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Lord McColl of Dulwich: My Lords, before the noble Lord sits down, he mentioned a large number of beds which were closed in the 1980s. Despite the propaganda to the contrary, does he accept that every year since 1964 7,000 beds have been taken out of service irrespective of which government were in power?
Lord Clement-Jones: My Lords, I thank the noble Lord for that question. I have no doubt that he is correct. However, it is my understanding that the process of reduction in acute beds accelerated during the 1980s.
7.52 p.m.
Earl Howe: My Lords, alongside other noble Lords, I congratulate my noble friend Lady Gardner on her excellent Motion. I am sure all noble Lords who have spoken recognise my noble friend's long experience of the National Health Service and her profound understanding of it. Her speech today bore eloquent witness to that experience and understanding and has allowed the House an opportunity to range over a broad and particularly interesting set of health-related issues. It has been a very good debate.
If there is one sobering theme which has permeated our debate today, whether in the perceptive comments of my noble friend Lady Byford about rural areas, the remarks about kidney patients by my noble friend Lord Norrie, the powerful contribution on dentistry by my noble friend Lord Colwyn, or the observations on hospital beds by the noble Baroness, Lady Thomas, it is surely the inexorable and ever-accelerating rise in the demand for healthcare. Those demands are a function of three simultaneous phenomena which have persisted ever since the founding of the NHS in 1948: a growing elderly population; the cost of new technology and medication; and, as a number of noble Lords pointed out, the expectations which inevitably accompany those two factors. Governments of whichever party have to acknowledge those pressures. It is a one-way bet that demand will continue to rise.
Stewardship of the NHS at a political level is about deciding on an appropriate measure of resources for the health service and ensuring that those resources are efficiently directed. I should like briefly to bring together a number of the strands running through today's debate by highlighting some aspects of the present Government's approach to these difficult issues and at the same time ask some questions about them.
Last November Frank Dobson said in another place that the health service could look forward to the winter with confidence. In the event, as we are all aware, the winter has been marked by some particularly intense pressure on acute services within the NHS resulting in some considerable distress for many patients and causing the staff and facilities in some hospitals to be stretched almost to breaking point. I think that there are several reasons why an outbreak of flu which fell a long
way short of an epidemic should have resulted in that situation. One reason, about which the noble Baroness, Lady McFarlane, spoke so well, is the shortage of nurses. The shortage of nurses is unquestionably the most pressing problem currently facing the NHS. The remarks of my noble friend, Lord Bridgeman, on nursing recruitment seemed to me cogent and very much to the point. The noble Lord, Lord Clement-Jones, mentioned abuse delivered to nurses. I think it is true to say that verbal abuse to nurses is far worse and more prevalent than physical abuse, although both occur. I am glad that the Government have recognised the importance of the nursing issue. Although I agree with the noble Baroness, Lady Emerton, there is still a great deal of work to do, in particular in some trusts as regards career development and flexible hours of working, if the retention rate for nurses is to be improved and if former nurses are to be enticed back from retirement to the NHS.When last month we debated the winter crisis, I put it to the Minister that another significant factor underlying these pressures was political in origin; namely, the Government's almost obsessive emphasis on cutting waiting lists. Were it not for that obsession, many hospitals would have been nothing like as full as they were when the emergency cases hit them. The Minister called that proposition a canard. I humbly suggest to the noble Baroness that she re-examines it because her answer is directly contradicted by many sources throughout the country. The BMA and the British Medical Journal, among others, have confirmed the point. Quite simply, had it not been for the imperative of reducing waiting lists that the Secretary of State imposed, there would have been more beds available and fewer trolley cases this winter.
The irony is that setting targets for NHS trusts to meet which are expressed purely in terms of numbers, and accompanying those targets with threats of dire penalties in the event of failure, is an invitation to managers to override strict clinical need and to deal instead with the cases that are quick and easy, and usually less serious. That unfortunately is what has been happening. People in need are being bypassed in favour of others whose need is less serious.
