at all levels, making most effective use of the vital national resource that the Defence Medical Services represent.

We demand of our Armed Forces that they should fight for our freedom and liberty and many of them face danger on a daily basis. The least their country can do for them is to ensure that they have the very best medical services to use should any of them become wounded at any time. Will the Minister ask those at the Department of Health and the National Health Service to address these matters in a speedy manner and with the due diligence that is required?

5.54 p.m.

Lord Bruce of Donington: My Lords, I wish to record my appreciation of the speech of the noble Lord, Lord Vivian, who put forward constructive proposals for closer integration between the Defence Medical Services and the National Health Service. I also appreciated the speech of the noble Baroness, Lady Gardner, who made what she described unashamedly as a political speech. It was all the better for that. There is nothing dishonourable about being a politician. As the House will be aware, I believe that all progress comes from an assertion followed by dissent, producing the eventual synthesis for a new argument. I thought that her speech was altogether good.

She will understand that during the earlier stages of the previous Conservative administration I suffered from a severe bout of depression--and I am by nature an optimist. The Conservative government presumed with the utmost folly to try to commercialise the whole internal workings of the National Health Service. That was a mistake and they know that it was. Therefore, I was most pleased by one of the first actions taken by my new Government in May 1997. That was the setting up by the Minister of State at the Department of Health, my right honourable friend Miss Tessa Jowell, of a committee to investigate inequalities in health. The

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report was referred to by my noble friend Lord Rea, whose lengthy speech on the matter relieves me of the necessity to do so.

It is obvious to all but the purblind that there are inequalities in health. It was a matter of intellectual conviction on the part of my right honourable friend the Minister of State immediately to initiate a study in detail. It was eventually run by Sir Donald Acheson, but unfortunately reported during the Summer Recess last year and did not receive the public attention that it deserved.

One of the favourite diktats of the former government, or its then leader, was that there is no such thing as society; that people were responsible for their own ill or good fortune. That government denied specifically--I have so many quotations that I will not bother your Lordships with them--that, for example, unemployment and poverty had anything to do with health. They said that it was no concern of society and it was all down to the individual.

One thing Sir Donald Acheson's report makes abundantly clear is that unemployment, poverty and homelessness, which are the lot of at least one tenth of our society, lie at the heart of much of the ill health which the nation as a whole suffers. I commend Sir Donald's report on that very issue. He proves conclusively by the production of detailed tables--to which, because of the limitation of time, I cannot refer--exactly the opposite.

It is a matter of common sense that people who are homeless, living in poor homes, or who have no personal domestic serenity connected to the place in which they live, will be subjected to stresses which have a most profound effect not only upon mental health but also on physical health. Sir Donald gives so many examples that the evidence is conclusive.

I was pleased to note that my Government are building on that. They have not only initiated inquiries, but also taken active steps to eliminate some--not all by any means--of the ridiculous administrative apparatus that was erected to maintain this fiction of some kind of internal market in hell, and they are doing that resolutely. The "Government" includes, I am happy to say, not only the political chiefs of the Ministry of Health, but also the dedicated civil servants that serve them and who sustain them fully and, above all, the nurses, the doctors, the specialists, the ancillaries, the administrators and all those who sustain the health service on the ground.

It does not say much for our ability to perceive gross injustice and to do something about it for society in the United Kingdom to tolerate the degree of violent assaults that are made by patients and others upon not only the medical profession but also the nurses that serve in the hospitals. It is rare for any hospital in the United Kingdom to be free for one day of violence inflicted upon its servants, and we should be thoroughly ashamed of that.

It may have occurred to your Lordships that one way in which we can reduce the costs associated with the National Health Service, and which inevitably lie at its roots, is by helping in whatever way we can to reduce

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the demands made upon it. One way in which we can do that is by bringing down unemployment, alleviating poverty and attaining a more agreeable and relaxed atmosphere between those who have a lot and those who have too little. Something that can be tackled sooner rather than later is an attitude that is exhibited in some sections of government, giving those with money, wealth and power most of the rights while thrusting the duties on the poorer and less well off sections of the community. I trust that that will be corrected.

The other thing the Government can do is study the extent to which the Treasury exercises what it would call "effective control" over expenditure in the National Health Service. Can the Minister say whether it endeavours to control it globally by fixing a ceiling or whether it confines its controls to certain parts of the health service? In that case, it is not only a question of enforcing those self-imposed limitations on expenditure that were laid down by the previous government--that is tough enough--it also means the adoption and encouragement of economic policies that will lead to less unemployment and to a redistribution of income. Those are matters to which I can legitimately call my party's attention.

I speak from long experience in my party and have the utmost affection for it. I criticise it with great reluctance. However, I warn that my anxieties are widely shared within the movement to which I have the honour to belong. But I am confident of one thing: that the Secretary of State for Health and his team--both bureaucrats and his political allies--have their endeavours firmly on a path that I fully and honourably support.

6.6 p.m.

Baroness Byford: My Lords, ill health results from many factors. My concern today is with the health services of people living in rural areas and the effect that they have, as things are currently organised, both on those who suffer and on the NHS itself. I shall therefore confine my remarks particularly to those in rural areas and to our growing elderly population.

Recent research and conference reports from the County Councils Network has thrown up some alarming statistics proving that the rural areas are disadvantaged in terms of social provision. It costs more money and more time to provide home-based care away from the urban area. For example, Manchester and Westminster, with lower costs and higher government funding through the SSA, are able to provide four hours of home care per 1,000 elderly inhabitants for every one hour afforded by Lincolnshire. This means that elderly patients convalescing from operations or other hospital-based treatment, instead of going home to home care, often have to stay in hospital until they are competent once again to look after themselves. Similarly, those living in rural areas often have great difficulty getting to a doctor, let alone to hospital appointments. Can the Minister give any figures of hospital visits per 1,000 elderly of the rural population compared with the urban?

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Not only is there a transport difficulty in rural areas, but they also carry a heavier loading of older people. For instance, in England 15.8 per cent. are over 65; in Devon the figure is 21 per cent.; in Norfolk, 19.4 per cent.; and in Lincolnshire, 18.6 per cent. But 91 per cent of rural parishes have no day care facilities for the elderly; 83 per cent. have no GP, which means they also have no practice nurse; 75 per cent. have no daily bus service; and 42 per cent. have no village shop. When things get too much for the elderly in these rural communities it is very often the NHS which has to pick up the pieces.

The County Councils Network reports also cover the position of children in the rural environment and the most damning statistics concern children at risk. In inner London the average yearly expenditure on a child at risk is £27,900; in Cumbria, the average is £12,330. In London help can be got to the child, or the child to the help, so much faster and more easily than in Cumbria. Moreover, children at risk are often children of mothers at risk. Has the Minister any figures of the relative burden placed on the NHS by that type of need?

The problems do not end there. Two weeks ago the Samaritans reported that there have been over 1,000 suicides in the past three years among small farmers driven to despair by the crisis in farming. How many of them would be here today had the support--medical and personal--been more closely available? And how much extra has the NHS had to spend on those left behind--on doctors' consultations, sleeping pills and anti-depressants?

