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Lord Burlison: My Lords, perhaps I may point out to the noble Lord that this is a timed debate. This is only the second time that anyone has gone past the allotted time.

Lord Bell: My Lords, I am sorry to have gone beyond the time allowed. My noble friend Lord Chadlington told me I would and he was right. I shall listen to him in future.

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My message to the Labour Government is: stop accusing the Conservatives of wanting to privatise the NHS--we do not; stop claiming that Labour has a monopoly of caring--it does not; stop claiming that more money is the only answer when it is not; the NHS can be run like a modern business; pay people properly, supply proper working conditions and training; create direct, decent facilities; stop talking about caring and ideology and do something. Empower the people who run the NHS.

6.10 p.m.

Lord Prys-Davies: My Lords, like other speakers, I am grateful to the noble Baroness, Lady Cumberlege, for having given us another opportunity to discuss the state of the NHS. It is right that this subject should be before the House regularly.

The debate has attracted a long list of speakers who have a great level of expertise and profound knowledge of the NHS. I am not so qualified. I am merely a patient of the NHS but I owe it a great debt. I want to refer briefly to three issues: first, the well-founded anxieties that the NHS is inadequately funded, which have dominated the debate tonight. It does not allay our concerns that almost from its inception the NHS has been under-funded. It has always been up against the growing pressures and demands stemming from huge advances in scientific knowledge and technology, and fundamental demographic changes which are still at work in our society.

I understand that over the next 25 years the number of people over 60 in the countries of the European Union is estimated to increase by almost 50 per cent. Therein lies a challenge in financial terms and in terms of delivery of service.

I wonder whether there is an answer to the question, "How much money do we need to run the health service?". All I know is that the NHS must ask for every penny it can possibly get. The justification for such a demand on public finances is that it is providing best possible value for money; that it is using the resources in the most effective way possible. I accept that.

One is bound to accept--it is undeniable--that the NHS requires an injection of substantially more cash. At the same time, I agree with the comments of the noble Baroness, Lady Cumberlege, that the arguments should not focus entirely on the issue of funding. I believe that another policy message is coming through: that the solution may not always lie in more of the same measures as were served up in the past. There is a need to encourage more innovation. I note that my noble friend Lord Rea has been rather cautious in his approach to NHS Direct. I submit that NHS Direct is a striking illustration of the importance of innovation. Can my noble friend the Minister say whether the Government are contemplating any further innovations possibly based on the experienced gained by and within NHS Direct?

I turn to my second point; that is, the needs of the medical schools for more funds to enable them to pay proper salaries to the teachers of medicine and their

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staff. The noble Lord, Lord Walton, who is specially qualified and interested in this subject, eloquently made the case today, and not just today; he also made the case in the debate on universities on 8th December last. It struck me as very worrying indeed that today there are at least 67 vacant clinical chairs across the specialties in the UK. I believe that half of them have been vacant for more than one year.

I welcome the news that there is to be a substantial increase in medical student numbers. But the quality of their education and training, and the quality of the National Health Service that we will need in the future, lies to a considerable extent in the hands of teachers of medicine today. When the Minister winds up the debate, I should like to hear from him that the proper funding of the medical schools is an ingredient that will go into the calculation of the current comprehensive spending review.

My final comment concerns the NHS and devolution, which has not been touched upon in the debate tonight. However, it is now nine months since responsibility for the health service in Scotland and Wales was transferred to the Scottish Parliament and the National Assembly for Wales. I greatly welcomed the devolution settlement. But the devolved institutions will also work in partnership with the departments of the UK Government.

It is important that, when the functional departments in Whitehall are considering new policy initiatives or formulating new primary or subordinate legislation in the area of or affecting the devolved subjects, the Assembly officials in Cardiff should be informed at an early stage so that the views of the Assembly can be fed in at an early stage and vice versa. That leads me naturally to ask: what steps have been taken to agree a concordat between the Department of Health in London and the Welsh Assembly executive?

I also believe that it would be of interest to the House generally to know how many new powers for making delegated legislation relating to health functions in Wales are included in primary legislation introduced since last May. I suggest that the answer may be one point of reference in the debate about the future role of the reformed House. If my noble friend the Minister cannot answer these questions today, I should be grateful if he could let me have the information in due course.

Be that as it may, I conclude by reminding noble Lords that the health services in the four countries of the United Kingdom are part of the National Health Service based on an Act of Parliament which remains, in the opinion of most of us, among the most progressive legislation of the past 100 years.