It is the time a patient has to wait, and the seriousness of their need, which counts, not the total number of people in the UK who happen to be waiting at any given moment. The Minister said recently that waiting times as well as waiting list numbers are coming down. I challenge the noble Baroness on that assertion. The number of people waiting over 12 months for treatment has doubled since the last election. But what is hidden even in that statistic is a factor referred to by, I think, two noble Lords: that is, the rise in those waiting to be seen by a consultant even before they get on to the waiting list for treatment. Between March 1997 and September last year the number of people waiting more than 13 weeks to see a specialist rose from 247,000 to 437,000. That is the flip side of the recent drop in the number of people waiting for treatment. The two issues are linked. But a rise in unseen referral patients is more serious because the referrals will include urgent cases
which have not even been assessed or prioritised. The Government's so-called "early pledge" on reducing waiting list numbers is not just a nonsense, well intentioned though it once may have been, but actually damaging to patients.Waiting lists are, of course, a barometer of patient demand. However, as I have tried to show, they are only a very crude indicator of patient need; and if one is looking for unmet patient need, look no further than the non-availability of certain drug treatments. Last week, I attended a presentation given by CancerBACUP, which highlighted the example of Taxol, a drug used to treat ovarian cancer. In many health authorities Taxol is simply not available on grounds of cost. If patients want it they have to pay for it themselves. Beta Interferon, which is used to treat multiple sclerosis, is also unavailable in many health authorities. The same applies to Statins, a class of modern drugs which treat heart attacks. The modern drug treatments for schizophrenia are regarded by many health authorities as too expensive to be made generally available. Instead, patients are prescribed drugs developed in the 1950s such as Haldol, which has crippling side effects. Those are only a few examples.
The Minister need not look anxious because in citing these examples I am not making any party political point. But as she will know, the unfair part about all this is that whether or not you receive the treatment you need depends on where in the country you live. What is wanted, and what I think people expect of the political representatives, is an open debate about priorities and affordability. It is an issue which we must confront head on and involve all concerned, including patients, in the process.
What we cannot have is any kind of obfuscation. The Government's answer to the problem that I have just outlined is the National Institute for Clinical Excellence, which is soon to be up and running. The Minister was kind enough to give me a copy of today's press release on NICE, which I see is headed "NICE proposals launched today". I do not believe that was meant to point up a comparison with yesterday's proposals on NHS Direct.
NICE will provide guidelines to GPs and clinicians about the most effective kinds of treatment and in doing so will rely on the principles of evidence-based medicine. There are high hopes for NICE, and indeed it has the ring about it of good common sense. Perhaps I may quote two or three passages from the publication.
- "NICE will command the respect of doctors, nurses and other clinical professionals and provide authoritative guidance on what treatments work best for patients. Its evidence-based guidelines will be used right across the country, so NICE will help end the unacceptable geographical variations in care that have grown up in recent years. By identifying which new developments will most improve patient care, it will help spread good value new treatments more quickly across the NHS".
All too often, you can demonstrate cost-effectiveness only with hindsight after a treatment has been put into practice. The classic example of that is combination therapy for AIDS patients. The Government's test of "clinical and cost-effectiveness" looks set to be a double lock from which two consequences are likely to flow. The first is that many clinically effective drugs will be unavailable, but this time their availability will not be localised, it will be nation-wide. The second is that clinical trials of new drugs will no longer take place in the UK. British patients will become the last to benefit from new drug treatments and not, as they have been recently, among the first.
A recent survey conducted by NOP Health Care found that nearly 60 per cent. of GPs do not believe that their patients always receive the best treatment available regardless of cost. Many of them said that their local health authorities had stated that they could not afford it or had issued guidelines not to provide it. Mr. Dobson's public reassurance that,
- "the money will always be there to guarantee that patients get the medicine they need when they need it",
Perhaps I may pick up a point made by my noble friend Lady Gardner. NICE must not become a vehicle for obfuscating difficult decisions or when a GP withholds a certain treatment, concealing from the patient that the decision may not be a wholly clinical one. I should welcome the Minister's comments on what I have said because, examined under the skin, NICE begins to carry the warning signs of exactly the syndrome I have highlighted on the management of waiting lists; namely, interference in the clinical process by government.
That is a theme I shall pick up in various ways when we come to debate the Health Bill next week. For now, at the end of a rich and satisfying debate, it only remains to listen to what the Minister has to say.
