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Lord Harris of Haringey: My Lords, before my noble friend sits down, perhaps I may point out that I did not say that the NHS needed respect from the professionals; I said that it needed to respect the people who use the service.
Lord Winston: I am sorry, my Lords. I misunderstood.
6.47 p.m.
Lord Rotherwick: My Lords, during a debate in February last year I drew the attention of the House to a list of community hospitals that were threatened with closure, and that applied especially to the Burford Community Hospital in Oxfordshire. On Monday, telephone calls made to six of the units on that February list resulted in the following responses: Burford, no answer; Winsford in Devon, number not available; Edward Main in Cornwall, number not recognised; Poltair in Cornwall, no answer; Stroud
Maternity Unit, still open with closure not expected; Lynton in Devon, now a resource centre with no beds available. Although this Government pledged themselves before the last election not to close hospitals, five out of the six rural cottage hospitals checked out are clearly no longer functioning normally as national health hospitals.What is the community deprived of when a health authority closes a cottage hospital? It loses local nursing and medical care for the acutely ill; local compassionate care for the terminally ill; local rehabilitation facilities; local half-way house care after specialist treatment at a big acute general hospital; and local respite care.
The meaning of the word "local" varies according to where you are. In central London it probably means a mile and a half; in Oxfordshire it will be more like five to 10 miles. London has the Underground, the bus and taxi services. Unfortunately, most of those affected by rural cottage hospital closures will have to travel considerably further than 10 miles to receive treatment. Burford to Oxford is a round trip of about 50 miles. There is no tube. There is an irregular bus service and taxis whose drivers charge what they think the market will stand. Car ownership, or knowing someone who does not mind giving lifts, is helpful. Anyone from a rural area where the local cottage hospital has closed must surely be prepared for few visitors, at well-spaced intervals, if they have to stay in a far away general hospital.
During the debate in February last year my noble friend Lady Byford drew the attention of the House to some of the other problems facing rural communities. She pointed out that rural counties have more elderly people; for example, they make up around 21 per cent of the population in Devon and 19 per cent in Norfolk and Lincolnshire, compared with an average for England of around 16 per cent. When a cottage hospital is shut in these circumstances the local vulnerable people are indeed badly served. However, it is not only that. What happens to the nurses? Do they travel 50 odd miles a shift to work in the John Radcliffe?
During the debate in February last year the noble Baroness, Lady Thomas, told us that the Secretary of State had set up an inquiry into the provision of beds and that early results showed that there were not enough NHS beds. Why have they been further reduced since that date? Records show that occupancy rates have risen from around 70 per cent in the 1970s to over 90 per cent now. No wonder the flu outbreak caused so much difficulty. Mr Milburn described it as an epidemic, but that was with only 192 people having flu per 100,000. A true epidemic has double that number of people having flu per 100,000.
The closure of cottage or community hospitals is a series of double whammies. Patients will have to be transported further for initial treatment, check-ups, further tests, etc. Relations and families will also have to spend more time and money in visiting the sick. The second part of the double whammy is that the general
hospital will have to spend more of its resources and use more precious, expensive bed space on sub-acute conditions, respite care and convalescence.Publicly funded healthcare, free at the point of delivery, has been pledged by all the major parties. In the case of new Labour, however, the point of delivery for those who dwell in the countryside and in more remote areas is certainly less likely to be at the point of need and threatens soon for all practical purposes to vanish from sight.
Like many others, I have recently been appalled to discover that the NHS has funded gay sex material. I take the example of Place West which produced the Gay Sex Now book. I shall not discuss the sordid pictures of this material which promote this lifestyle, but can the Minister say whether it is correct that the underfunded NHS should squander its money on funding such promotional material when lesser sums of money could have saved many of our community hospitals, especially the Burford Community Hospital?
6.52 p.m.
Baroness Whitaker: My Lords, I, too, congratulate the noble Baroness, Lady Cumberlege, on initiating this debate. She drew attention to the health service as a whole, as have other noble Lords. I wish to discuss a narrower, but often neglected area; namely, the need for mental health provision. I should declare an interest as a non-executive director of the Tavistock and Portman NHS Trust, whose new work on the outcomes of psychotherapeutic treatment and recent TV series have demonstrated the value of mental health intervention.