6.17 p.m.

Baroness Seccombe: My Lords, I wish to add my thanks to my noble friend Lady Cumberlege, who, as always, spoke with distinction and informed knowledge. I begin by declaring an interest. I am the unpaid deputy chairman of Nuffield Hospitals, one of

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the country's largest charities. I hope that your Lordships will accept that I am not speaking on behalf of Nuffield Hospitals but on a point of principle.

There is no need for me to tell your Lordships that the NHS is in dire straits and so, for the sake of everyone, we all have to search for initiatives which will alleviate this serious problem. One of the first measures that the newly-elected Labour Government took in May 1997 was to remove the modest tax allowance available to those older people who had private medical insurance. At a stroke the Government increased the demands on the NHS and, as my noble friend Lord Forsyth of Drumlean stated, an extra quarter of a million people, who had stretched themselves to pay the premiums, were no longer able to cope.

It is the elderly who need the service the most. As a consequence, many of those who had prudently catered for their medical requirements became an additional responsibility on an already fully-extended NHS. We have an ageing population who naturally want and expect to benefit from all the developments in techniques and drugs to enhance the quality of later life.

It seems incredible that a political party can be so hidebound and blinkered by dogma that it is not willing to accept the consequences of its actions. For the Prime Minister to state that private health insurance is not the answer is a disgrace. Of course it is not the complete answer, but it could go some way to relieving pressure on an over-burdened service whose loyal staff do their best to cope with a dreadful situation. It is our duty to provide high quality care to everyone in this country, regardless of his or her financial situation.

It was with revulsion that we read of gravely ill people being bussed hundreds of miles in search of the necessary care when I understand that local private hospitals in London were not even consulted as to whether or not any intensive care beds were available. I found the mealy-mouthed words of the Minister in answer to my noble friend Lord Howe quite unacceptable when he said that national health trusts could make their own local arrangements with the private sector. Surely when people are dying from lack of beds and lying on trolleys for hours, the Government should have taken the lead by welcoming and supporting the involvement of private hospitals, wherever possible, for the common good of all our people.

Personally I believe that the tax concession should be restored to those who had it previously, and in addition should be extended to anyone who wishes to provide for their care. It is strange that the Government are so hostile to private medicine when the NHS, with 25 per cent of all private beds, is the largest provider. NHS trusts would benefit from the increased income generated. In the public debate that must now ensue it is vital to see, as we have heard from many other noble Lords, how other countries manage their healthcare. It seems clear that in France and Germany private involvement is providing a much higher quality of care than in Britain.

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I remember with incredulity the commotion over Jennifer's ear in the run-up to the 1992 election. There was a problem, but not one that can in any way be compared with the crisis of today. Mr. Blair appears to be at best complacent over the situation which has arisen during his stewardship. Like my noble friend Lord Bell, I shall never forget the scandalous advertisement that appeared the day before polling day in 1997--"24 hours to save the NHS". Inflammatory remarks like that can only cause fear and anguish for many elderly people. I am sure that many of those who were seduced and voted new Labour the next day regret their actions as they contemplate the service today when one cannot even arrange an appointment with a consultant, never mind get on to the waiting list for a hospital admission.

I was alarmed that the pay increases for nurses and other staff over and above inflation are not to be funded. That will undoubtedly lead to cuts in some services, thus reducing patient care. The time has come for the Government to stop listening to their spin doctors and face reality. The noble Lord, Lord Winston, a most highly respected, distinguished and dedicated consultant, criticised the Government's handling of the NHS. I understand from the press that he was treated most shabbily by Alastair Campbell for stating the truth. But people are not stupid and are much more likely to believe the noble Lord than the propaganda machine of new Labour.

The most frequent toast given anywhere is "Good health". We have always accepted that good health is a gift much treasured, but today it is even more essential to stay fit and well as we do not know, should we fall ill, how the system will care for us. Will we receive treatment? Will we be given essential drugs?

Some people will receive the care we expect. But some--the old, the weak and the vulnerable--may not. It is up to us, collectively, to do everything in our power to ensure that those who need care receive it with dignity as and when it is required. Our goal must be an NHS of the highest standard and a beacon of excellence that we can cherish.

6.24 p.m.

Lord Patel: My Lords, I thank the noble Baroness, Lady Cumberlege, for making it possible to conduct this debate and for leading it. I regret that, due to my NHS commitments this morning, I could not be here at the start of the debate. I was particularly sorry to miss the contribution of the noble Baroness, Lady Cumberlege. I hope that I can be forgiven for this transgression by your Lordships, the noble Baroness, the Minister and all those who spoke earlier, and I thank all for allowing me to speak at this late stage of the debate.