Let us not forget the impact upon the NHS of the unsuccessful suicide. In 1992 Shropshire published figures showing that in the previous year 43 people in the county committed suicide, 27 of them from the rural areas. At the same time, in those same rural areas, in the first four months of 1992 paramedics had attended 220 attempted suicides. Will the Minister, in due course--not tonight--supply more up-to-date figures for each of the shire counties compared with the national average?

Such problems are made worse by the spread of GPs across the country. We heard last week of the coming crisis in the inner cities as those doctors who arrived, mostly from Asia, 30 years ago start to retire. A BMA spokesman confirmed that the salaries in inner city areas are often much lower than those in more affluent suburbs, making it difficult to attract replacements for those hard-working GPs. However, he stated that earnings in rural areas are also below the average. There is already a GP shortage in some of the more remote places.

There are also problems caused by the sheer variability of service provision in individual hospitals and between health authorities. An old person living in one neighbourhood, suffering a stroke in the night, may be taken to one hospital which perhaps does not have a specialist unit and will be offered twice-a-week day care services. He or she will survive, but will be more disabled than his or her counterpart in a similar

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neighbourhood who is taken to a different hospital which has a stroke unit and daily phsyiotherapy while the patient is in hospital.

Variability seems to be the watchword. There is variability in social service provision, about which other noble Lords have spoken, and variability in transport facilities, access to GPs, day care and shops. Above all, there is variability in the results of the Government's sharing out of the national cake among the various authorities charged with delivering those services.

Inner London receives £338 per resident for a person over the age of 65; Dorset receives £175. Inner London's allowance for residential care is calculated on £632 for every resident over the age of 65 while North Yorkshire's allowance is only £277. Those figures mean that fewer old people in rural areas receive the equivalent help in hours or minutes than their counterparts in urban areas. In turn, that must mean that the NHS carries a larger part of the burden which may be unnecessary and unjustified.

So what should the Government do to make sure that good healthcare is available for all regardless of where one lives? I urge the Minister to consider greater flexibility, acknowledging that different measures will be needed in differing locations. Savings can be made, as the Royal College of Nursing points out. The college states that there is now a substantial and expanding body of evidence which proves that employing registered nurses is both cost effective and improves the quality of care.

The development of primary care is the key to the development of a cost-effective NHS, reducing costly and unnecessary admissions to acute services. North Hampshire Lodden Community NHS Trust has shown how £9,000 could be saved on the care of just three children through providing community children's nursing teams to care for them in their own homes instead of in hospitals.

Better use of NHS staff is essential. The BMA's recommendations point out that many doctors wish to work part-time. With 50 per cent. of new medical graduates being women, such flexibility should be encouraged. The new graduates will supply fewer full-time working hours than their predecessors.

Providing good quality healthcare is a matter of across-the-board and across-department working to make it a great success. I believe that greater flexibility in approach and greater local freedom in making those decisions are crucial to achieving those aims. I join with others in thanking my noble friend Lady Gardner of Parkes for instigating this timely debate and I look forward to hearing the Minister's response.

6.14 p.m.

Lord Laming: My Lords, I am also grateful to the noble Baroness, Lady Gardner of Parkes, for initiating this important debate. My starting point is that the National Health Service is one of the treasures of post-war Britain. By being equally accessible to all, solely on the basis of clinical assessment, it is a tangible expression of social inclusion and a commitment to an integrated society. Despite having to deal with many

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unpredictable demands and unforeseen challenges, the service has survived and adapted for over 50 years. That is a great credit to the million or so staff in the service. I feel sure that Members of this House will want to wish the NHS well for the next 50 years and beyond.

As time is pressing, I shall make just three points. First, too often the National Health Service is spoken of as though it were a national hospital service. Yet, as has been said, the vast majority of healthcare is delivered in the community; perhaps as much as 90 per cent. of healthcare is not delivered in hospitals, but delivered where people live. Furthermore, although we can celebrate the great increase in the number of people living to an advanced age, including people with learning difficulties and those with profound physical difficulties, the number of beds for geriatric and long-stay patients in the health service has been dramatically reduced. In addition, the average length of stay in hospital has been reduced to the shortest period on record--generally only a few days.

All of that is to be welcomed, provided that proper regard is given to the needs of primary care and to the community-based domiciliary services. Those services must be properly staffed, financed and supported. In the past, it was often the case that hospitals appeared to be inward-looking and acted as though they were self-contained units. Nowadays, it is possible to meet the needs of patients and their carers only if hospitals operate as genuine partners in care in the community. That requires an entirely different approach by hospital-based staff. I would be interested to hear how the Government are tackling that issue.

Secondly, it follows that hospital-based staff should no longer confine their interests solely to treating the illness. It is essential that they consider, not only the whole person, but also the unique social circumstances of each person. To achieve that, all staff must play their part in a multi-disciplinary team.

In particular, I would like to mention the important work of hospital social workers, who very often are the link with the family and act as the advocate for the patient. Patients who need special help when discharged from hospital should be identified no later than at the time of admission so that the necessary arrangements can be put in place. If that is not part of the initial treatment plan, undue delays will occur that are often followed by frustration and recrimination. For patients who need special help on discharge, it is essential that the treatment plan includes effective rehabilitation. Without effective rehabilitation there is a real danger of a speedy return to hospital or, worse, an inappropriate admission to long-stay care.

We must recognise that the organisation of efficient care in the community, involving a number of different agencies, requires a much more sophisticated management system than care in a hospital. Most of all, it depends on staff of all disciplines being willing to work across organisational boundaries, and with volunteers and carers.

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In this country, we owe a debt of gratitude to the increasing number of carers. I want to pay a very warm tribute to the noble Baroness, Lady Pitkeathley, who, more than anyone else, has helped us to understand better the contribution made by carers in society.

Finally, I am sure that it is well understood that the essential team-work, to which I have referred, and to which, I am sure, everyone attaches great importance, will not happen solely because it is encouraged in government circulars and guidance, important though they are. I suggest that one of the most effective ways of achieving the goal of genuine multi-disciplinary working is by creating new opportunities for multi-disciplinary training. It is by learning together that staff learn to value each other's skills and responsibilities and, furthermore, to develop confidence in working as part of an integrated team. At present, a great deal of professional training is both specific and compartmental. I should be interested to hear whether the Government have any plans on how to promote new opportunities for joint learning. It is by that route that staff will form trusting relationships.

As we look to the next 50 years and tackle the challenges of planning and delivering effective community-based healthcare, I hope that more ways can be found to help those rugged individuals, who still exist, to become comfortable and genuine team players.

6.20 p.m.

Lord Norrie: My Lords, I should like to focus on NHS care for patients with kidney disease. I declare an interest as president of the National Kidney Federation, a charity run by kidney patients, for kidney patients. The NKF represents and promotes the interests of the major part of the UK's 30,000 patients with renal failure.

