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Lord Callaghan of Cardiff: My Lords, will my noble friend allow me to intervene? I find it a little difficult to follow what he is saying. Can he translate it into a simple proposition so that I can see what he is really saying?

Lord Winston: My Lords, in summarising, Professor Jacobs says,

one where they do not see too many patients, even though it would be cheaper for the health service--

    "to a GP fundholding contract then the institution neither benefits nor gains".
He summarises by saying,

    "This Alice in Wonderland version of economics is called the contracting system in the National Health Service".
That muddle is totally unintelligible. It means that it is unfair because, if a patient is not from a fundholding practice and if he is referred to an over-performing hospital, he may not get his operation this year but have to wait until next year because of the needs of the health service. How many administrators does it take to work that nonsense out?

There are bed shortages due, partly, to the burgeoning administration and the money spent on it. It is interesting to note that nurses have had a small pay rise; chief executives have had pay rises of up to 7.6 per cent. When I asked the noble Baroness, Lady Cumberlege, on 21st February, how the extra money for the nurses' miserable pay rise will be funded or whether it will simply come from trusts' hard-pressed budgets, she mentioned that some would come through, to use her words, improved "efficiencies and other economies". What does that mean? It means improved efficiency and economies in those hospitals. That adds to the increased cost of the administration and, among other things, leads to fewer beds.

The chairman of the Health Services Research recently stated that the pressure on emergency beds is up by 15 per cent. The Middlesex Hospital this week had nine patients waiting for cancer treatment, which was cancelled because it had no beds available for them. One can imagine the problem for those patients who had to wait until the following week to receive their oncological care. That can be cancelled again and only then are they placed on a priority list when they might receive their treatment. I understand that that is the situation in that excellent hospital.

This week I was delayed in coming to this House because there was a young woman in her thirties who was bleeding and for whom I could not find a hospital bed. Three of us had to phone round to try to find her a bed and all the time we were giving instructions over the phone to explain to the people who were with her how to staunch the bleeding by internal pressure. That procedure was carried out in the 17th century but, because there was no other alternative for that patient,

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we were forced to give that advice. God intervened, otherwise the patient would have died, and the bleeding stopped. But we could not find her a bed in a National Health Service hospital or in Queen Charlotte's Hospital.

In the last few minutes available to me I want to touch on medical education. It is worth bearing in mind that we used to have probably the best medical education in the world. Students came from all over to study in the United Kingdom. It is worth looking at the problems that the universities are now facing. The cut in capital budget, which involves equipment as well as building, is 30 per cent. this year. The PFI, in spite of the Government's claims, cannot possibly replace that funding. It is doubly serious for the NHS because many projects are jointly funded by the National Health Service and health authorities in collaboration with universities.

What do the Government do? They promote the Dearing Report. They kick it into touch at a time when universities are in crisis and so we are delayed for at least another year and it is probable that any implementation of that review cannot take place until 1999. This week we sat through a committee at the Royal Postgraduate Medical School to work out what we could do about the 3 per cent. cut with which we were immediately faced. Because we are particularly well managed, it will not actually prevent our continuing to build the library. But there is no doubt that this is the last cut that we can possibly sustain, and certainly our building scheme constitutes a serious problem.

Another matter which I should like briefly to draw to your Lordships' attention is the Calman reorganisation of junior staff training. The idea of a unified training system is not bad. It is due to start in April. But even my own highly intelligent medical staff who are entering that training system do not understand it. It shortens the training programme for staff in specialist training, but limits the choice of hospital department; it limits their freedom of movement and thence experience; above all, it will inhibit their ability to do clinical and basic research in hospitals--in fact, there will be no advantage in doing clinical research because they are in a set programme. Who will look after the patients? The consultants will not only have to continue their clinical work, but will also have to give lectures to students and demonstrate operations to them. That is a real crisis which worries medical people in the health service.