One in six of the UK population is likely to experience mental illness of greater or lesser degree--commonly an episode of depression--sometimes no more than the mental equivalent of a bad bout of bronchitis. However, it is not regarded as that by the public or the media, nor by employers. There is a great deal of stigma attached even to healed mental illness. Recruitment panels probe any sizeable gap on CVs with mental breakdown in mind; would-be parents can be refused by adoption agencies if there has been depression in the family; and I know of at least one effective employee who contemplated falsifying a health declaration to omit chronic mental ill health that was perfectly well controlled by medication.
When it is not properly treated, mental illness can have the most serious consequence of all. Of the 6 per cent of the population who suffer from depression, some 15 per cent will commit suicide. Most of the 4,000 suicides in the UK are associated with depression. But, common as it is, incapacitating as it is and treatable as it is, mental health expenditure attracts only just over 16 per cent of the national average budget, and in some health authorities the figure is as low as 11 per cent.
In children the incidence of mental health is also disturbing--about 10 per cent of five to 15 year-olds in England, Scotland and Wales. Some reports say that it is increasing. The need far outweighs the resources. I am sure that we would all want to reduce this cause of
acute distress and erosion of the capacity to cope, often at critical times in the school career, including for those traumatised refugee children who have had among the most damaging experiences a child can have.There are some useful initiatives in this dearth. Will my noble friend the Minister say what he thinks of the development of community child mental health services which aim to increase expertise available to families and to make services more accessible in a way which reduces stigma by using specialists attached to GP surgeries and training all those who work with children? Have these initiatives been evaluated and are they to be replicated?
In conclusion, anyone aware of mental health concerns will know of the grossly disproportionate number of black patients who are confined in secure psychiatric units. It is not clear whether the disproportion happens in causation, in the diagnostic process or for some other reason. However, the existence of this disproportion is deeply disturbing. Can my noble friend say what research is being carried out to find out why so many more of our black fellow citizens are incarcerated in mental hospitals?
6.57 p.m.
Viscount Bridgeman: My Lords, I am well aware of my position in the speaking order and I shall endeavour to break into a trot! First, I thank my noble friend Lady Cumberlege for her excellent introduction to the debate.
I want to say something about nurses which I am well aware could have been included in the excellent debate last week initiated by the noble Baroness, Lady McFarlane, but as nurses are the artery--if I may be forgiven the metaphor--of the National Health Service, it is just as appropriate to mention it in this debate. After talking to a nursing director a few days ago, I am prompted to refer once again to Project 2000, to which the noble Lord, Lord Winston, briefly referred in his excellent and inspiring speech. This is not a political point. I am well aware that Project 2000 was an initiative of the previous government and was very much inspired by the nursing profession. Let us be quite clear of the totally laudable aims of that initiative; namely, to acknowledge the higher standards of education of trainee nurses and to reflect a sophisticated programme of academic training for them. Indeed, the noble Baroness, Lady Emerton, has given an impressive list of nursing specialties for which a high level of education is required.
The effect on the wards has not been good. Previously, the ward sister could count on, say, five good nurses training in practical nursing who were able to take the load off the trained staff and, at the same time, gain excellent patient experience. Nowadays, trainee nurses under Project 2000 come on the wards for a restricted period. They require closer supervision--which in itself is a vicious circle as there are many fewer trained staff to supervise and to instruct--and they are not so effective with the patients. Who suffers? It is, of course, the patient.
Project 2000 has been in operation now for more than 10 years and there is much that it has achieved. What should be addressed now is the question of balance between academic and practical training. I urge the Government to put in hand an early review of Project 2000 to see how this shortcoming can be addressed. In that respect, I welcome the remarks made by the noble Lord, Lord Hunt, when he replied to the debate last week. Certainly the message coming from the senior nursing staff on the wards is a plea for a much greater clinical element in the training of nurses--to the benefit of the patient, to the benefit of clinical administration, and, last but not least, to the benefit of the training of nurses themselves.