The raw fact is that end-stage renal failure is fatal unless a patient receives regular dialysis. Transplantation can offer a permanent solution, but the number of patients on the waiting list for a kidney transplant is for ever growing. For those patients, as well as for those for whom a transplant is not a possibility, dialysis is the only form of treatment which can keep them alive.

The number of patients who need dialysis is also growing. Research supported by the NKF suggests an increase of between 10 and 15 per cent. annually. The Government have acknowledged the need for action to increase access to renal care, raise standards and reduce geographical variations in renal services. With that in mind, the NKF has set out four areas of action to tackle those shortcomings.

First, overall treatment levels in the UK are lower than in most western countries. In a recent survey, 12 per cent. of kidney specialists stated that they had refused treatment to patients because of limited resources. That shameful situation was recognised by the Government and must be addressed. In the UK, 87 patients per million are accepted for dialysis in a year. The take-on rate per year in Germany is 163 patients per million. The contrast is pretty stark. The Renal Association recommends a minimum take-on of 100 patients per million per year in the caucasian population

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in the UK. Among the Afro-Caribbean and Asian populations, this should be closer to 320 patients per million. In addition, treatment rates across the UK vary considerably. In Oxford, for instance, latest figures show that only 44 patients per million per annum are accepted for dialysis.

On the question of finance, is the Minister aware that the NHS spends £70 million per year on laxatives and only £25 million per year on kidney transplants? Dialysis and transplantation are life-savers. Tough choices need to be made about where limited resources are spent if the Government are determined to improve NHS renal care.

The second area for action that the NKF has identified is the early introduction of a national renal service framework. These frameworks act as a guide to help health authorities spend their budgets in the most effective way. I am aware of work taking place in the department on a framework for renal services, but once again progress is slow. Can the Minister reassure the House that there will be early publication of a national service framework for renal services?

The third area of action on which the NKF is campaigning is to improve NHS dialysis facilities and the quality of treatment that patients receive. One of the outstanding developments in renal services over the past 15 years has been the construction and operation of new, fully equipped, satellite dialysis units. Those units are provided in a partnership between the NHS and the private sector. They have grown up in areas where the NHS alone has been unable to provide adequate services. But until the Government publish the conclusions of their review of the use of private finance in the NHS, there is a question mark over their future.

The Government have previously expressed a policy not to allow commercial companies to provide clinical services within PFI contracts. Although this policy might be appropriate for large-scale hospital projects, I believe that it is important for the Government to allow some flexibility for renal services which are, after all, small, specialised and local. Wherever there has been such a partnership the services are provided under stringent NHS contracts; all care is provided by NHS consultants; referrals to the unit are undertaken by the NHS according to strict clinical priority; and clinical responsibility for nursing staff rests with the NHS consultant. The NHS remains firmly in control of clinical decisions but patients do receive their care in modern facilities with state-of-the-art dialysis equipment.

I would urge Ministers to look sympathetically at the role of the private sector in NHS renal care. If, as a result of decisions that the Government are about to take, those projects are no longer viable for the private sector, the NHS will lose future opportunities for thriving and innovative partnerships.

The final area of action identified by the National Kidney Federation is the establishment of an independent transplant commission to increase transplant rates in the UK. As I indicated in my opening remarks, a transplant is the best treatment option; and in

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the UK we have some distance to go before we can match the transplant rates of other European countries. The role of the transplant commission would be to review the current organ procurement system and break down barriers to organ donation. I commend the Minister for her efforts to increase the National Organ Donor Register and I ask her to consider carefully the merits of such a commission.

6.26 p.m.

Lord Haskel: My Lords, I would not normally speak in a debate on the National Health Service. Apart from being an occasional grateful recipient, I do not really know much about it. However, the Motion is sufficiently wide--I am most grateful to the noble Baroness, Lady Gardner of Parkes, for that--for me to be able to contribute some thoughts on management and the National Health Service.

My only management qualification is in building up a business over some 30 years. When I was young I worked in a textile factory in Yorkshire. It was there that I learnt my first management lesson. When the chairman came round he asked questions in his blunt Yorkshire way. He had only one question for me: "Young man", he said--I liked that--"do you add cost or do you add value?" What a pity that he did not put that question to those who introduced the market system into the National Health Service. It is now apparent that carrying that out required huge added costs with little added value. My noble friend Lord Warner called it an unnecessarily expensive system.

Indeed, that system made things worse because an internal market can work only on numbers, so it gives greater importance to that which can be easily measured, such as operations per hour or blankets per hundred patients; but at the same time it fails to measure that which is important, such as the quality of the care or the effectiveness of the treatment. The internal market measures the wrong things--and the Government are absolutely right to get rid of that "ridiculous apparatus", as my noble friend Lord Bruce called it.

Internal markets were fashionable with managements in the 1980s. I advise the noble Lord, Lord Chadlington, that branding is in danger of becoming the management fashion of the 1990s. Fashion in management comes and goes nearly as quickly as it does in the clothing business. That is why many of us looked on in amazement as those fashionable ideas were applied late to the National Health Service just as they were going out of fashion because of the size and the nature of the National Health Service. So just as the previous government were introducing internal markets business was realising how wasteful it was and moving towards alliances, co-operation and partnerships to reduce costs. That is why I welcome the Minister's announcement that health authorities, primary care trusts and local authorities will be able to work in partnership and transfer funds between themselves. That was "walls being broken down", as my noble friend Lady Pitkeathley put it. As the National Health Service was introducing strict discipline and "Do as you are told", business was recognising the importance of the needs and aspirations of employees and moving towards

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empowerment and training to improve people's performance. That is why the Government are absolutely right to concentrate on introducing best practice. As my right honourable friend Mr. Frank Dobson said,

    "Hospitals will be comparing, not competing".
My noble friend the Minister may be interested to learn that, according to the current edition of the Harvard Business Review, the latest management fad is called, "The Human Moment". That has everything to do with human contact. I am sure that the Minister is already well aware of its importance because she will understand that it is important to find out from people what they want from their health service. Surely it is the task of any management to prioritise and allocate and, in the case of the National Health Service, to provide services based on the evidence in a humane and open way. We all know that the Government cannot provide everything for everybody.

That is why talk of rationing is nonsense. Like any good manager, the Government have decided on their priorities and chosen to give priority to nurses' pay, NHS Direct, on-line appointments, primary care groups, promoting clinical excellence, and learning how all these measure up to people's expectations, which the noble Baroness, Lady Gardner of Parkes, criticised. This is not following a management fashion, it is dealing with the realities of the National Health Service as any competent management should do.

Many noble Lords have pointed out that the fundamental purpose of the National Health Service is keeping our nation healthy. Sir Donald Acheson's report to Mr. Frank Dobson dealt with that fundamental. He pointed out that poor families suffer more from ill health. As my noble friend Lord Rea told us, the poor suffer more from lung disease, cancer and coronary problems. Sir Donald Acheson was right to remind us that this is because they cannot afford proper heating, clothing, shelter, food, or to live a healthy lifestyle. The noble Lord, Lord Butterfield, made that point as did my noble friend Lord Bruce. But I have to say to my noble friend that I believe that the Government are responding to that in a fundamental way by helping the poor out of poverty with Welfare to Work, the minimum wage and the Working Families Tax Credit. I suspect that that may have more impact on the nation's health than any management system.