It is not surprising that we have serious concerns in the National Health Service. In answer to a question I asked on 17th January in relation to the acute bed problem in West London, the noble Baroness, Lady Cumberlege, replied with pride,

    "I believe that we have a remarkable National Health Service; it is a near miracle".--[Official Report, 17/1/96; col. 591.]
I weep at that reply. I believe that they do not understand what is happening. We face a serious situation. Of course this Government have spent on the health service. Of course they have spent in real terms--no doubt we shall hear more about that from the Government Benches. We are familiar with their story of spending on the National Health Service. The truth is that this is a spent government. Having spent unwisely

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on the National Health Service, they may have to pay the cost at the next general election. Sadly, another government will have to pick up the bill.

My Lords, I beg to move for Papers.

Lord McColl of Dulwich: My Lords, before the noble Lord sits down, in view of the fact that he said extensive cuts had been made in the NHS funding, can he say by how much he would like that funding to be increased? Will he also declare an interest?

Baroness Gardner of Parkes: My Lords, this is a time-limited debate and we do not normally have interventions because that takes from other people's time.

3.49 p.m.

Lord Clark of Kempston: My Lords, I am sure that the whole House is indebted to the noble Lord, Lord Winston, for drawing the National Health Service to the attention of your Lordships. I believe that the general public are getting a bit sick of the denigration of what this Government have done in the past 15 or 16 years. Whether it relates to the economy or the National Health Service--perhaps the noble Lord would be kind enough to listen for a few moments--welfare, education or whatever, it is always a question of underfunding.

The noble Lord spoke about cuts in the National Health Service. What he did not say is that those cuts were projected expenditure which the Treasury then reduced. That is not a cut. There were increases, but not as much as asked for by the departments. I remind your Lordships that when one considers the situation between 1979 and today, some £41 billion has been put into the National Health Service. In simple terms, that means that for every man, woman and child in the country in 1979, £433 was spent on the National Health Service. Today the figure is £697. In real terms the increase in the National Health Service budget is 66 per cent.

Noble Lords will probably ask how that has been done. In my view, it has been achieved because of good national housekeeping. Perhaps I may return to that in a few moments. The noble Lord agreed that more patients are being treated. The figure is now 3 million. Waiting time has been reduced; and the noble Lord paid tribute to that. Those are the kinds of things that we need to talk about regarding the National Health Service. Fund-holding for GPs has been a great success. God forbid that the noble Lord's party should ever get into power!--they would abolish that.

What we must remember about the National Health Service is the fact that the advances in medicine are beyond our comprehension when one considers what patient treatment was some 20 or 30 years ago. There is no comparison with today. There are so many new cures and we are living longer. Quite obviously these factors produce extra drain and strain on the National Health Service.

As regards the nurses, as your Lordships know, the Government have accepted the independent review body's offer of 2 per cent. In addition to that, there is whatever the nurses can negotiate locally. I believe that

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even the noble Lord will pay tribute to the fact that the National Health Service is generally very healthy. It employs more nursing staff, care staff and so on.

Perhaps I may return to the question of nurses' pay, and something which the noble Lord did not mention. In real terms, over the period of this Government since 1979, nurses' pay has increased by about 79 per cent. Perhaps I may remind the noble Lord that under the last Labour Government in real terms nurses' pay was reduced by 3 per cent. How does that square with what the Labour Party are saying today? It is hypocrisy for it to criticise the National Health Service. I remind the noble Lord of the time when the Labour Government had to go cap in hand to the IMF. That meant a cut-back not only in nurses' pay, but also a tremendous reduction in capital expenditure within the National Health Service and other departments.

Perhaps I may now turn to hospital trusts, to which the noble Lord paid some tribute. As regards hospital services, 98 per cent. of them are hospital trusts. Consequently, that means that there is more power held locally in running the local health service. The Government are shortly to abolish the regional health authorities. That again will create more efficiency and more local power as regards the National Health Service.