I turn now to the recent pay award for nurses. This is wholly welcome. But let us be under no illusion that this award must come out of the NHS purse, in which, as I understand it, there will be no increase. My noble friend Lady Cumberlege referred to this, as did my noble friend Lady Hogg. Can the Minister enlighten us as to what adjustments will be made in the National Health Service budget to reflect this increase?
May I, with an involvement in the private sector, reinforce a plea for greater interface between the private and state sectors, a point made most eloquently by my noble friends Lady Cumberlege and Lord Howe? Admittedly, the use which can be made of the private sector will inevitably be limited in value because of the relative sizes. However, in the case of the independent charity hospital with which I am associated, we have a regular programme of out-placements of student nurses, for the technical training of such people as ECG technicians, and a wholly beneficial mutual arrangement with a major teaching hospital for a regular rotation of housemen, who, in many cases, are studying for membership of one of the Royal Colleges and who provide a quality of RMO of which any hospital, of whatever kind, would indeed be proud.
Relations at hospital and local health authority level between the two sectors are excellent and wholly beneficial. Higher up in the management of the health service, the jury, I suggest, is out. The "them and us" attitude, to which my noble friend Lady Seccombe referred quite forcefully, is still there--although I am happy to say that it improves by the year. I hope that the Minister and his colleagues will do all that they can to foster and encourage this improvement.
The Labour Party has always regarded the National Health Service as its own cause, to the frustration and irritation on many occasions of my party. We have had a number of hagiological speeches from the party opposite on which my noble friend Lady Hogg has poured some statistical cold water, which is very welcome.
However, I finish on a constructive note. This magnificent service requires the intellectual efforts of all of us to see how it can be improved. My noble friend Lord Forsyth has suggested that there is a unique window of opportunity and my noble friends Lord Biffen and Lady Fookes have made some practical
suggestions with regard to a Select Committee. I hope that the Government will give them serious consideration.7.3 p.m.
Baroness Warwick of Undercliffe: My Lords, I apologise to the House for speaking in the gap. There was a mix-up as to the debate in which I was listed to speak. I thank the noble Baroness, Lady Thomas, for her indulgence and the Whips for their forbearance. I know that I must be very brief.
I should like to make two brief points that have not been alluded to. The first point concerns the contribution that higher education can make to the modernisation of the health service. I declare an interest as the chief executive of the Committee of Vice-Chancellors and Principals. Universities, in partnership with the NHS, now provide virtually all pre-registration education for the nation's doctors, dentists, nurses, midwives and all other professions allied to medicine. They are also significant providers of post-graduate training and continuing professional development--CPD--in all the health professions.
We hear regularly--we have heard much today--about the shortages of many of these staff, an inheritance which the Government are now addressing. They have made available funding for an additional 1,000 medical students, the biggest expansion in medical student places for 30 years. A successful recruitment and retention campaign for nurses and midwives last year has raised the profile of those professions. Applications for nursing diploma courses have risen by 18 per cent and for nursing degree courses the increase is even higher at 24 per cent.
Several noble Lords have mentioned pay. Recent evidence suggests that successful recruitment and retention in the health service depends as much on the ability of the NHS to provide staff with continuing professional development opportunities as it does on pay. So the key to recruitment and retention depends on the NHS developing CPD and there is a need to bring the level in all the health professions up to the level of the best.
The Secretary of State for Health has noted that the way the clinical professions train and work together is the key to unlocking the potential of the 21st-century health service. Together, universities and the NHS can ensure that professional preparation of the nation's doctors, dentists, nurses, midwives and all the other professions allied to medicine, captures leading-edge practice and prepares healthcare professionals for a fast-changing working environment.
The National Health Service has rightly been set challenging targets for service delivery by the Government. It is essential that there are sufficient healthcare professionals who are educated and trained to high standards and who are fit for the purpose to enable these targets to be met. Quality patient care is at the heart of the Government's strategy for the health service. They are determined to address long-standing deficiencies, and the university/National Health
Service partnership is a mechanism for moving forward the modernisation programme to deliver quality patient care.7.6 p.m.