6.33 p.m.

Lord Colwyn: My Lords, the noble Lord, Lord Haskel, may not be an expert, but I believe he made a very interesting contribution. Perhaps he is looking for a job in Richmond House. It is almost exactly one year, less one day, since the noble Lord, Lord Hunt of Kings Heath, called the attention of the House to the National Health Service and its 50th anniversary. My noble friend Lady Gardner of Parkes made a notable contribution. I thank her for introducing the debate, and I apologise for being unable to be here for some of the earlier speeches, including hers. I cannot claim to have been working within the NHS, but I was in my dental surgery. I had over 20 years' experience working for the general dental

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service before moving into the private sector where it is possible to achieve higher standards by having more time.

The noble Lord, Lord Hunt, is an expert, but, despite his enthusiasm for the NHS, he did not mention dentistry. Nor did his noble friend the Leader of the House when she wound up the debate. This is now fairly routine. Unless my noble friend Lady Gardner or I specifically raise the subject, there is never a word about the dental service, with 19,800 NHS general dental practitioners looking after 29 million registered children and adults. Unfortunately, this is becoming routine for the Labour Government. There were a lot of promises before the election, but very little action occurred afterwards.

There are 29,055 dentists registered in the United Kingdom of whom only 500 are purely private practitioners. But the private figure will almost certainly increase owing to the lack of investment by successive governments. Dentists do not leave the NHS for ideological reasons; they leave because they find it harder to provide an acceptable quality of care and spend the appropriate amount of time with each patient under the present NHS fee structure and still maintain a viable practice.

Despite stringent pressures on professional ability where dentists can be sued for malpractice if they miss some minor gum problem, fail to ensure adequate cross-infection control or overlook a small cavity, the fee for a routine dental examination is only 80 pence more today than it was in 1991. Practice expenses, which include staff wages, premises, materials and laboratory costs, have escalated and must be paid before the dentist receives anything as personal income. Unlike doctors, dentists in high street practice receive no help from the NHS towards staff or premises costs nor for the capital costs of equipment. It can cost more than £25,000 to equip a single practice to modern standards. This inevitably involves a large bank loan.

The Minister will remind me of the government initiative "Investing in Dentistry" where funds are available for setting up practices in areas where access to NHS dentistry is a problem. Sadly, it is inadequate and only of short-term help.

The Government pledged £19 million, but up to date only £7 million of funding has been allocated despite over £20 million worth of bids by health authorities. About one in four have not had any bids approved and the profession is concerned that the funding will not now be received before the end of the financial year. Other figures of gross expenditure show that in the 1997-98 financial year the Government spent £56.5 million less on dentistry than had been budgeted. I should be grateful if the Minister could comment on that and the fact that the British Dental Association has estimated that about £50 million will be needed each year for the next three years to improve access to NHS dentistry around the country. Can the Minister confirm that further funding for the "Investing in Dentistry" programme will be allocated next year and the process of grant application speeded up and made less bureaucratic? In addition, there is still a shortage of

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NHS dentists and while "Investing in Dentistry" provides capital grants for new NHS practices, it does not address the problem of recruiting dentists to work in NHS practices.

The Minister may know of a recent British Dental Association survey of young dentists which shows that more of tomorrow's dentists are likely to work in private practice or for a company like Boots or other corporate bodies. The survey found that 88 per cent. of all young dentists are confident about the future of private dentistry compared to 16 per cent. who are confident about the future of NHS dentistry. Seven out of 10 would like to have the option to become salaried employees of company chains.

The survey found that a clear majority of salaried dentists are confident about their economic future but those working in the community dental service are not. In general practice there is little confidence in the NHS but a great deal in the future of private practice. My noble friend Lord Butterfield stressed the same point.

Last year's Green Paper Our Healthier Nation recognised that oral health is an important part of general health. Inequalities still exist and, once established, persist throughout life. As my noble friend Lady Gardner explained and the Acheson report, Inequalities in Health suggested, extending water fluoridation and improving access to NHS dentistry would address this problem.

For nine months my profession has waited for the Government to publish their strategy on NHS dentistry. Until they do, inequalities in oral health and the problems of access to NHS dentistry will not improve. The dental profession has shown that it can deliver improvements in dental health. Enormous gains have been made, but more resources are needed to make further improvements. An investment now will lead to savings in the long term.

I should like to return briefly to the recent ruling by the General Dental Council on the use of general anaesthesia in dental surgeries and again ask the noble Minister two important questions. Would she not agree with me that there is a moral obligation on the part of the Government to find a way to recompense those dentists who took up the government initiative to undertake further training in anaesthesia, which also involved the purchasing of new equipment, and have now, overnight, been prevented from using their special skills and have suffered considerable financial deprivation?

Secondly, can she tell me what is happening to all the patients who were previously treated with general anaesthesia in dental surgeries? About 250,000 patients were treated in the NHS last year at an average cost of about £50. Because of the GDC ruling, they are all now being transferred to the hospital service, where the average cost is over £1,000. This must have an effect on waiting lists and budgets. Can the Minister say whether this is influencing current waiting figures and whether the Government are happy with this change in treatment pattern?

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Finally, I know that the noble Earl, Lord Baldwin of Bewdley, would have wished to remind the Government of the benefits of non-conventional medicine, but he is unable to be here. Despite the hundreds of millions of pounds spent on the NHS and similar amounts spent on the development of different drugs, we have not actually become any more healthy. One in two of all adults takes a synthetic drug of some kind every day. Seventy-five per cent. of all visits to a general practitioner involve the prescription of a synthetic drug and something like 16 million adults take synthetic drugs on a regular basis. At any one time almost one-third of the nation has a long-standing illness. The incidence of heart disease, cancer and respiratory diseases is increasing and we are becoming more aware of diseases like Alzheimer's and osteoporosis, which are having a massive effect on the health budget.

The benefits of alternative and complementary medicines have been recognised by the public. There is an increasing demand for these treatments in the private sector and calls for wider availability through the NHS. The Minister recognised this in an Answer to the noble Earl on the 27th January but denied that there had been any cuts in the funding of complementary medicine by health authorities. I hope that she will continue to respect the need for the individual to have freedom of choice when seeking treatment and that she will encourage the new primary care groups similarly to respect this choice.

In conclusion, I am sure that the dental profession will be grateful for yesterday's award of a further 3.5 per cent. Most will have forgotten that, for technical reasons, this will be reduced to 2.6 per cent., which sadly will not be sufficient to prevent the move into the private sector, but perhaps that is the Government's hidden agenda.

6.42 p.m.

Baroness Emerton: My Lords, I too would like to join with other noble Lords in thanking the noble Baroness, Lady Gardner of Parkes, for introducing this debate today. I declare an interest in that I am chairman of a healthcare trust, I am a nurse of 45 years' standing and I was a past chairman of the UKCC when Project 2000 was introduced. I am also a lay member of the General Medical Council.