I referred earlier to how this was being done. The Government have increased taxpayers' expenditure on the National Health Service and also on other departments such as education. That has been achieved because of the Government's economic policy. Whatever one likes to say about this Government, their economic policy has reduced inflation from 26 per cent. to under 3 per cent. That helps everybody: it helps the National Health Service and the nurses. Bank interest rates are down from 15 per cent. to something like 6.25 per cent. and they are falling. I have no doubt that they will fall further. Unemployment is also down. The unemployment figures have come down for 29 successive months. It is due to good national housekeeping.

When one considers inward investment, that is proof positive that the foreign investor looks on this country as a good bet and a good place in which to put his goods. Exports have increased and also the number of small businesses. This is good national housekeeping. The standard of living has improved for everybody in this country by about 40 per cent.

These are the factors which determine whether any government can spend money on, for example, education, the National Health Service or whatever. Government are only the trustees of the taxpayers' money and unless the economy is buoyant then this money will not be available for the National Health Service. That is how this Government have increased expenditure on the National Health Service.

When one hears from Labour Members of Parliament and noble Lords in opposition, one never gets a figure or an explanation in relation to their grandiose schemes. Whether that is the frivolity of opposition, I do not know. They announce grandiose schemes but they never price them. That is what the general public want to

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know. If expenditure on the National Health Service is to be increased, the public want to know where the money is coming from. Will it come from the taxpayer; will it be borrowed, or what? Will it lead to an inflationary spiral as we had under the last Labour Government?

If the Labour Party want to show any credibility, it really is high time that the leaders of the Labour Party came out fair and square and said, "All this is going to cost more. More teachers will cost the taxpayers more. More money spent on the National Health Service is going to cost so much more". At the end of the day the Opposition should say where the money is coming from. That is something they shy away from. It is becoming so serious that I believe the Opposition are losing credibility. Anyone in opposition can promise, but it is only if one is in government that one has to deliver and that can only be done if there are the resources available.

The future danger for this country is that if there were a change in government, that would mean a minimum wage. I believe that all economists and many Members of the Opposition agree that that would increase unemployment. If we accepted the social chapter that would increase the unit costs of production, which even the Germans and the French now realise. They realise that the social chapter is not really working. If there were a change of government and we ended competitive tendering, that would be disastrous so far as the economy is concerned. Any diminution of our economy must mean that there will be fewer services for the National Health Service. Therefore, I trust that my noble friend will resist the criticism.

3.59 p.m.

Lord Walton of Detchant: My Lords, I am grateful to the noble Lord, Lord Winston, for introducing this debate and for the opportunity of contributing to it. At the outset I must express my sincere apologies to him and to the noble Baroness who will reply for the fact that I only learnt last week that this debate was to be held. I had already accepted a pressing engagement for later this afternoon which may prevent me from listening to the entire debate. I shall read all the closing speeches.

I have been a fervent supporter of the National Health Service since it began in 1948. That resulted from the fact that my salary as a medical registrar at the very beginning of the NHS was immediately increased from £400 to £775 per annum. In 1958 I became a consultant. I later held an honorary Chair and later still had six university sessions as a professor while retaining five NHS sessions. Even when I was translated to the dreaming spires of Oxford in 1983, I continued to hold two honorary sessions as a consultant until some four years ago when, on reaching a certain age, I was told by the health service that my honorary clinical contract had expired and that I could visit the hospital for social reasons, but without any clinical facilities.

That introduction may be irrelevant, but the point I want to make at the outset is that I lived through the halcyon days of expansion in the NHS when my

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department and the facilities and staffing available continued to expand. We saw almost incredible advances in medicine with imaging, transplants, spare parts surgery, immunology, rehabilitation, cardiac surgery and many more developments. I eventually headed an academic and research unit which received referrals from all over the country and, indeed, from many parts of the world. Those were wonderful days--they were days when I was very proud to work in the NHS. Indeed, we can still take a justifiable pride in our National Health Service, upon which we still spend less than 6 per cent. of our gross domestic product, one of the lowest proportions spent by any developed country.