There can be no one in this House or in the land today who is not affected by the pain and suffering inflicted on the relatives and friends of the victims of the evil deeds committed by an evil man. I extend my deep-felt sympathy to all relatives and friends of those who suffered at his hands.

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The fact that that evil man belonged to my profession--a profession privileged to have the skills to save lives--puts a responsibility on me and others in my profession to do whatever is necessary to ensure that that never happens again. But the profession must do more if it is to regain any lost public confidence and maintain the privilege of self-regulation. It must rid the profession of incompetent doctors; be more accountable and transparent; and, above all, regulate only in the interests of the public. That is what the profession must pledge to do, whatever else the government inquiry recommends, for the relatives and friends of those that were murdered.

I also believe that many thousands of doctors who work in the NHS, in the best interests of the patients, will also wish that. No doctor should ever abuse the trust and confidence placed in her or him by patients and their relatives. If they do, they cannot remain members of the profession. We must also demonstrate that we practise to high moral and ethical standards and remain competent.

I should like to say something about the state of the NHS today. It is an NHS destabilised by the reforms of an internal market; with clinical services starved of funds by the resources spent in establishing, maintaining and then dismantling that internal market. Now we have fewer beds, and a shortage of nurses, midwives and doctors. There is low morale among those who provide the service. There are long waiting times and waiting lists. To tell a lady that she needs surgery but cannot have it for at least eight months is not pleasant. We have poor outcome indicators of diseases, including cancer, and a service that is under-resourced.

With the will to go with the intellectual thinking, there is no reason why the NHS cannot deliver a world-class service in every aspect; a service with which the public will be pleased; of which those who provide it will be proud; and a service for which the politicians who make it happen will receive the credit. Surely a worthy aim is a service adequately resourced. I hope that the Minister agrees.

6.28 p.m.

Baroness Fookes: My Lords, it is with a real sense of diffidence that I rise to speak tonight because I am very much a layman amid a galaxy of experts of all kinds.

I should like to place on record my own good feelings in relation to the NHS and my family. A few years ago, an elderly relative of mine was found to be suffering from cancer. The treatment she received was swift, excellent and kept her alive for six years. My personal recollections, therefore, are good.

However, I know that there are many ways in which the NHS is a creaking machine and it behoves all of us to try to seek a consensus, as others before me in this debate have indicated. Alternatively, if not a consensus, we should seek at least a constructive debate as to the best way forward without impugning base motives to other parties. I have seen this over the years in my political life in the other place. I found it increasingly depressing that the NHS was treated like

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some political football. At the beginning of this new century, surely we ought to turn over a new leaf to try to look for ways in which we might go forward together.

I was much interested in the suggestion of my noble friend Lord Biffen that this might be the subject of inquiry for a Select Committee in the other place. I should like to go one step better than that. I think that the ideal Select Committee would be here, in this House, where there are so many people who could contribute because of their deep knowledge and experience. I hope that this might be something which could be seriously considered, and soon. I hope that such a committee would not rule out, as, sadly, the Prime Minister seemed to do, the possibility of using the private sector. I do not think that anyone is suggesting that total reliance on an insurance scheme or anything else would be the ideal or something for which we should be working. There are many compromises; many other suggestions that might be made. It would be disappointing if the Prime Minister ruled out all of those as a matter of principle. I hope that he may be persuaded to think again on that particular issue.

Certainly, we may need to look to greater taxation. I suspect that the public would be far more willing to accept higher taxation if the taxes raised were earmarked for that purpose. I believe that the technical phrase is "hypothecation". I am very well aware that this will be deep, dark heresy so far as the Treasury is concerned. Throughout my political career, the Treasury has taken absolutely every care to ensure that it has a free rein in how they dispose of the money that comes in through various sources of taxation. None the less, I think we should still look at this; Treasury mandarins notwithstanding.

I turn to other issues that are of concern to me. One is what I call this obsession with targets. We have seen this notably in the drive to shorten waiting lists. It seems to me that unless the means--either of money, manpower, equipment, hospital beds or nurses--are there to support this, it is really an unrealistic expectation and it can only lead to distortions in care. I do not know how much truth there is in this, but it seems to me quite feasible that it would easier to take the easy operations rather than the difficult ones in order to reduce one's waiting times. That does not seem to me to be excellent healthcare. I do not think that we should put the practitioners in the National Health Service under that kind of pressure unless we are prepared to will them the means to carry it out in a reasonable fashion.