The NHS, as we have heard this afternoon, has throughout the last 50 years been facing constant battles to match demand for the range of services required against supply, whether that be shortages in finance or workforce or outdated buildings. Today we also see that the Government have set out a range of policies in an attempt to meet these competing demands, not least in their policy document First Class Service, which emphasises the need to develop even higher quality services.

We have also heard this afternoon about the establishment of the National Institute for Clinical Excellence (NICE). There will also be an effective monitoring of progress through CHIMP, and a new national survey of patient and user experience. The establishment of clinical governance at local level

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within the NHS marks a disciplined approach to delivery of care within quality protocols and the management and monitoring of these. For the first time, NHS trusts will be required to sign a statement that the clinical care is of a satisfactory standard. This will be the responsibility of the chief executive officer, as the accountable officer. The success of this important step forward will be dependent on a range of factors which contribute to the establishment of a sound clinical governance programme locally, which is effective in delivering a high quality of care in diagnosis and treatment, having identified best practice and having set in place monitoring systems to measure effective implementation.

Within the overall aims set out in the First Class Service document, emphasis is placed on the local delivery of high quality healthcare through clinical governance, underpinned by modernised, professional self-regulation and extended lifelong learning. At the heart of clinical governance is the requirement for individual practitioners to be involved in local professional self-regulation. Professional self-regulation is a privilege, not a right. The professional accepts several obligations which distinguish him or her from other groups of workers. The regulatory bodies admit to their registers only those who are fit to practise and fulfil the obligations of a professional. For self-regulation to work, it is clearly dependent on good self-regulation by practitioners themselves, and they need to see that standards are adhered to and poor performance is dealt with in an appropriate manner. The regulatory bodies have a long history, and the professions of medicine, nursing, midwifery and health visiting are proud of their self-regulatory bodies.

One of the greatest concerns of the professions today is the uncertainty of the future for these bodies within the new health Bill published last week which proposes new powers for the Secretary of State with regard to the professional regulatory bodies. The parliamentary process of achieving legislation for the regulatory bodies has always followed the normal parliamentary process. There is great concern among professionals, especially doctors, nurses, midwives and health visitors, that this might be short-circuited and that effective consultation within the professions will not be allowed. Could the noble Baroness reassure professionals that any proposed changes to the self-regulating bodies and to self-regulation will be given proper consultation and the use of affirmative procedures for parliamentary scrutiny? Could she also confirm that primary legislation will be required to repeal, for example, the Nurses, Midwives and Health Visitors Act 1997, which might lead to abolishing the council?

One of the other essential ingredients to successful clinical governance at local level in delivering a high quality service to patients is to ensure that practice is based on best practice which is evidence-based. This can only be assured by a sound knowledge base and essential skills of each professional as a result of education in the form of lifelong learning.

Today there is considerable ongoing discussion relating to the education of nurses, as has already been referred to. The Secretary of State in a recent Statement

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announced that there must be a reform in nurse education. The UKCC, as we have also heard, has established a commission to look into the current education of nurses, and the commission is due to report later this year.

There is no doubt that the process of nurse education needs to be re-visited, but the introduction of Project 2000 has provided the means through higher education programmes to equip nurses, midwives and health visitors with the theoretical base required for nursing, midwifery and health visiting in a very fast-changing clinical scenario. This was set out eloquently by my noble friend Lady McFarlane. Could the Minister agree to take account of this when the Government are seeking to deliver changes? There needs to be a closer correlation between theory and practice--but please let us not throw out the baby with the bathwater.

It took 45 years from the time of the first report, when Wood recommended changes in nurse education, to follow up through the Platt Report, the Briggs Report and the Royal Commission, which was followed by the introduction of the Nurses, Midwives and Health Visitors Act in 1997. Finally, we have now emerged with Project 2000.

Clinical governance is also dependent upon the right number of professionals in the right place at the right time to effect a high quality of care.

Recruitment and retention of staff are key to achieving this and the Government are addressing the recruitment of nurses, midwives and health visitors by the commencement of the recruitment campaign this week. Hopefully, this will pay dividends as well as cover the pay awards which have also been referred to this afternoon. The retention of nurses, midwives and health visitors, however, requires much energy into developing career pathways. Within the clinical governance, nurses, midwives and health visitors--but particularly nurses and midwives--must take a leading role with responsibility and accountability. Nurses require equal status with the clinical director and business manager. Nurses need to have that power restored to them in the organisational structure if clinical governance is to succeed.

Much can be done at local level to address employment practices in terms of hours of working, creche arrangements and family-friendly policies. However, resourcing development programmes in an already overstretched budget presents a problem. I ask the Minister to take resourcing of continuing education within the lifelong learning process in a multi- professional context--which has already been mentioned as being so important--as an essential part of the programme to aid retention. Doctors, dentists and other health professionals also suffer from the problems of recruitment and retention. Therefore, it would be extremely helpful to bring them together in these educational programmes.

The title of this debate,

    "To call attention to the state of the National Health Service",
is one of great public interest, as well as to Members of this House and the Government. At the end of the day, everyone's interest is in the health service delivery being

3 Feb 1999 : Column 1553

of high quality. I believe that the introduction of clinical governance at local level will go a long way towards achieving that aim, provided the issues around self-regulation, lifelong learning programmes and recruitment and retention of health professionals are addressed as a matter of urgency.

6.51 p.m.

Viscount Bridgeman: My Lords, I should also like to thank my noble friend Lady Gardner of Parkes for initiating this wide ranging debate which has attracted so much informed and interesting comment from all sources. I should like to begin by making an even-handed observation. I believe it is a fact that the decline in bed places since the inception of the National Health Service has been virtually a straight line over the years. The previous government were virtually continually taunted for 18 years on this point. If the trend continues under the present Administration--as I am sure it will--that at least, on this specific point, is a charge of which they will not be guilty.

Following the speeches of the noble Baronesses, Lady McFarlane and Lady Emerton, I speak on Project 2000 with some diffidence. As we know, Project 2000 was a move by the previous government very much on the initiative of the nursing profession. It was to ensure a much higher degree of academic training than in the past, and nurses now emerge from their training at diploma or degree level. The intention was that they would be fit not only for nursing but also for administrative and management jobs; and that, in their clinical work, they would be technically trained to deal with the ever-increasing technology associated with patient care in all aspects--to take only one example, the operation of high tech equipment in accident and emergency units.

The intentions lying behind that initiative were and are wholly admirable. But the effect of the academic element of the training "off site" at colleges and universities has been to take away from hospital wards a large number of what, under the old system, would have been trainee nurses and state enrolled nurses, about whom I shall say more later. There are a number of reasons why the problem is exacerbated. The shorter hospital stay means that there is a greater demand for expert nursing while the patient is in. Thanks to modern treatment, low dependency cases are frequently transferred to GP and community health services, leaving hospitals with an increasing proportion of critically ill patients whose survival rate is welcomingly much higher than it was in the past; but these critically ill patients frequently remain in the wards where, formerly, they would have been transferred to an intensive treatment unit. All this places greater physical, emotional and intellectual demands on today's nurses.