However, we have an ageing population and we have a population with greater expectations than ever before about what the NHS can provide. Why should they not have hip replacements? Why should not everyone who can benefit from it have cardiac surgery? The introduction of new expensive drugs such as Beta Interferon for multiple sclerosis and of new procedures has imposed immense demands on our NHS.

I still believe that the NHS provides the best emergency care in the world, but even in the early 1980s we began to see the gathering clouds on the horizon and to recognise that no developed country can ever produce a health service which provides every conceivable medical treatment irrespective of cost. At that time I suggested, rather interestingly, the possibility of predicated taxation and the introduction, which I believe that the country would welcome, of an index-linked income-related health tax, but I was told that the Treasury would never stand for it. I often wonder whether we will ever be able to relax the iron hand of the Treasury in promoting desirable developments. However, that is water under the bridge.

The Government's response to the problems that we saw at that time was to introduce a review of the National Health Service. I believe that what has followed has in many respects been very beneficial: better management and better cost control, with doctors for the first time fully understanding the costs of the procedures and forms of treatment that they offer. I think that GP fundholding has many great benefits to offer, although there is clearly a risk of a two-tier service. Nevertheless, with the academic and vocational training of general practitioners we have seen an enormous improvement in community care and in the quality of British general practice which I now believe to be the best in the world.

The contractor-customer principle carries certain benefits but, as the noble Lord, Lord Winston, said, it has also brought problems, some of which were highlighted in a report on medical research in the NHS in the light of the reforms which was based on a Select Committee inquiry which I chaired and which was debated in your Lordships' House last year. There is no doubt that tertiary referrals for patients with difficult clinical problems requiring specialised treatment in centres of excellence have fallen sharply, if only because local managers have taken the view that the treatment can be equally well offered in a local hospital instead of sending the patient to, say, Hammersmith or

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to the Newcastle General Hospital, where I once worked, or to other centres where highly specialised care can be provided.

I know full well that the Minister will give us much information about the increasing resources that are being devoted to the National Health Service, about the reduction in waiting lists and the increased standard of care. I accept all the points that she will make: more money is being spent on the NHS. Indeed, I congratulate the noble Baroness on her spirited and dedicated advocacy of the National Health Service, which has invariably won the respect of the entire House.

However, without doubt the storm clouds are gathering again--and they are deepening. Morale in many of the professions in the National Health Service in many of the professions is at its lowest for a decade. Many hospitals have improved their standards of care through day surgery and short stays, but I believe that the closure of acute beds has happened too fast. That can be seen from isolated examples, such as the Sidcup patient who had to be flown to Leeds, the Stepping Hill case where a scanner was not available in the evening, and the recent story of the cancer care unit in Bristol which has had to turn away patients. Those are isolated examples occurring against a background of increasingly high standards of general medical care, but they are happening far too often. The National Association of Health Authorities and Trusts has produced figures to show that over the past three years there has been a 14 per cent. increase in emergency admissions. One of the inevitable reasons for that is our ageing population.

But why in certain areas has there been a veritable stampede of consultants seeking early retirement at the age of 60 rather than wanting to continue to serve the NHS to the age of 65? Why are we unable in many areas of the country to recruit consultants in psychiatry, anaesthetics, paediatrics, accident and emergency, and orthopaedics? Why in the region in which I used to work has the Shotley Bridge Hospital had to close its accident and emergency department because it is unable to recruit doctors to staff it? When I was the Warden of Green College and when I was Dean at Newcastle many of the brightest medical students wanted to enter the new, developing and exciting branch of general practice with vocational training, but there has been a 14 per cent. reduction in the number of young doctors entering general practice training as registrars. I shall not comment on the nursing shortages as I am sure that other noble Lords will mention them, but I do believe that the recent pay award was unfortunate, to say the least.

