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Viscount Bridgeman: My Lords, I meant to say that the trend was downwards solely on account of clinical improvements, not through any quality of service.

Lord Graham of Edmonton: Thank you. I accept that point.

I shall begin by talking not only about the period before 1st May and the period of the health service, but about the history of the National Health Service, why it was so necessary and why it was not universally applauded when it came in.

If Members of this House look at my face, they will see that I have a scar on my cheekbone. That came when I was attacked on Tyneside at the age of 11 or 12. I was taken immediately to a doctor's surgery, where the doctor put clips in. I am the oldest of five children. My dad was not only on the dole but on the means test, and had 37 shillings a week to keep the seven of us. My mother then had to begin to pay off that doctor's bill; she paid it off at tuppence a week. At the end of the period there was great relief. Later, when I spoke to her about the matter, she said, "I was terrified that I would not be able to pay". The working class put aside their rent and insurance money to make sure that they were not in debt. Clothes, food and other things could go, but they knew what their responsibilities were.

When I was a child on Tyneside, in my class half the boys had their heads covered in what was called Gentian Violet--scabs. When I fell down and injured my knee or elbow, scabs formed very quickly. I later found out that this was a result of malnutrition and poor health. People on Tyneside and elsewhere suffered the indignity of the situation.

During the war I had my guts shot out by machine gun fire. I received the best medical treatment available. I can remember my mother sending me to the man who made false teeth and giving him thruppence a week to pay for them. She bought her glasses at Woolworths.

I very much respect the profession of the noble Baroness but, when I had my teeth out, I was not taken to the dentist but to the dental school, where I queued up with other boys so that those training as dentists could practise on me.

The noble Baroness and others can forget about the 50 years of the health service and concentrate on the current problems, but others, like myself, remember how it was and why we needed the health service.

I admire my right honourable friend Frank Dobson because he has admitted that there are great problems and great issues to be resolved. He has not run away; he has pledged to put them right. But they are not all of his or this Government's making. I have a very good friend who took early retirement as a nurse. The other day I told her that I was going to take part in this debate and

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asked her to tell me of her memories of the health service of not many years ago. I asked her the genesis of the problem of nurse shortages. She said this:

    "Many experienced nurses were made redundant during the change to purchaser/provider split and in the first year afterwards. This was because management was trying to push down costs in order to compete with other health authorities for contracts.

    This was particularly so in the large cities where there were more than one provider. The quickest way to save money is on the largest slice of the cake--the nursing budget. Many managers were tempted to drive down the grades by having ward sisters at grade F instead of G etc. This meant that the most experienced nurses left. The NHS lost those with the greatest experience, who knew how to work the system, who were confident in their own abilities, were able to deal with medical staff, could do three things at once with their eyes shut and teach the junior nurses these skills and of course were coincidentally the ones who were also best able to argue with the new managers!"
The letter contains a lot more, but time will beat me if I continue. In the face of that history, it is no good complaining at the inadequacies of what the Government and the Minister and his team are trying to do.

Reference has been made to the size of the National Health Service. It is not just a business; it is an enormous business. Inevitably there will be good people, bad people, fair people, reasonable people and unreasonable people.

When we look at the health service we have to be fair about comparisons with my childhood and with the history of the health service. I now go to a group practice in Loughton to see my doctor, Dr. Anwar Khan, a marvellous man. Over the past few years, whatever my problem has been--sciatica, thrombosis, arthritis and prostate--I and my family have been dealt with by that marvellous group practice. When I or my family need reference to Barts, Whips Cross or St. Margarets at Epping, the treatment is there. We may not get it on the day that we want--we may have to wait a week--but it is there. We also have to be fair on this issue.

I conclude by noting the manner in which the noble Baroness, Lady Gardner of Parkes, has sought to make the problems political and the solutions political. I do not blame her. In that she was aided and abetted by her noble friend Lord McColl of Dulwich who repeated remarks made by his shadow ministerial colleague Ann Widdecombe. She said that the NHS had suffered 18 years of Labour lies. I make the noble Lord a firm offer which I hope he will not refuse: stop telling lies about us and we shall stop telling the truth about you.