So the reality is that there are far too few nursing staff left, to use a current buzz phrase, "to make the beds". It is here that the NHS is feeling the loss of the state enrolled nurse. This was the large body of nurses to which the noble Baronesses referred who may not have had the time, inclination or ability to be fully qualified state registered nurses but who had a thoroughly sound

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basic nursing training. They formed the backbone of the hospital clinical staff. The noble Baroness, Lady Masham, and the noble Lord, Lord Rea, both referred to this and the noble Lord, Lord Morris, made the interesting suggestion that training could perhaps be stopped half way through to give a limited qualification.

I understand that the bias of Project 2000 training has shifted from 60 per cent. clinical/40 per cent. academic to being approximately even between the two. Clinical experience is provided by placements of student nurses in hospitals. All too often, one hears stories of hard-pressed ward staff not being in a position, through no fault of their own, to give student nurses proper instructions. Of course, the end-sufferer is the patient.

Nurses emerge from their training in many cases with inadequate clinical experience. Certainly some nursing agencies--and here I speak as a former director of one of them--report that there is a significant proportion of nurses who they have difficulty in placing in hospitals on that account. It is true that many graduates make good administrators at junior level with the prospect of going on to higher things within the health service; but it also, let us face it, equips them to take jobs outside the health profession. This is all to be welcomed, but it does not solve the problem of the wards.

So what is the remedy? I was very pleased to hear the noble Baroness, Lady McFarlane, refer to a committee which has been set up to review the progress of Project 2000. There are no easy solutions. In particular, the relationship between academic and clinical has yet to be fully resolved. From his public utterances, I know that the Secretary of State is fully aware of the subject. However, perhaps I may make one or two suggestions. First--and I hope that this is not genderist--girls are increasingly out-performing boys in GCSEs and A-levels, especially in maths and science, thereby providing increasing competition for jobs in the marketplace. In itself, that could lead to a further shortage of nursing recruits among young women. Therefore, I suggest that the Government ought to do all that they can to encourage males to enter the nursing profession.

Secondly, there is basic difference between doctor and nurse training in that whereas medical students are taught by practising clinicians, nurse training is, for the most part, given by those who are either not nurses or those who have left clinical practice. My suggestion is that funds should be made available for greater exchange between nurse teaching academic staff and clinical nurses, to the great benefit of both. That would go some way towards rectifying the perceived deficiency in the clinical education of nurses. In passing, part of such funding could come from clawing back grants to students from overseas on Project 2000, who give nothing back to the health service when they disappear home without doing any post-academic clinical work.

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My other suggestion is to encourage longer teaching contracts between the NHS purchasing consortia and the universities. This should make it possible to deliver a more structured and effective Project 2000 education, to turn out nurses equipped to face the health challenges of the next century.

Finally, I should like to say something about nurses' pay. The increased pay for nurses is, of course, wholly to be welcomed. But much of the money for that pay is likely to come from so-called "efficiency savings". I ask the Minister to be aware that, if this means cutting back clinical care budgets, it will only exacerbate the central problem which nurses face--that they are over worked and over stressed. I am not alone in my conviction that British nurses are the finest in the world. We must do everything to foster this precious resource.

6.59 p.m.

Lord Prys-Davies: My Lords, at the outset of my few remarks I pay tribute to all those who work in the National Health Service, both the professional and the non-professional staff. The NHS has been a magnificent achievement. It has survived the test of time and I believe that that constituted the essence of most of the speeches that we have heard over the past four hours. The health service continues to provide a splendid service, as some of us have reason to know through personal experience as patients.

There has been a range of questions and criticisms this afternoon, as well as praise. I listened with considerable concern to the noble Lord, Lord McColl, who identified the fact that unless new consultant posts are created over the next two years about 200 obstetricians will be without permanent posts in the NHS. I have heard the noble Lord, Lord McColl, identify that problem before. Should there not be a relationship between the numbers under training and the numbers needed? There is no suggestion that the Government are responsible for this state of affairs but I very much hope that the Government can look into the position to see who ought to be responsible for correcting the situation.

I also listened with great interest to the noble Baroness, Lady Byford, who focused attention on the difficulties of delivering health services to people living in rural areas. That is a problem which confronts us in Wales. I shall listen carefully to the Minister's response to the suggestions that were made.

Looking to the future, it seems to me that the single most important challenge facing the NHS is that of rising expectations and advances in medical science. The implications of those twin forces constitute the challenge. Your Lordships will recall that the House visited this theme on 9th December last. I have reread the debate and it seems to me that everyone welcomed the progress that has been made in medical science. The advances are inevitable and desirable but reservations have been voiced in this House and elsewhere that the progress in medical science is ahead of the growth in public funds available for the health service. I believe that point was made this afternoon in particular by the noble Baroness, Lady Sharp of Guildford. I believe there

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is a real issue here which cannot be ignored. In fairness, the Minister would say that it has not been ignored by this Government. I noted her speech of 9th December in which she pointed out that, since they came to office, the Government plan,

    "to spend an extra £18 billion on the NHS in England over the next three years on top of the £2.25 billion that has already been invested,"--[Official Report, 9/12/98; col. 1010.]

In that speech the Minister emphasised that the investment was "targeted on change" to ensure that the NHS provides,

    "cost and clinically-effective interventions".
Cost effectiveness has been on the agenda since at least 1956. I welcome very much the acceptance of the need to demonstrate clinically effective intervention. I should have thought most people would agree that it must be right to look carefully at the effectiveness of expenditure. I would find it helpful if at the end of the debate my noble friend the Minister would indicate when the Government expect benefits to come through from the Institute for Clinical Excellence.

Of course there are other important and encouraging developments taking shape under this Government which point the way to great advances. They include the development of healthy living centres which will, over time, promote good health in our communities and in the longer term reduce demand for health services. My noble friend Lady Pitkeathley dealt admirably with the potential of the healthy living centres. I wholeheartedly support the steps being taken by the Government to tackle inequalities in healthcare. My noble friends Lord Rea and Lord Bruce of Donington emphasised that point.

I now turn to the final point I wish to raise in this debate, and that is the position in Wales after the inauguration of the national assembly in four months' time. The assembly will take over responsibility for the health service. I believe that this will represent the most important change in the NHS in Wales since its founding. Many people in Wales believe that they are now repossessing the NHS which was given to us by Aneurin Bevan. I believe that there will be pressure in the Welsh assembly to address the inequalities in healthcare which still exist within groups and communities in Wales. I believe that the assembly will be a more radical body than the Welsh Office has ever been.