I turn now to academic medicine. Professors, senior lecturers and lecturers have a clinical contract and do a great deal of clinical work, but the evidence from our Select Committee inquiry showed that at present 24 clinical Chairs in the United Kingdom are vacant for lack of suitable applicants, 10 of them having been vacant for more than 12 months. Fortunately, the Committee of Vice-Chancellors and Principals has established an inquiry under Sir Rex Richards of Oxford to look at the future of clinical academic medicine which, without any question at all, is in crisis.

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Yesterday we considered the Reserve Forces Bill on Report. That presents us with another little problem. I served for 16 years in the Territorial Army and was happy eventually to command a Territorial Army general hospital. I understand that there is now pressure from managers not to allow doctors to enrol in the reserve forces in case they are called out in an emergency. There was a problem during the Gulf War when the NHS suffered through the call up of many doctors in the Territorial Army.

Those are just a few of the problems which the NHS is facing. I believe fervently in its future. I believe that the NHS is one of the things of which this country may be justly proud. However, I urge the noble Baroness, her colleagues and her right honourable friends to undertake discussions with the medical royal colleges, the nursing profession and many others, and to look at some of the emerging problems to which I have drawn her attention because they present a considerable threat to the future of our beloved NHS.

4.8 p.m.

Baroness Hayman: My Lords, it is a pleasure to follow the noble Lord, Lord Walton of Detchant, and to express my gratitude and, I am sure, that of the House to my noble friend Lord Winston for initiating this debate. We are grateful to him--the NHS is grateful to him--for his professional contribution over many years. I know that that gratitude is shared by many patients.

My only quarrel with my noble friend lies in his framing of the Motion. Inevitably he started with the word "staff". When I talk about the NHS I think that it is a good principle to start with "patients", but that word does not appear until the very end of the Motion.

The noble Lord, Lord Clark of Kempston, said that we should declare our interests. I declare an interest as the Chair of an NHS trust hospital. But there is an interest that we all share as patients or potential patients of the National Health Service. It is a very real interest, even for those who are covered by private insurance and who normally take their healthcare elsewhere. I refer to the fact that there is no alternative in terms of emergency provision to the National Health Service. We all may have cause to be grateful for and be dependent on the qualities of care within that service.

There is a justification for focusing on the concerns of staff in our deliberations today because it is proper that we should be aware--and that anyone involved in the political process should be aware--that it is not within the purview or power of a Secretary of State to deliver the quality of care and the kind of health service to which we aspire. That can only be delivered by the staff who work within that service. It is only because of the commitment of the staff who have worked within that service over generations that we have the National Health Service of which we are all, I think, rightly proud.

We have therefore to take very seriously the concerns of people who work within the service. I hesitate to make wild assertions about morale. It is very dangerous to talk about morale because it is a difficult and notoriously dangerous area to try to quantify. In my

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experience of the public services it is unusual for members of staff to come up to you and tell you how high morale is. That having been said, it would be wrong not to acknowledge the wide-ranging and deep-rooted concerns that exist among various groups of staff within the National Health Service. The noble Lord, Lord Walton, alluded to some of them.

When the explicit commitment of the National Health Service is to a primary care led service, we must all be concerned about the extremely worrying difficulties of recruitment into general practice. General practice in this country has been the jewel in the crown of the National Health Service. It has been of tremendous importance to the quality of care for individual patients and to the continuity of that care. It has also been of crucial importance in keeping down the costs of the NHS because of the gate-keeping role of the general practitioner. We sacrifice that role and demoralise those people at our peril. The difficulties of recruitment into general practice are something that should cause very great concern.

Looking at morale, the nursing profession is also faced with enormous changes. Its members are being asked to take on--and want to take on--developing roles in response to our commitment, as a service, to reducing junior hospital doctors' hours, by expanding their practitioner roles. That is foolish in the extreme when recruitment is getting more and more difficult. There was a time during the recession when recruitment was not as difficult, when there was a great stability in the nursing workforce, but that is gradually changing and recruitment is becoming more and more difficult. It was foolish as well as insulting to treat the nurses' pay round as we have done this year.