Baroness Thomas of Walliswood: My Lords, on looking at the clock I think that we are, if anything, two or three minutes ahead of schedule, but I will not, I hope, extend my time for that reason.
I should like to congratulate the noble Baroness, Lady Cumberlege, on introducing the debate. Her formidable experience and knowledge in this field are beyond dispute. I know that when I first came into this Chamber she was a Minister on the other side. I always thought that I would have to be very careful before I tangled with her because she was--and still is--such an expert.
The noble Baroness asked for a civilised debate and, on the whole--with perhaps one or two exceptions--we have had one. It has certainly been very wide ranging--from the noble Baroness, Lady Whitaker, who spoke about mental health problems, to the noble Lord, Lord Rotherwick, who spoke about the problems of services in rural areas. The noble Lord, Lord Walton of Detchant, gave an insight-- repeated by the noble Baroness, Lady Warwick--about the problems of staffing the essential higher education services upon which the training of all our doctors depend. If I may say so, the whole debate was set alight by the passionate and expert speech of the noble Lord, Lord Winston.
January has been a bumper month for "Crisis in the National Health Service" stories. There have always been such stories, of course, but last month seems to have been particularly severe. Whether or not there has been a flu epidemic, let us hope that we have seen the winter crisis peak in terms of the stories that people have been able to write about patients lying on trolleys and similar sad stories.
Individuals have been speaking to me about the kind of healthcare that members of their family have experienced. They have spoken about incidents in hospitals of which I thought I would never hear. They have spoken about dirty wards and, much worse, dirty lavatories, and about rather skimpy and incompetent care. I am referring to the care of a seriously injured patient.
The fact that there is a crisis in winter is not new. As a non-executive director of a National Health Trust hospital until the end of 1997, I was aware that the summer case load was already up to what had been previously considered a winter case load level. The rapid decrease in the number of beds, despite everything that the hospital was able to do in terms of day case treatments, put the hospital under an impossible strain when anything went slightly wrong.
All those factors are underlaid by long term problems, as a number of noble Lords have pointed out. The NHS is still in some ways a "national sickness service" rather than a National Health Service. The noble Baroness, Lady Ashton, addressed that syndrome in a most interesting speech, as did my noble
friend Lord Addington. They both referred to the necessity of preventive care. Other noble Lords referred to low-cost approaches to improving the level of care and to the importance of good examples of care being spread further within the service.Recent news stories have emphasised the poor equipment available in hospitals. Surely that has something to do with a history of underinvestment. It is not this year's problem, but a long-term problem. The number of beds has been under pressure for years, which has resulted in some of the most extraordinary efficiency rates of which anyone could conceive. It has led to extremely high bed occupancy and turnover of patients--some people believe too high, because of the aftercare problems that may arise--and an inability to cope with the peak and the crisis moments.
Some noble Lords put forward the interesting idea that we must not only take action over the longer-term trends, but also do something about patients' own ability to look after their own healthcare and negotiate their own treatment. If that idea is taken up, it will place new challenges upon the health service, but also possibly new opportunities to ensure that health rather than sickness becomes the preoccupation of at least part of the NHS.
A crisis or acute strains in staffing are features of many stories. They are reflected in the levels of stress and disillusionment expressed by medical staff themselves. Official representatives of doctors have recently been outspoken--I am talking not only of the noble Lord, Lord Winston, but of others--about levels of stress and disillusionment and their fears about what is happening in the health service, which is not only their employer but also the service to which they have dedicated their lives. The BMA has decided to conduct a fundamental review of the NHS because, despite record levels of funding and the extra investment currently going in, the system remains overstretched.
The decision--to which the noble Lord, Lord Davies of Oldham, referred--to pay the recommended full wage increase and to pay it at once rather than in stages is obviously welcome. I am also much struck by and in agreement with the well made point of the noble Baroness, Lady Hogg, about the need to pay people to some extent what the market offers outside. Fewer and fewer people are going into nursing in particular. Surely that has something to do with the level of pay.