I have been reading the excellent report entitled Devolution and Health, commissioned by the Nuffield Trust. It explores the possible implications for the UK National Health Service and for the health services in Scotland, Wales and England that may flow from devolution to Scotland and Wales. The authors suggest that there is little evidence that Scotland and Wales will develop radically different models of care from those in England, at least in the short term. However, they then say that there is scope for considerable variation in responding to the health agenda. I thought of that point when the noble Baroness, Lady Byford, made her contribution. It seems to me that this is the kind of area where one could expect the assembly to develop different, and possibly radically different, programmes for the delivery of care. The authors also point out that

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health gain policies should be easier to implement because the small scale in Wales and Scotland makes it easier to work across departmental boundaries. They also envisage that there will be a strong desire in Cardiff and in Edinburgh to form direct links with international bodies such as the WHO and the European Union.

When my noble friend the Minister replies to the debate it would be helpful if she could explain what role will be held post-devolution for the Department of Health in London as a UK health department. For example, what responsibility will it have for research and development in this field? That point was raised by my noble friend Lord Winston. I believe that to be an appropriate question to address to the Minister as this debate may be the last major debate on the NHS in your Lordships' House before the health service is repossessed in Wales and in Scotland by the new assembly men and women.

7.8 p.m.

Lord Ironside: My Lords, my thanks go to the noble Baroness, Lady Gardner of Parkes, for initiating this debate. The noble Baroness said that we do not hear enough about radiologists. I shall partly put that right by touching on radiology and radiotherapists. But, first, I must declare an interest as my wife is founder president of RAGE, Radiotherapy Action Group Exposure, whose members, numbering hundreds in the United Kingdom, have suffered disastrous and disabling injuries following radiotherapy treatment for breast cancer.

Having submitted a claim for compensation to the Secretary of State for Health, RAGE collaborated with the Royal College of Radiologists which printed and published the RAGE response to the Department of Health independent audit report, which was commissioned by Sir Kenneth Calman, the former Chief Medical Officer. But what I think is disturbing is to read in the Royal College of Radiologists' latest clinical oncology journal about the complex and detailed High Court proceedings involving some 130 plaintiffs suffering alleged injuries from radiotherapy treatment for breast cancer, which are the subject of a legally aided multi-party action on which more than £2.3 million has already been spent. The injuries, as shown in the audit report, are real, but as negligence was not proved the plaintiffs get nothing. I think £2.3 million would have made a very nice compensation package for the injured plaintiffs, but the only beneficiaries seem to be the lawyers. Many people are wondering whether there has been any public benefit or whether the proceedings were merely a waste of public funds.

The authors' message to oncologists is, "Keep doses low and don't injure." I am not sure whether this is an invitation to practise defensive medicine, but the journal authors suggest that it could be. The safety of the patient remains very much in the hands of the radiotherapist, while operating staff are protected by the ionising radiation regulations. Training is in the hands of the Royal College of Radiologists, which also sets standards, but I think red lights have been flashing constantly ever since Roentgen discovered X-rays a hundred years ago. The recent quality assurance

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management weaknesses in mammography services, which were exposed in November 1997 at Exeter, are the latest example of danger signals flashing. Exposure can injure and when radioactivity is beamed and vectored wrongly there is trouble ahead. There is absolutely no margin for error.

"Quality assurance" is a forbidding term to a doctor. After the introduction of the QART standards in 1991, following studies at the Bristol Oncology Centre, which has ISO 9002 approval, and at the Manchester Christie Hospital, can the noble Baroness say whether all the 53 UK radiotherapy treatment centres have been certified to the QART standard? Can she say who is accredited to carry out these assessments and how often approval has to be renewed? I assume that it is once a year.

Following the Exeter incidents, I find it strange that the Government said in 1997 that the NHS mammography facilities were not required to have ISO 9002 approval. I think it should be mandatory, as in the US where every facility has to comply with the US Mammography Quality Standards Act 1992. I hesitate to draw an analogy between the miners' claim for pneumatic drill injuries and RAGE's claim for radiotherapy injuries. But when the Government say they have a moral obligation to compensate the miners, surely they should have a moral obligation too to compensate RAGE members injured through no fault of their own by radiotherapy treatment.

Safe treatment services remain a top priority, so I wonder whether the randomised standards in the radiotherapy, or START, trial is going in the right direction when it is designed to justify, I understand, the high dose-fewer fractions treatment regime to step up productivity, which the audit report suggests contributed to the causes of injury. Surely we are looking for the optimum safe dosage regime which will not injure. I should like to ask the noble Baroness what stage the randomised START trial has reached. Has it, in fact, started, if that is the right word? And how many centres have been found to take part? When is it due to complete?

Returning to the breast screening programme, equipment installed eight to 10 years ago on the recommendation of Professor Forrest has reached the end of its working life and is due for replacement. There is a case for the Department of Health to follow up vigorously the next generation advances in digital imaging, together with the advanced display techniques being promoted by DERA at Farnborough from its diversification bank of defence technology, which offers the substantially improved resolution that radiotherapists are looking for to detect the tiny non-evasive calcifications in the breast. Results can be transmitted speedily by tape. I have written to DERA about this. Can the noble Baroness say what plans her department has for getting a nationally co-ordinated programme into place instead of leaving hospitals to follow their own procurement routes using the NHS purchasing guide in Publication No. 32 so that we do not end up with a fragmented network of different devices.

I have touched on only a very small sector of NHS affairs, but I believe that management and quality assurance are assuming a much more prominent position

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in underpinning clinical judgment. If litigation is growing, it is because of the greater role that management and quality assurance have to play in medicine. These are the areas of contention that can arise. The fact that the independent audit report found that there were as many protocols for breast cancer treatment as there are radiotherapy treatment centres in the UK is a cause for concern. As Professor Sikora, of the Expert Advisory Group on Cancer, has said, "They can't all be right." But I am glad to see that the audit has now ensured that each radiotherapy centre has a written protocol to keep practice in step with changing techniques and delivery in step with prescription.

7.15 p.m.

Lord Sawyer: My Lords, I am grateful for the opportunity to speak in this debate and I add my thanks to the noble Baroness, Lady Gardner of Parkes, for initiating it. I worked in the National Health Service for many years and I continue to have great admiration for those who work in the service today. I also have great respect and genuine admiration for the enthusiasm and hard work of this Government in trying to improve the service after many years of dreadful neglect. The pay awards announced this week are a measure of the Government's commitment.

Making improvements to the National Health Service is a mammoth task. The National Health Service is the largest employer in Europe. It employs more than 1 million staff and more than two-thirds of its budget goes on staff wages. Without substantial increases in revenue from taxes, it is difficult to pay fair wages and to keep up with rising costs from the demographic and technical changes taking place in the health service and in the wider community. That is why even the most dedicated politicians and managers find it difficult to make the National Health Service work. Given the dedication and professionalism of the current politicians, managers and staff, it is with some humility that one attempts to offer advice or suggest possible ways forward that do not involve tax increases. But it is necessary to try because increases in taxation and additional money cannot always be the solution to public service problems.

When Nye Bevan built the National Health Service in 1948 he had to build it top down. He brought together all the services--the hospitals, the community services, the general practitioners and others--and built a service that was organised and managed from the top. That has changed over the first 50 years and some serious and successful initiatives have been taken to bring the service closer to the patient. But I doubt whether those changes have been comprehensive enough.