As to the state of morale among managers, it is very easy to attack managers. It is very easy to call them bureaucrats, to talk about grey suits and to assume that if we only got rid of them and saved the money we spent on them it would solve all the problems within the NHS. The NHS is an enormous, expensive, labour-intensive and extremely complex organisation, and it deserves the highest quality of management.

It is hypocritical to say that we have to cut the costs of management without taking away any of the tasks of management. My quarrel--one of my many quarrels--with the reforms is that the tasks that have been put on the NHS have not been of management but of bureaucracy; of dealing with the nightmare of year-on-year contracting which takes up huge amounts of time and energy to very little avail, and which turns it into an organisation more interested in patients' postcodes than their prognosis, and into a paperchase of trying to build different parts of the service for different bits of care that is given. That has been a terrible distraction, among the reforms, from the very real problems that affect the service.

I was surprised at the speech of the noble Lord, Lord Clark. It seemed to me that he was harking back to a vision of a Labour Government that I did not very much recognise, and to a vision of a future Labour Government--which I certainly did not recognise--with a little synopsis in the middle of an NHS under the

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Conservative Government that no one that I know who works in the NHS would recognise. Certainly everything in the garden is not as rosy as he suggested.

I am not suggesting that there are simple answers or that these are black and white questions. There are, internationally, huge and recurring problems that have been alluded to: the problems about rising expectations, about changes in demography and about what we can do by the extension of technology, which has both pluses and minuses on the treatment and the costs side. They are dilemmas for every country and every health service in the world, whether you are in Bangladesh and paying $10 per head per year on health care or in the United States where the government is looking at $2,500 per head on health care. We are still talking about affordability, about the best structures for delivering high-quality, cost-effective care. They are real and difficult issues that we must tackle.

There are real and difficult issues in this country that we have to tackle. We must look at the Calman changes for doctors in training and the changed role that we are asking consultants to take on. The correspondence in the BMJ illustrates the real concerns about who will deliver the care to patients when consultants are doing more teaching, junior doctors are doing more learning, and there are more and more demands from patients. So there are real issues there.

There are real issues raised by the Culyer Report and how we will finance research within the NHS. There are real issues about what a primary care led NHS means, what the public think it means and how much they want to support it. There are real issues, which were discussed in the House recently, concerning community care, the spectrum of community care and whether, when we closed the long-stay institutions, for very good reasons, we perhaps looked after patients who were already in them but did not anticipate well enough what would be needed for patients who would have gone into those institutions in the future. That was a real problem.

There are enormous, real difficulties. No one within the health service thinks that we can spin gold out of straw. We know that there are resource constraints and we know that there are real dilemmas about priorities that all governments have to face. What distresses me is that we have spent the past few years pretending that the market had a solution to those problems and that we could deal with structures and not deal with the real problems, and that we have been diverted from facing them.

4.19 p.m.

Baroness Gardner of Parkes: My Lords, it is good to have this opportunity to debate the NHS, and I thank the noble Lord, Lord Winston, for his choice of subject. To listen to him, is to hear one side only of the health service story. Let us not be too depressed. There is a great deal of good news to tell. Indeed, one concern that the noble Lord did not mention is that many staff working in the NHS feel that they tend to be taken for granted by the public who do not appreciate their great contribution. Instead of flagging up the marvellous results they have achieved, and valuing the efforts that

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have gone into that, they hear only moans about what more the health service should do. An example of that is that 17 per cent. of patients failed to keep their NHS appointments in hospitals.

My interest as chairman of the Royal Free NHS Trust is one that I have declared often, and I do so again. In many ways, the introduction of the Government reform of the health service has been highly successful. At the Royal Free we have treated more in-patients each year. This year we have treated 25,000 more than in 1990. We have now more beds, many new facilities, a newly built renal unit, many state of the art pieces of new technology, a gamma camera, CT scanners and MRI scanners. We are currently developing an expanded A&E department. Next year we shall have increased out-patient facilities.