I turn to the issue of dentists who have had hardly a mention in this debate so far. There is a very great shortage of dentists. I know that the Government have what I think they call "easy-access centres" to try to increase the numbers of those seeing a dentist. I understand from the British Dental Association that it calculates that up to 4 million people are waiting to see a dentist and do not have one under the National Health Service. If that figure is correct--or even if it were half that--it seems to me a very great worry,

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bearing in mind that neglect of dental problems can lead to other health problems as well. I know that in my latter years as a Member of Parliament, one of the recurring worries that constituents brought to me, either through letters or at advice bureaux, was inability to find a dentist. So far as I can judge, the situation has changed very little at all. In fact, it is probably worse.

I turn to the question of the shortage of nurses. I am sure that my noble friend Lady Hogg put her finger on it absolutely when she pointed out that as there are many other careers open to young men, and particularly to young women, there therefore needs to be far greater incentives to bring them into nursing. Although I am quite sure that good pay will be an incentive, the conditions in which they work also seem to me to be important. If they are working in poor conditions under great stress, I do not think that money will be enough, either to bring them in or to retain them.

That brings me to those nurses who have already left the service, having trained. I have spoken to one or two friends who have been nurses in the past. I have asked them why they do not go back, even if only on a part-time basis. They seem slightly scared of the changes that have taken place in medicine, understandably--it is a period of great change and improvement in many ways--and they worry that they will not be up to standard. It is very important that there is real encouragement and understanding of those fears so that we may bring back more women. In particular where they have other responsibilities, we must ensure that working hours and shifts match their requirements. I think we have long passed the stage where a hospital can say that staff will have to do this, this and this. They must see what women are prepared to give, and work out a sensible compromise.

I should like to make one further point on the question of drugs, not on the issue of whether new expensive drugs are rationed but on whether drugs that are routinely dispensed are to some extent wasted by patients, and whether there is room to reduce that wastage and, therefore, to reduce the cost. I have one small anecdote from a distant relative who was something of a hypochondriac. When she died and a cupboard was opened, there was revealed the most immense number of half-used prescriptions. If she was anything like typical of others, that must have represented a great waste of National Health Service resources. Surely, that is something in our hands with which we should deal.

I see from the clock that my time is up. We have a very distinguished contributor to come next, so I resume my seat.

6.37 p.m.

Lord Winston: My Lords, I am deeply grateful to the noble Baroness, Lady Cumberlege, for introducing this debate. I am also grateful for the offers of salve for the wounds on my back. It is curious to note that most of the offers of salve have come from the Benches on the opposite side of the House.

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I am going to take the unprecedented step, at least for me, of sticking to a prepared written submission. I am not going to apportion blame to any side. I do not think that there is any point in doing that and it was never my intention when giving the interview to the journalist in the New Statesman. It is inevitable that journalists do perceive slants of a particular kind. But it is true that as a country we have never really faced what it is that we want from our National Health Service. Until that question is asked and answered we cannot begin to address the question about what it should cost, nor how much we are prepared to pay for it. In the latter respect, one of the only comparators that we have comes from other countries.

We repeatedly "talk up" our National Health Service. We keep on saying what an asset it is and how much more excellent it is than those of other countries. There is a growing conviction that these views are harder and harder to sustain.

According to the figures issued by the Government, which are likely to be the most favourable available, our total healthcare expenditure is certainly not excessive by the example of most other civilised countries. It runs at about 6.8 per cent of GDP, of which roughly 5.9 per cent is NHS spending. The rest, as my noble friend Lord Walton said, is mainly private. Despite the protestations of different governments, this percentage of GDP has actually remained unchanged since 1992, even though costs have increased. The managerial bureaucracy has also increased; for example, in the hospital service it has increased fivefold, which is quite considerable.

How do we compare with other countries? The United States spends the most. Even allowing for its largely privately-funded health service, we see an overall picture of 14 per cent of GDP being spent on healthcare. None the less, US public spending is 6.8 per cent of GDP, which is considerably more than we spend. Indeed, we spend less than nearly every other civilised country, including Germany, Switzerland, France, Canada, Sweden, Holland, Australia and Portugal--all of which spend more than 8 per cent of GDP. We even spend substantially less than the Czech Republic, both in public and in private terms. Of the OECD countries, only Hungary, Poland, Mexico, Turkey and Korea spend less than we do in terms of a proportion of our gross domestic product.