7.40 p.m.

Lord Clement-Jones: My Lords, it is a pleasure to follow the noble Lord, Lord Graham. This evening we have had an extremely wide-ranging and absorbing debate. I join with other noble Lords in expressing gratitude to the noble Baroness, Lady Gardner, for instituting this debate. I do not envy the Minister in her task of winding up.

Strong feelings have been expressed about the problems in the National Health Service that the Government need to address. However, your Lordships have rightly not made this debate simply an attack on the Government's record. It has been much more

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thoughtful than that. The noble Baroness, Lady Knight, made a very strong point about the impact of relentless criticism on the NHS. I inform the noble Baroness that despite her speech I shall stick to my old-fashioned glasses.

I did not recognise the benign internal market that the noble Baroness described in her opening speech. I preferred the description of the impact of the internal market given by the noble Lord, Lord Warner.

There are aspects of government policy that we on these Benches particularly welcome: the priority and further resources given to mental health; the new approach to public health which recognises health inequalities, which I believe the noble Lord, Lord Bruce, put clearly in context; the more effective framework for health improvement and preventive medicine with the setting up of health action zones and healthy living centres; the new emphasis on information to both the public and professionals; and the new quality agenda, in terms of both outcomes and clinical practice, which is now being reflected by the GMC under Sir Donald Irvine. We shall be debating the contents of the NHS Bill next week. But there are many elements to be welcomed, not least the abolition of the two-tier GP system.

Tonight I want to examine the three key issues of rationing, resources and recruitment, the new three Rs of the health service. I could go wider but time does not permit. That does not diminish the importance of a number of areas, such as dentistry, complementary medicine, the problems highlighted by the noble Lord, Lord Pender, relating to deaf children, and all of the commissioning issues raised by the noble Lord, Lord Winston.

The fact is, however, that opinion polls reveal that people believe that, despite all the efforts of the Government, there has been very little improvement in the health service since they came to power. I believe that rationing, resources and recruitment are the reasons for that.

I shall deal first with resources. Whatever the provenance of the waiting list--we have had some reflections upon it--as pointed out by my noble friend Baroness Sharp, it has almost doubled. I refer to those on the list who are waiting for more than three months for an appointment with a consultant. The number of those waiting longer than a year for treatment has doubled. As to beds, there was a major reduction in the 1980s. There are now only about 100,000 acute beds in this country. For a Western country that figure is of a very low order. There is no spare capacity. In some trusts occupancy is 95 per cent. There is also a shortage of intensive care and high dependency beds. We appear to have one of the lowest number per head in Europe.

The private finance initiative will make matters worse. It is clear from recent Answers to Parliamentary Questions I have received that the new developments may mean significantly fewer beds because of the need to cover the costs of private financing. A strategic review of beds is now taking place, but those PFI developments are going ahead in the meantime. An

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alternative to the private finance initiative is public funding, which we on these Benches believe is cheaper in both the short and long term. It is time the Government woke up to the fact that PFI represents poor value for money.

I turn now to the comprehensive spending review. We are aware that in their first two years of office the Government, with their eyes open, have, with some minor exceptions, effectively stuck to the former government's spending plans for the National Health Service. As a result spending will be only about £1 to £1.4 billion per annum more in the last year of this Government compared with the Conservative government's spending plans. The settlements announced earlier this week must be met from those additional resources. I am sure that many noble Lords will have received a briefing from the NHS Confederation which shows that despite the increase in resources because of additional commitments the result will be fewer resources for the NHS in the coming years.

Yet all the talk of an extra £21 billion for the health service has raised expectations enormously. It raises questions about what the expenditure policy for the NHS should be. Can we stay ahead of inflation in funding the health service? Should we introduce charges? The noble Baroness, Lady Gardner, raised this issue. This has been a favourite issue ever since the formation of the National Health Service. The noble Baroness was against hotel accommodation charges in particular but was in favour of other kinds of charges. I am highly sceptical about charges.