Recently a world famous actor came to the hospital to unveil our replacement and updated CT scanner--a great improvement in technology and patient comfort. He asked me who had donated it, and expressed great surprise when I was able to tell him that it came out of the national health budget. He had been led to believe that the health service was so strapped for cash that only generous donors or public appeals could supply any equipment even if it were considered to be essential. The patients and staff need to know that the health service is still making a huge investment in patient care.

It is true that the staff are working harder than ever. That is true also of jobs in industry. Those who are in employment find that the demands made on them are increasing. New computer technology which is planned to assist can often involve considerable extra effort, especially during a learning phase. Hospital patients dislike the fact that the nurse or receptionist can see the screen while they cannot. That causes friction and adds to the staff burden.

The reduction in junior hospital doctors' hours has been good for them, and we hope for the patients, but it means that nurses are taking on duties which were previously done by the junior doctors. Someone else will need to take on the duties that were done by the nurses. NHS work is never ending.

In any health system there are always concerns about growing demands and the availability of resources to meet those inevitable demands. The demographic changes of an ageing population and the constant advance of technology are familiar to us all. I know from my own experience that the staff express anxiety about that dilemma.

Local pay is an issue. Trusts have supported the introduction of local pay, and it is right that successful trusts should have the opportunity to reward staff fairly; but there is anxiety that with the additional 3 per cent. central funding for pay in the NHS, it will be difficult to meet reasonable expectations above that level, especially when central decisions on those staff with national arrangements--for example, the Doctors and Dentists Review Body groups--have given rises in excess of 3 per cent., and for senior registrars and registrars at a nett cost of 4.63 per cent. in 1996-97.

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Some issues are creating staff concern in the Royal Free Trust. There has been a national reduction in the funding of HIV/AIDS services in the light of the anticipated flattening out and potential reduction in new AIDS cases in the future. However, there is concern that those national reductions take little account of local variation in the delivery of service at designated treatment centres. Our trust has seen a continuous growth in the numbers of HIV/AIDS cases under treatment--20 per cent. more last year. As those patients can go to any treatment centre, and often choose to be away from their own areas, predictions cannot be made accurately. The actual trend needs to be recognised in funding terms. The Minister has agreed to look retrospectively at where those patients receive their treatment.

The Royal Free is one of the largest providers of specialist services to haemophiliacs in the country. Great strides have been made in the treatment and care of those patients, but the costs are rising inexorably. New methods of purifying the products necessary for blood clotting are being developed. They will increasingly ensure safe transfusion, but they cost more. Those services are not supported by any national funding arrangements and must be met from local resources. The rising costs cause huge pressure on existing budgets and have a knock-on effect on other hospital services in-year.

I quote those two points as they are examples staff have taken up with me of highly specialised treatments where the financial pressures are concentrated on only a few treatment centres in the whole country.

New management procedures have been successful, and there is a greatly improved standard of managers. Our trust does not have all the excess management staff of which I hear talk. Our managers work hard with all the other staff, and a genuine effort is put in by all in the trust to provide the best possible patient care. Better use is made of beds. Complaints, no matter how few in number, are taken seriously, as we aim to learn valuable lessons and to ensure that mistakes are not repeated.

It is time to reassess the Patient's Charter standards, to see whether they have proved to be the most relevant or whether they require amendment. There is a case for a degree of variation to cover chief teaching hospitals where the aim is to combine education and treatment.

Health of the Nation priorities should be reviewed regularly. The health needs of our population are changing constantly. We have good NHS staff and a good NHS. We must be sure that that continues in the future and that the efforts of those working in the NHS are valued. A number of conflicting statements have been made in the debate. For example, the noble Baroness, Lady Hayman, spoke of when GPs were better, but I think they are better now. Many GP practices now offer amazingly good services. They run minor accident centres.

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