All this may be what the British people want, but it is certainly something that needs proper debate. We have to accept that an increase must imply either increased taxation or some form of insurance scheme, in addition to what currently operates. We cannot stand on our own perception of our record. I believe that we need to study in greater detail, with a good deal more honesty and some humility, what actually goes on in other comparable countries such as Holland and Belgium, which have gone into this in some detail. In this respect, it was extremely encouraging to hear the Prime Minister's commitment to raise our spend to the European average, even though that, in itself, is a slightly vague and difficult area.

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One of the particular problems is how this spending is distributed. Many of my adverse remarks were made because I come from London. There is no question that London is poorly financed in many ways. We have a poor population in this city and that adds further to NHS costs. Although we have a National Health Service, it is worth pointing out that it is regional in distribution. The spend per capita in England is around £741. That is a substantial sum and it has risen considerably. Incidentally, I should tell my noble friend Lord Prys-Davies that the spend in Wales is now around £823 per head, while in Scotland it is £904. Sections of the community in Northern Ireland might complain about the British Government, but we spend almost 30 per cent more there per head than we do in any other part of the United Kingdom; indeed, I believe it is about £1,023.

The problem with this is very clear: much of the driving force behind the NHS is in the academic sector; and it is primarily England that is being starved. It is a real problem. We have the risk of a skewed service and one of the problems is that government action can skew it further.

That brings me to my next point. As I say, the reason for much of our pride in the NHS is its excellence. It is excellent in research; it is excellent in innovation; it has excellent public databases, which lead to better population-based clinical research than that in nearly any other country--except, possibly, Iceland; it has a highly-educated workforce, linked to some of the best higher education in the world; and it is assisted by an industrial base linked to some of the finest industries, particularly the pharmaceutical industry, which is undoubtedly excellent and adds to our international economic competitiveness. This excellence drives it to be capable of providing medical care that is unparalleled in most other countries and a dedicated hard-working workforce which, at its best, is highly respected internationally.

However, there is no questioning the fact that this excellence is under threat. This is not journalistic hyperbole; it is a perception held by virtually every medical academic in this country. The universities are stretched as never before, but the university base is a major reason for our clinical and research excellence. We now have a situation where the Government, not unreasonably, have focused on primary care and on a GP-led service. That has major implications for the real driving force for excellence in the NHS--our secondary and tertiary services. They are what we ourselves, and our elderly relatives, face when the chips are down. That is where we meet the NHS interface, whether it is in casualty or in hospital.

Specialist services are increasingly under pressure and are often working in hospitals where, frankly, the fabric of buildings is shameful, at least in cities like London. Unacceptable waiting in casualty is accepted surprisingly stoically and dirt and crowded bed spaces are far too common. The number of nurses is inadequate and there is fatigue, disillusion and understaffing. Our figures for cancer treatments are among the worst in Europe. We only have to look at the breast cancer services to see, for example, that

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Northern Ireland, Scotland and England all do worse than almost any other country in Europe. Although we focus on cancer services, they are only one example: they are a paradigm of many of these specialist services.

We have serious problems with nursing recruitment and training. In many ways, Project 2000 was misguided. It was an excellent idea, but it was the wrong way to give nurses status. What we need is caring in the hospitals. We also have problems with medical training. The Calman system has not been an unqualified success. The fragmentation of the NHS into free-standing trusts has led to poor medical manpower control and we are turning out doctors who, frankly, do not have sufficient experience to be entirely safe, particularly in the surgical and anaesthetic fields. That is partly to keep in line with Europe. The training system is a matter of great concern.

Due to the time factor, I shall finish my remarks very shortly. However, I have one final point to make. We keep on saying that we have abolished the internal market. But we cannot say that. It is simply not true. We have not abolished the internal market. Truly we have not. We have replaced it with a different kind of market and a new kind of bureaucracy--the primary care group is now to become the primary care trust. It is a significant problem, which still skews things because it means competition between trusts, which we also claim to have abolished. One only has to look at the situation in West London to see that that is not true.

I have been a little disappointed in the contributions to this important debate from this side of the House. For example, with all due respect to my noble friend Lord Harris, it is not fair to say that the NHS needs respect from its professionals. That will resonate very severely in our profession. Noble Lords from the professions who have spoken in today's debate actually have great respect for the NHS. It is out of that respect that we wish to speak.

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