8.6 p.m.
Baroness Hayman: My Lords, it has indeed been a rich and interesting debate, as the noble Earl said. I, too, congratulate the noble Baroness, Lady Gardner of Parkes, on introducing it and on making five hours go very quickly. My only reservation occurred when one noble Lord described it as a preliminary canter for our debate next week on the Health Bill. I believe that stamina of Grand National proportions will be needed.
Furthermore, the debate has presented me with the huge task of trying to respond appropriately to such wide-ranging topics. We have heard from nurses, dentists, doctors and people who have served for many years as chairs and non-executive members of health authorities and other bodies. We have heard from some well-known and effective patient champions and we heard, appropriately, from patients, as my noble friend Lord Sawyer reminded us. We were reminded of the importance of having patients at the heart of the National Health Service.
It has been a wide-ranging debate. We moved from fluoridation to party lenses, which was my discovery of the day. We examined the Defence Medical Services and heard some potent and powerful messages about individual groups of patients. We heard about people with renal disease, of the needs of deaf children and about those suffering from the effects of organophosphates. We debated the general themes of resources, rationing, nursing and joint working. There was even a moment in the debate when, having heard my noble friend Lord Bruce of Donington talk about the synthesis which occurs after argument and counter-argument, I thought that he had discovered the third way. I suspect that he might shout at me if I say that, so I shall not pursue that line of argument. We even heard some management speak during the debate.
It has been interesting and I suppose that this is my human moment to echo my noble friend's contribution. The National Health Service is an institution of whose genesis we were powerfully reminded by my noble friend Lord Graham of Edmonton. It binds people together in the most extraordinary ways. From all sides of the House we heard contributions from people who are united in their commitment and passion for the National Health Service. It made me think in terms of the "human moment" and "management speak" of my own stretch objective as a Minister to make a wind-up speech in a debate with 34 contributors that is both coherent and comprehensive. I have not yet got there, but I am hoping that by the end of my ministerial career I shall be somewhere near.
I should like to say two things in beginning my wind-up speech. First, I echo the comments of my noble friend Lord Prys-Davies--it was repeated in different ways in many contributions--regarding the tribute we all want to pay to those who work in the health service in all their different capacities. The comments of the noble Lord, Lord Chadlington, were fascinating. His contribution was perhaps coming from a different perspective and was particularly interesting.
It is interesting to consider the representation of this winter and the actuality for many people who worked in the service and perceived it. While I do not for a moment suggest that everything was perfect, that some patients did not have an extremely difficult time and that the service was not under stress, in some places the most inspiring joint working was being carried out. People under pressure were responding effectively to that pressure and providing high quality care a great deal of the time.
If there is a morale issue in the health service, I suggest that it does not lie in some of the party political banter as to whose fault it was or where problems occurred, but in a representation of dwelling on the failures rather than on the successes. I was interested therefore in what the noble Lord, Lord Chadlington, said and agree that it is important that we celebrate the success of things like NHS Direct. That is going to be enormously important; and it is already enormously popular with those who use it. It will help us with some of the real conundrums about increasing demands and, as in any system, limited resources and the need to allocate those resources as effectively as we can.
It is important therefore to recognise the successes. I say to those noble Lords who suggested that some of the fault in the current situation--whatever that may be--lies in something that I certainly did not recognise as coming out of the Labour Party manifesto; that is, that it contained some kind of magic promise that a Labour government would transform all the problems that exist in the health service and put everything right overnight. There are long-standing difficulties and problems which will take time to improve and put right. But a point echoed by my noble friend Lady Pitkeathley is that it would be absolutely wrong to have low expectations of the National Health Service. We will not get the best out of people working in the service; we will not get the best out of public support for the service and resources in the service by having low expectations. It is right that we have high expectations. We must try to live up to them--sometimes it will be difficult and sometimes we shall stumble on the way. But that is not a reason for downgrading those expectations.
Perhaps I can also get out of the way some of the ideological issues. A recurrent theme throughout the debate related to the effects and imposition of the internal market on the health service. I was working in the health service at the same time as the noble Baroness, Lady Gardner of Parkes. Though we disagree fundamentally on many political issues and in our analysis of how the health service should be run, it was another illustration of how it brings people closer together that we managed amicably and successfully to work together as chairs of neighbouring trusts in north London.