I believe that the really big change that is still required is the cultural revolution to make the service absolutely dedicated to empowering patients--to make it bottom up instead of top down. Somehow we have to stand the service on its head. We have to make the patient king. We have to supply the information and advice that will increasingly allow patients to make decisions about their own health.

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That is not easy to explain in the short time that is available. But it is not a call for, or an endorsement of, a shopping list of modernising improvements, as has been set out in speeches on how to equip the NHS for the millennium, how to provide more money and more resources and how to do things better. It is more than that. I would call it a paradigm shift in the way we think about the National Health Service and how healthcare is delivered.

That shift would start with a consideration of the health and well-being of all people, not merely those who are sick and who need the National Health Service. In so doing, we should put preventive healthcare and medicine at the heart, not the periphery, of health policy. That is easy to say, but very difficult to do.

Then, we should focus carefully on those in the population who require healthcare. We should think of ways of empowering them. That would involve patients being given information about the full range of options available to treat their condition. Information would be provided about the use of drugs or, alternatively, the availability of complementary and natural medicines and treatments such as acupuncture and homeopathy. The aim of such an approach would be to enable the values, aims and goals of the service to be driven by patients, not politicians, managers, doctors and staff, important though they are.

The recent report by Mr. Greg Dyke on the Patient's Charter goes some way towards at least considering these changes. I hope that my noble friend can assure me that careful consideration will be given to his recommendations. In particular, his recommendation for a value statement that would set out the guiding principles underpinning the service is very important. It would help to focus the minds of those who work in the service on exactly what they are trying to achieve and have the effect of empowering patients. His recommendations for a strong local element in the Patient's Charter for process and service standards would also drive down the delivery of services to patients at a local level. The recommendations on disease-specific user guides would also help patients to consider the options available and would enable them to be active rather than passive in their choice of treatment and care. The recommendations on improved communications, particularly IT, are essential if we are to give patients open access to the information they need to make advised choices and decisions regarding their treatment.

In his report, Greg Dyke frequently refers to the importance of staff. He understands that it is crucial to win the hearts and minds of staff if there is to be change. National Health Service staff deserve fair pay, and many have a strong commitment to the service. But, in addition, staff need a strong sense of involvement and direction, and most of all a sense of being valued by the population. Involvement, direction and value can come from good leadership on the part of managers and politicians. Learning and development opportunities for staff must be placed at the centre of the NHS rather than on the fringes. Managers must concentrate on the fundamentals: patient empowerment, patient care and staff motivation.

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Running the National Health Service is a tough job. I wish to emphasise how much I respect the enthusiasm, vigour and professionalism with which the present Government are tackling those duties. However, we need new ways of thinking. We need radical solutions to the various problems. I hope that some thought will be given to the points I have made.

7.24 p.m.

Lord Pender: My Lords, we are all grateful to my noble friend Lady Gardner of Parkes for initiating this debate. In these brief remarks, I wish to focus on one aspect of this broad subject. I ask your Lordships to turn your minds to those who live in a silent world--the deaf, and in particular deaf children. I should declare an interest as vice-president of the Royal School for Deaf Children.

If you are deaf and other people cannot communicate effectively with you--and you are with them--how do you develop your self-confidence; your skills in sharing in interaction and control; and your feelings of being valued? How do you develop positive relationships and effective learning and communication? How do you develop positive mental health?

Most children who are deaf are successful. About 90 per cent. of deaf children are successfully placed and make sound achievements in ordinary schools, including those in small classes and resource centres linked to ordinary classes. That success is aided by the skills and knowledge of teachers of the deaf. However, there is a minority group of deaf children who are failed by learning environments which damage them. They are failed by inappropriate assessment and advice, inadequate resources and a lack of opportunity to identify with other deaf children. They need to communicate and relate with other deaf children on equal terms and to succeed in competition with other deaf children. They need teachers and other adults who can communicate effectively with them, who understand their needs and can structure learning activities and experiences to provide success.

For deaf children who are damaged by inadequate or inappropriate provision, the Department of Health is developing improved services, such as the Pathfinder psychiatric services for deaf children and adolescents based at Springfield Hospital in Tooting. Sadly, that children's service has to seek charitable funding to enable it to develop long overdue facilities for severely emotionally and behaviourally disturbed deaf children. Should not all funding for such a facility--a national provision--come from the Department of Health and not rely on charitable funds?

How can we identify, prevent and reduce the degree and incidence of mental health and behaviour disorders among deaf children--particularly when many difficulties may be preventable? We have early identification, informed assessment and adequate resources to enable the development of effective and successful communication. If this provision were

3 Feb 1999 : Column 1562

supported by highly trained and specialist professionals, it would reduce the incidence of mental health and behaviour problems for children who are deaf.

So why have schools such as the Royal School for Deaf Children in Margate and its Westgate College for deaf people--like the other non-maintained charitable schools for the deaf--seen a steady increase in the numbers of pupils referred to them who have some form of emotional or behavioral difficulty? Too often, this minority group of vulnerable pupils have been placed in integrated or inclusive educational environments where they have become more isolated--unable to communicate and interact equally and effectively, unable to assess learning. Why do we wait until they are failed by systems which are supposed to support them? With all the available technology and reassessment, why are children still being wrongly referred? It is because health, education and social services are not working jointly to promote the best interests of every child.

I wish to ask the Minister--who carries her heavy workload with such grace--what the Secretary of State for Health is doing to ensure that his department collaborates with the Department for Education and Employment to ensure that medical and educational specialists are properly trained and resourced and that they collaborate to identify and assist those deaf children who are at risk of mental health problems? Will the Secretary of State collaborate with his colleague, the Secretary of State for Education and Employment, to ensure that local education and health authorities are properly resourced to ensure positive enabling provisions to meet the needs of deaf children and to include placements in schools for the deaf as a positive and preventive measure to enhance their mental health and learning opportunities? Will the Secretary of State work with his colleague, the Secretary for Education and Employment, and continue to monitor this important issue to ensure continued improvements in provision for this minority group? If the Secretaries of State improve provision for this group, they may help to reduce the longer-term costs of lives wasted and long-term demands on the health and education budgets.

7.30 p.m.

Lord Graham of Edmonton: My Lords, I also thank the noble Baroness, Lady Gardner of Parkes, for introducing the debate. I must also comment on her remarkable stamina. Everyone else in the House has left the Chamber at least once--I have been out twice--but when we came back in the noble Baroness was still in her place. She wants to listen to everyone, and has given us all an opportunity of discussing this important issue.

However, I was somewhat puzzled when she derided my right honourable friend in another place, Frank Dobson, for wanting to debate and discuss his inheritance. She said, "Get on with the job". But you cannot really get on with the job of solving today's problems without having due regard to the history of this matter. The noble Baroness sits next to a colleague who, in his speech, said that the trend was downwards over the period--not only since 1st May but before.

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Sadly, he felt that it will continue to go downwards. I share the view of many others that we have the prospect of reaching the bottom and turning back.

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