There has been much talk of a crisis in funding. Again, there is nothing new in that. The previous government's approach led to a continuous squeezing of performance out of resources which did not keep pace with overall inflation. NHS inflation is higher as a result of new technology. Meanwhile, people's expectations of what the NHS should deliver to them are rising all the time as they become better educated, more well-off and more demanding as consumers. I do not believe that patients like to be called "consumers", but technically one may call them that. They prefer to be thought of as patients and the notion of a patient-doctor rather than a consumer-seller relationship within the health service is important.
Many recommendations have been made in the debate as to how the funding crisis--the mismatch of funds to demand--could be solved. The noble Lord, Lord Biffen, the noble Baroness, Lady Cumberlege, the noble Lord, Lord Desai, and the noble Lord, Lord Bell, produced a variety of approaches. As always, the noble Lord, Lord Desai, was erudite in his economist's approach to the way that we should cost and measure inputs and outputs.
The noble Lord, Lord Biffen, was more down-to-earth. He said that we need to be honest and to tell people that extra costs are involved--as did the noble Lord, Lord Forsyth--and that if they do not want to pay them in one way they will have to pay in another way. The most likely and possibly the best choice is on the whole for the NHS to be funded through taxation. We on these Benches support that policy. As my noble friend Lord Clement-Jones said in his opening remarks, we are still committed to an NHS funded largely by the public purse through the system of taxation. It has been said that taxation is the price we pay for living in a civilised society. Despite the many attacks made on that point of view, I still believe in it.
On the other hand, I see no reason why--as other noble Lords have suggested--we should not make better use of excess capacity in the private sector to solve some of our capacity problems. That would be one way forward. If we could move towards more preventive medicine in the long term it might slow down the rate at which costs increase. I do not believe in solutions such as proceeding with a totally insurance-based system or relying heavily on the PFI, which, as the noble Lord, Lord Rea, sapiently remarked, merely increases costs. Neither of those suggestions would provide long term solutions.
January was a rotten month for the Government. The millennium bug--okay; the Millennium Dome--not so good. There were rumblings from the Robinson case and chaos in the NHS. The situation was not made better by some rather clumsy efforts to control the expressed opinions of the noble Lord, Lord Winston. It was capped by the resignation of Mr Kilfoyle from the Government so that he could serve his locality and the Labour Party better. That is an interesting combination of things going wrong. It has nothing to do with international problems. It is, as a former Prime Minister said, "Events, dear boy, events".
My noble friend Lord Clement-Jones reminded the Government of our support for some of their major initiatives. I remind the Minister also that my noble friend asked about the whereabouts of the 100 extra intensive-care beds, the national beds inquiry and the Government's response to the Royal Commission on ageing and care for the elderly, which is, of course, another long term problem. I should like to ask the Government a different question. Do they have the honesty and quality of leadership to take the British people into their confidence to explain clearly what the problems are and that they cannot all be solved--just as doctors cannot be educated--in a month or a year or perhaps even in five years, but that the Government
will make efforts to solve them? That might have the effect of giving people greater confidence in what is happening in the NHS, so that when minor things do not go right they will understand that the general progress of the NHS is nevertheless going along in the right way.If the Government show leadership on that issue they will probably be able to take the public with them. If not, they will have more disastrous Januarys.
7.19 p.m.
Lord Astor of Hever: My Lords, I, too, congratulate my noble friend Lady Cumberlege on enabling so many distinguished and expert Members of your Lordships' House to consider the state of the National Health Service. We on these Benches very much welcome the opportunity and the timing of the debate. The Conservative Party believes passionately in the NHS and our commitment to its future is unequivocal.
This has been a constructive debate. I doubt, though, that the Government will welcome the public spotlight on their recent management, or rather mismanagement, of the NHS. The Government's election manifesto proclaimed in very large letters:
- "We will save the NHS".
- "You have just 24 hours to save the Health Service".
His "pledge" for increased public spending on the NHS, announced, inevitably, on television rather than in the House of Commons, has subsequently become merely an "aspiration" and then, in a matter of days, only a "conditional commitment". Moreover, this is a "conditional commitment" that is untested, uncosted and unrealistic. A Whitehall aide apparently told The Times:
- "Of course Tony wasn't meant to say it. He can't make huge financial commitments like that".