However, it is not necessarily a question of cash in all cases. We spend only 6.9 per cent. of GDP on health versus the European average of 7.7 per cent. Thanks to our health service workers, that represents extremely good value for money. But what is the Government's long-term funding policy? Is it believed that the needs of patients can continue to be met out of general taxation? What are the implications of using the private sector to ease the peaks of the health service? We know that private beds are being used in the crisis this winter. What are the Government doing in this respect? If we do not increase capacity in the health service that will become a permanent feature. I have no desire to see an expansion of the private sector funded by the National Health Service.

I turn to recruitment. We know now that 12,000 to 13,000 extra nurses are required in the health service. We have seen photographs in the national press showing new recruits from overseas arriving at, for example, Kingston Hospital. Massive use is made of agency nurses. The number has doubled over the past 10 years. Taking into account the cost of overtime by bank nurses, about £600 million a year is being spent. We are still unable to staff beds, even if they were available. Last year the Government phased nurses' pay, which effectively meant that the award was less than the rate of inflation. We acknowledge that the new settlement helps to tackle the issue of new recruits, but it does very little for retention at the higher grades. Other important aspects apart from pay are working conditions in hospitals. This matter was highlighted by a recent

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tribunal case. Family friendly, flexible rota systems are extremely important in retaining nurses in the health service.

A number of noble Lords have referred to violence in the NHS. This matter was touched on particularly by the noble Baroness, Lady Masham, and the noble Lord, Lord Bruce. This is an extremely important area. The Government have given their support to the campaign by the Royal College of Nursing to stamp out violence and to the setting of targets by hospital trusts, but undoubtedly more needs to be done at trust level to improve security for both staff and patients. They must also join community safety partnerships to make that a reality.

Another question that is increasingly raised, not least by the Secretary of State--I commend him for it--is the training received by nurses and whether it is over-academic in nature. A number of noble Lords referred to Project 2000. Did this go too far in stressing the academic aspects of training? We are aware that the UKCC review will be published in September. Many of us want to see the reintroduction of a stronger practical element of nurse training but without tipping the balance too far the other way. Although many of the comments of the noble Viscount, Lord Bridgeman, were well taken, the making of beds has long gone from the nursing profession.

As regards the way wards are managed currently, although much of its tone was old-fashioned, Goodbye Miss Nightingale by the Social Market Foundation highlighted some of the issues about patient care and ward management.

The noble Lord, Lord Winston, and my noble friend Lady Thomas referred to doctor shortages. We have a massive shortage of doctors coming down the track as a result of the Calman training reforms and the New Deal. As the noble Lord, Lord Winston, rightly pointed out, we need more consultant posts. The speech of the noble Lord, Lord McColl, concentrating on the lack of obstetricians and the need for more consultant posts, was extremely potent. Those factors will be further exacerbated by the working time directive which in due course will reduce to 48 the working hours of junior doctors.

On previous occasions we have had some debate in this House on the rationing issue. It is not acceptable simply for the Government to deny that rationing exists, to reassure us that there are enough resources in the health service, and then without further ado to impose rationing by diktat. We need a public debate. We need mechanisms, such as a standing conference as in Holland, which will allow us to have a proper debate. As the noble Lord, Lord Sawyer, indicated, it ties in with the Patient's Charter. Many proposals in the Patient's Charter--setting priorities, perhaps at regional level, but having a statement of values at national level--need examination. It is those issues that we need to examine. Every health professional admits that there is some form of rationing at every level in the National Health Service.

We on these Benches do not lay claim to all the answers but we believe that we are asking some of the right questions. The Government need to enter the debate

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before direction of the National Health Service becomes incoherent. There are strong public expectations of the Government. I hope that they are not disappointed by any failure to address some of those issues.

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