I believe that the language and the structures of the market were deeply inappropriate to what was and is an extremely cost-effective public service. Our best hope of cost-effectiveness and value for money from the health service is in encouraging the collaboration and co-operation which goes with the grain of what people in the service want to do and what those receiving the service expect from a publicly funded, publicly available service. It is that which will encourage the sharing of good practice and the learning from experience that, again, is a way of maximising the considerable investment that we make in the health service.
Another point which came out of tonight's debate--it was made by my noble friends Lord Warner and Lady Pitkeathley and the noble Lords, Lord Laming and Lord Butterfield; so it came from all sides of the House--was the importance of joint working in different parts of the
health service. That was illustrated during the pressures faced this winter; that is, how important it is to have the secondary sector, primary healthcare and, most importantly, social services working together so that they can provide the sort of service for patients that goes across institutional boundaries and responds most appropriately to needs.Another point that was made very clearly by the noble Baroness, Lady Sharp of Guildford, was that when we come to the fundamentals of tackling inequalities in health, in addressing not simply how we provide a sickness service but also how we encourage and foster good health in the population, it is essential that we work across departmental and government boundaries; that we recognise that the contribution to the health of the population of this country comes not just from the Department of Health; and that it is the sorts of initiative that come out of, for example, Sure Start, the New Deal, the education and welfare reforms, the minimum wage and action on smoking that in the long term will have enormous benefits in terms of the health of the population.
It is important too to concentrate on education. It is a difficult phenomenon but one that is well known in public service that to those who have shall be given and that those who know how to use public services get the most out of them. We must tackle that phenomenon and be solid in our determination to improve the health of the least well off disproportionately faster than the health of everybody else. That means that we must ensure that health action zones and health improvement programmes are structures for taking that focus to those who get least out of the system as a whole, who are most socially excluded and most likely to suffer ill health, and give them the highest importance.
I turn now to some of the specific points made in the debate. Some interesting questions were raised as to the availability of beds in the acute sector. I take the point made by my noble friend Lady Pitkeathley that we are not only talking about the hospital service, but we must look also across the community and into social services as well. In reply to the noble Baroness, Lady Thomas of Walliswood, I can say that the bed survey is under way and will be reporting in the spring.
The noble Viscount, Lord Bridgeman, was right to point out that if we look at the graph of the declension of bed numbers over the years, it has been steadily falling. I do not think that we should assume from that that at some point no beds at all will be provided in the health service, which is what happens if you continue the logical progression. Given the pressure that there has been, particularly on general medical beds, it is absolutely appropriate that at this point we ask whether we have adequate provision. It is enormously important that we look, not only at acute hospitals, but also at intermediate care, at care offered in nursing homes, across the whole range, and at the care offered at home. Often a higher quality of service can be offered to a patient by a rapid-response team going into the patient's home, avoiding the need for hospital admission. That is important.
However, we have seen an issue concerning ICU beds this winter which has been worrying. We have managed to provide some extra beds through additional investment in "winter pressures" money, but we are looking carefully at whether we need more and we are reviewing the availability nationwide.
Another winter issue that arose, to which the noble Baroness, Lady Masham of Ilton, referred, was that of the availability of blood through the National Blood Service. Stocks were very short, as they traditionally are over the Christmas period. One of the successes that I hope that the noble Lord, Lord Chadlington, will be pleased to celebrate is that the advertising campaign that was launched in January was very successful. A great number of new donors have come forward in response to that campaign. Stocks of blood are now up to a much better level.
Perhaps I can share with your Lordships' House that I wrote to every MP suggesting that they should give blood. Much to the amazement of the department, nearly 90 MPs did give blood in their own localities. That was a great success and I believe that the local publicity encouraged other people. I have persuaded Black Rod to allow us to have a blood donation session in your Lordships' House. If I may say so, the upper age range for blood donation is now 70 years of age. I hope we can publicise this initiative and receive contributions, whether blue or red, from your Lordships' House.