These are important questions and I hope that the Minister will answer them when he winds up. I shall look forward to his reply. I certainly associate myself with the remarks made by my noble friend Lady Cumberlege about the Minister personally.
I turn now to one of the Government's five key election pledges: NHS waiting lists. Labour's manifesto promised to take 100,000 people off the
waiting lists. The reality, as everyone knows, from NHS staff to the general public, is completely different. My noble friend Lord Bell told us that for every one of Mr Blair's first 1,000 days, an extra 264 people have joined the waiting list to see a hospital consultant. Clinical priorities have been replaced by political ones. Decision-making is being taken away from doctors and hospitals and centralised in Whitehall to help the Government's re-election programme rather than to improve patient care. There is now a considerable backlog of complex surgical procedures, which have been postponed to rush through straightforward ones. The sickest patients are waiting longer. This is currently a dangerous country in which to fall seriously ill. The noble Baroness, Lady Sharp, made that point very well.I should very much like to pay tribute to the valiant efforts of all NHS staff during this winter's flu outbreak. The noble Lord, Lord Clement-Jones, questioned whether it really was an epidemic. Although the number of reported flu cases fell well short of an official epidemic--with the system haemorrhaging all round--the spin doctors decided to put their own interpretation on the statistics. I do wish that the Government would concentrate on real doctors rather than spin doctors.
Why was the immunisation programme so limited? Only 30 per cent of the "at-risk" groups received anti-flu jabs, compared to 75 per cent in France, where the mortality rate has been far lower. Why, particularly, were vulnerable groups and hospital staff not immunised? Large numbers of the most vulnerable people caught flu from those caring for them. Why was there no publicity campaign urging people to get their jab? Perhaps the Minister will outline what immunisation programme the Government will put in place for this coming winter?
The Conservative Party believes that it is now time to put patients before politics. As my noble friend Lady Cumberlege said, we are the world's fifth largest economy, yet we suffer second-rate standards in many casualty departments and a scandalous lottery of care for life-threatening diseases. My noble friend Lord Bridgeman referred to last week's very interesting debate on nursing, in which we heard of a shortage of 17,000 nurses. Like the noble Lord, Lord Clement-Jones, and my noble friend Lord Howe, I have a sister who is a trained nurse. She is married to a consultant surgeon who runs a vital department in a provincial teaching hospital. He sees it as a matter of professional pride to keep the service running. But the spring has now been stretched beyond its elastic limit.
The current crisis must be a turning point. The truth is that, as a direct result of government policy, the system is unable to cope, at times, with the demand for basic services. The failure to tackle structural reform of the NHS means that real people suffer as the Government stand by preparing the next excuse. Given the continuous advances in expensive medical science, the need for substantial future wage rises to retain trained staff and an ageing population, the refusal to admit that the current system needs to change shows an alarming lack of realism.
The Government's old-fashioned, dogmatic, socialist objection to working with the independent health sector is every bit as damaging to the nation's physical health as was Clause 4 to the nation's economic health. The ability of people in Britain to afford private medical insurance makes a greater difference to their standard of healthcare than is the case in other health systems in Europe. As my noble friend Lord Forsyth said, other socialist governments in Europe see private medical insurance as a supplement to state spending. We can surely learn from other countries, as the noble Lord, Lord Winston, said. I agree that the noble Lord set the debate alight. We need to encourage both individuals and firms to utilise the resources of the private sector as well as the NHS. Currently, this Government actually penalise, through the tax system, those who seek to alleviate the burdens on the NHS by using private healthcare.
It is for all these reasons that we have invited the Government to begin a meaningful dialogue on the future of the National Health Service--a request that has fallen, so far, on deaf ears. The Government show no enthusiasm for radical thinking.
The Conservative Party sees the NHS as the mainstay of healthcare provision when we return to government. We will increase its funding in real terms, and we will put clinical priorities back--where they belong--above political ones.
We on these Benches urge the Government to make a fresh start and introduce an uncharacteristic level of honesty into the debate on the NHS. We believe that to ignore the present situation and the challenges it presents is a betrayal of this country's future. We urge the Prime Minister to show real courage and leadership and to do the same.
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