The noble Baroness, Lady Masham of Ilton, also referred to the meningitis outbreak that occurred this winter, as in every winter. Its incidence tends to mirror that of flu. We certainly recognise the importance of paediatric intensive care being available wherever it is needed. As I said earlier, we do not necessarily need a paediatric intensive care unit in every hospital, but we must make sure that the retrieval services are in place to ensure that a child can be transported very quickly.
I also recognise the point that the noble Baroness made about medicine and services for adolescents, which in the past has been somewhat neglected.
The plea of the noble Lord, Lord Pender, was that we should work co-operatively with the Department for Education and Employment on the needs for deaf children. It is particularly important that education and health come together for that group.
Several other specific points were raised. The noble Lord, Lord Norrie, referred to kidney patients. He is absolutely right to point out the current pressures on renal replacement therapy services, hospital haemo-dialysis, in particular, and the increased demand for treatment. We hope to make progress in reducing regional variations, to offer guidance in the coming months about regional services to health authorities and to improve the commissioning of those services. Both the noble Lord, Lord Norrie, and the noble Baroness, Lady Fookes, who, as I was pleased to see, carries her donor card with her, raised the issue of organ donation. We are trying to increase the numbers who carry cards, who talk to their relatives on the subject and who put themselves on the register. We are specifically looking at the need to have a campaign among the Asian communities where the need is greater in terms of renal
disease but where the knowledge and commitment to organ donation is less well developed. I have to take the noble Baroness's remark about Plymouth seriously, having left my appendix there about 40 years ago while on holiday in Cornwall. I shall certainly look into that issue.My noble friend Lord Laming referred to the need for joint learning. That is an important area. I had some experience of how a school of nursing and a medical school on the same campus, using some of the same facilities--whether schools, laboratories or libraries--can encourage partnership working, which is important for the future.
I cannot avoid saying something about dentistry because the noble Lord, Lord Colwyn, would never forgive me if I did not. On the issue of fluoridation, we are determined to break the impasse where, despite the majority of the public supporting it, there has been no new scheme since 1985. The public health White Paper will take us further on that.
The noble Lord referred to the uptake of the money available for the "investing in dentistry" schemes. That uptake has been limited so far. That is not because the Department of Health has not made the money available. The department has funded every proposal that met the criteria, but it is dependent on the local health authorities putting forward proposals.
The noble Lord, Lord Colwyn, also raised the issue about general anaesthesia and the possible transfer to the secondary sector. At the moment we have seen no evidence of that, but we shall monitor it.
I turn now to the issue of radiotherapy, as raised by the noble Lord, Lord Ironside, arising from a group of patients who suffered very traumatic injuries in the course of their treatment. The START trial, to which he referred, began recruiting on 4th January this year and has recruited so far 21 patients. All the participating centres will be scrutinised by a quality assurance team before patients may enter the study and any radiotherapy centre may volunteer to participate. The trial hopes to recruit 4,000 patients in four years, so completing recruitment in 2003. Follow up of patients will continue for 10 years or more after radiotherapy.
On the new approach to mammography, I know that some NHS trial hospitals are already using computers to display X-ray information to enable precision biopsies, and research is considering the use of that technique in treatment.
The noble Lord, Lord Vivian, referred to the defence medical services and the Royal Hospital, Haslar. The decision was taken that Haslar should close. That is unlikely to happen before 2002 because we are committed, as is the Ministry of Defence, to ensure that the change is properly planned, that the implications are dealt with and that the healthcare provisions for both the civilian and service populations of that area are safeguarded.
We want to establish the Centre for Defence Medicine as soon as possible to enhance the role that Haslar played as a focus for professional excellence in military medicine. On the broader issues facing service families, who often have difficulties of access to a broad range
of facilities--education and welfare, as well as health facilities--an inter-ministerial group has been set up--I serve on it--to address some of those issues and to see that those families are not disadvantaged by being service families.My noble friend Lord Sawyer referred to the work that Greg Dyke has done on the new NHS charter. I can reassure him that we will consult the public and the NHS in the spring on a new charter programme. He felt strongly that we should not impose that from above. It should grow from below. The value statement for the NHS will be one of the issues on which we shall consult.
The noble Earl, Lord Howe, referred to the accessibility of drug treatments. Yes, there are enormous divergences; and the post-code prescribing phenomenon was not diminished--perhaps I may put it that way--by the existence of both GP fundholding and the internal market. However, through the mechanism of national service frameworks and the National Institute for Clinical Excellence, we are trying to ensure that unacceptable variations are reduced and that we consider both clinical matters and cost-effectiveness. We must do that not only to encourage the rapid spread of new and effective technologies, but also to tackle issues relating to the ineffective practice and treatment of the past. That could free some resources for the extra things that we want to do.
I end by commenting on nursing, which was a recurrent theme of the debate and on which, as one would expect, we had many contributions. The House values particularly the long experience and wisdom which the noble Baronesses, Lady McFarlane and Lady Emerton, bring to discussions of nursing issues. Many points were made, such as the need to consider nurse training, including the need for clinical experience and practice early in the course. The need for the recognition of clinical nurses in teaching was raised by the noble Viscount, Lord Bridgeman. As was said, we need to end some of the negative separation that has grown up between academic institutions and the NHS so that we can make nursing students feel more part of the NHS. That is not to say that we should go backwards and completely dismantle what has gone before.
The UKCC Commission for Education will be enormously valuable in making us able to take on the real concerns, such as the need to have a range of skills among our nurses and to recognise the very important bedside skills, as well as the basic care provided for patients. We should value them just as we value the enormously responsible and demanding tasks that some nurses at the top of the profession are undertaking in jobs which, five or 10 years ago, would have been considered completely the province of doctors.
As my noble friend Lord Morris said, we must consider also the grading system within nursing and find a way, not to introduce performance-related pay--my right honourable friend always says that he has never mentioned performance-related pay for nurses except to say that we are not going to have it!--but to have a clearer system that does not impose restrictive ceilings on developing skills and practice but which recognises those who develop competences and take on further
responsibilities. That is most important. Indeed, it is part of the range of issues which go together with the very real investment in pay that we announced this week.However, as my noble friend Lord Rea suggested, those are not the only issues. Violence against staff is an important and destructive issue within the health service and we must be absolutely adamant about protecting staff against violence. We must improve the conditions in which they work. That is why providing the money to improve one in four A&E departments is important. That is why the hospital building programme is important--not only for patients but also for staff. That is why we must have family-friendly employment policies which recognise that people have commitments and that we cannot expect people to work on some of the rigid shift patterns of the past. All those things are tremendously important. It must also be possible to enter the profession at different entry points and to have retraining on a part-time basis for those who have family responsibilities, and which does not mean a diminution in income for, say, a healthcare assistant who wants to train as a nurse. Those are all things that we can do to reverse the current shortage of nurses.
Perhaps I may advise the noble Lord, Lord Vivian, on one point. He is not correct in thinking that money has been taken out of the capital fund to fund the nurses' pay award. The £100 million that is coming from the modernisation fund had always been allocated for staff. There is no impact whatsoever on the capital moneys, the IT money, the mental health money or the primary care money in the modernisation fund. We are not sacrificing that in order to fund the pay award.
Pay is one element, but other issues are also important. Good morale and feeling part of an important organisation are absolutely vital. The best news that I have had this week was to know that as of 6 p.m. today, since the first television advertisements were shown in our £4 million television campaign launched on Monday, which gives a central telephone number to call, we have received more than 8,000 calls. That is enormously heartening not only for the recruitment of new entrants to the profession but also in terms of luring back those who have left. Furthermore, it will enhance the value that we put on nurses and show them very clearly that we recognise the importance of their role. In that way, it will enhance the most important element of all, the retention of our existing nurses. That is the piece of good news on which I end. I am afraid that I cannot give the House the exact number of callers because I believe that responses are running at 10 per minute.
I am certainly not despondent about the state of the NHS at the moment. I would not say that it is without its problems or that it could not always use more resources. However, I believe that we have put in place the structures for building on what was created 51 years ago and for taking it, with strength, determination and affection, into the 21st century.
8.37 p.m.
Baroness Gardner of Parkes: My Lords, I thank all those who have contributed to the debate and I beg leave to withdraw my Motion for Papers.
Motion for Papers, by leave, withdrawn.
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